Critical (15 page)

"Hey!" Riva called out after several minutes had ticked by. "What are you doing?"

Laurie's head bobbed up. She apologized, belatedly realizing her rudeness. "I've stumbled onto something quite extraordinary."

"Like what?" Riva asked dubiously. She knew Laurie to be a passionate woman who loved her work and who frequently became excited over problematic cases. Sometimes it was appropriate, and sometimes not.

"There has been a mini-epidemic of nosocomial MRSA that's gone essentially unnoticed."

"I wouldn't say it's gone unnoticed," Riva said. "It's been happening for a decade or more, not only in this country but internationally as well. Didn't it start in Britain?"

"Let me phrase it differently. Within the last three and a half months or so, there's been a number of very severe MRSA inpatient infections resulting in rapid death, all occurring at three hospitals owned by Angels Healthcare."

"Just those three hospitals?"

"That's it! Except for one I uncovered five minutes ago that happened at Manhattan General, all the others have been at the three hospitals."

"How many cases are you talking about?"

Laurie looked back to her ballooning matrix and silently counted what she had recorded. "I've got twenty-one so far, but I have yet to talk with Chet, our deputy chief, or Jack, for that matter."

"Are these cases of necrotizing pneumonia involving this newer, community-acquired MRSA?"

"Most of them," Laurie said. "A few of the others are described as toxic shock syndrome. In those cases, there is extensive lung inflammatory damage from the bacterial toxins and from the overproduction of cytokines by the deceased, but the infection itself is elsewhere. As for the involved strain, it's been the community-acquired MRSA in those cases where I've seen the case files. The problem is I have yet to see too many case files."

"Then you have twenty-three, not twenty-one."

"How so?" Laurie asked. She looked back at her matrix and started to recount.

"Because I have had two," Riva explained. "It was three months ago and maybe a week or two apart." Swivelling around in her chair, Riva took down a small, bound notebook from her bookshelf above her desk. Unlike any of the other medical examiners, Riva kept a longhand chronological journal of all her cases. On several occasions Laurie wished she had thought of doing the same. In it, Riva added personal observations and feelings that were inappropriate for the official report. It was more like a diary than a mere case-by-case compendium. After rapidly flipping the pages, Riva came to the respective entries. She quickly read them before raising her eyes to meet Laurie's. "You definitely have twenty-three: One of mine was from Angels Orthopedic Hospital, and the other from Angels Cosmetic Surgery and Eye Hospital."

"Can I see?" Laurie asked eagerly.

Riva handed over the journal and pointed to the two entries.

Laurie read rapidly. As an exceptionally thorough pathologist, Riva had recorded the name of the hospital and even the specific strain of MRSA involved in both cases. She had written it as: CA-MRSA, USA400, MW2, SCCmecIV, PVL.

Laurie looked at Riva. "In the few case files I've seen, the bacteria wasn't so specifically typed. Was there some reason it was in your cases?"

"I had it subtyped," Riva explained. "Like you, I was impressed with the pathology in the lung. More for general interest, I sent an isolate of each case to the CDC because I'd read they were looking to obtain MRSA samples for their MRSA library."

"Do you have any idea what all the alphanumeric acronyms mean?"

"Not a clue," Riva admitted. "If you read further, you'd see I'd promised myself I'd look it up, but unfortunately, like a lot of good intentions, I never did it."

"Was the CDC surprised that the strains were the same despite coming from different hospitals?"

"I don't believe I mentioned there were two hospitals involved."

Laurie nodded, but the fact that the two strains were exactly the same bothered her, considering what Agnes had told her about how easily staphylococcus exchanged genetic material. She felt pleased that she'd asked Cheryl to get an appropriate contact with someone involved with MRSA at the CDC, as it would give her an opportunity to ask the question directly to someone particularly competent.

"You wrote in your journal that you obtained hospital records," Laurie said. "Do you still have them?"

"Probably," Riva said. "They came in as e-mail attachments. I usually save those just for this kind of situation."

Riva turned to her computer keyboard and began typing.

Laurie picked up her own phone and called down to Cheryl Myers. Luckily, she was still at her desk rather than out on a site visit. Laurie apologized in advance before telling her she needed quite a number of additional hospital records from the Angels Healthcare hospitals.

"Not a problem," Cheryl said. "Just e-mail me the names."

"I did save the hospital records," Riva said when Laurie hung up her phone.

Laurie got up and looked over Riva's shoulder. "Fantastic!" Laurie said. "I guess I can access that from my computer. What's the file name?"

Within a few minutes, Laurie had Longstrome and Lucente's hospital medical records on her screen. Of all the MRSA cases that had come in to be autopsied over the last four months, these were the first hospital records she had. Arnold Besserman had provided her with several of the OCME case files he still had in his office, but he couldn't put his finger on the hospital records.

"Well, I've got to get downstairs and do my next case," Riva said.

Laurie waved over her shoulder, preoccupied by printing out the documents.

"Don't you have another case as well?" Riva asked.

"Oh! Shit!" Laurie said. With her burgeoning interest in the MRSA cases, she'd forgotten. It was embarrassing to think that Marvin was patiently waiting.

"You're preoccupied," Riva said. "I'm sure I can get someone else to do it."

"I'll do it," Laurie said. While she didn't want to take time away from her current project, she felt guilty about not doing her share. "If you see Marvin down there, tell him I'll be calling him shortly."

With a final nod, Riva disappeared, leaving the door ajar.

Laurie went back to her computer and made the final click to load the second document into the printer queue. Knowing she'd have to wait five or ten minutes for the two documents, she went back to her matrix, adding Riva's cases. When she was finished, she leaned back. It was a sizable list, certainly bigger than the two matrixes she'd made in the past. Now she had to decide how to label the columns. Some of the information she thought appropriate was intuitive, such as: age, sex, race, doctor, date, hospital, diagnosis, type of surgery, predisposing factors, anesthesia, and staph type. Laurie then drew more vertical lines next to the ones she'd already drawn. She knew she needed little space for things like age and sex, and more for predisposing factors and diagnosis. When she was finished, she made sure there was room for more columns. And it was for that reason she was pleased to have the hospital records. She knew that by going over them, she'd come up with more categories.

Satisfied with her progress, Laurie leaped up from her desk with the intention of dashing to the computer room, only to collide into Jack as he appeared in the doorway. Both were surprised, but more so for Laurie, who let out an involuntary yelp. In the process of grabbing Laurie's upper arms, Jacked dropped the case files he was carrying, as well as his crutches.

"My God!" Jack joked. "What is there, a fire in here?"

Laurie pressed a hand to her chest. It took a few breaths before she could talk. "I'm sorry," she managed. "I guess I'm preoccupied and in a hurry."

"I heard as much about the preoccupied part," Jack said. "I ran into Riva getting off the elevator. She said you'd come across something that you found particularly interesting but didn't elaborate. What's up?"

"Have you had any MRSA cases in the last three months or so with pulmonary involvement?"

"You have to give me more of a clue what you are asking. You know I'm not good with acronyms."

"Methicillin-resistant staphylococcus aureus," Laurie said.

"Uh-oh. Is this a setup? Isn't MRSA what your ACL case had this morning?"

"It is," Laurie admitted. She started to bend down to retrieve Jack's case files and crutches.

Jack, who was still holding onto Laurie's upper arms, restrained her and then bent down to gather his belongings. "I can't recall having any MRSA ever," he said, while straightening up.

"How about Chet?"

"Now, he might have. It seems to me I heard him talking on the phone about staph with Miss Smiles, Agnes Finn. Whether it was MRSA or not, I have no idea."

"Thanks for the tip. I'll have to ask him."

"So it's obviously MRSA that has you so preoccupied and in a hurry."

"It's certainly the preoccupied part, but the reason I'm in a hurry is because I forgot I've got another case to post. Poor Marvin's been waiting for several hours."

"Riva mentioned the case as well. She said she offered to have someone else do it. She said you didn't take her up on the offer, although she sensed that you wanted to."

Laurie let out a small laugh. "That's sensitive enough on her part to be almost scary."

"Then let me do it," Jack said. "I'm done with all my cases, and from what Riva said, the post itself should be straightforward. I mean, it's going to be plain blunt trauma with the poor guy falling ten stories onto concrete."

"You don't mind?" Laurie questioned. "Maybe you should give it another thought. Riva mentioned to me earlier that there are three stakeholders who are very interested in the case. All three want a different manner of death. No matter what you come up with, two other people are going to be disappointed. That's not your favorite kind of case."

"I think I can handle it."

"Well, then I'll take you up on the offer. But there's one important fact that didn't get in the PA's report, which I got from Cheryl, and which might be important. It was the distance from the building that the body landed. It was twenty-one feet."

"Sounds like I might have to dust off my high-school physics," Jack said. "Now that we have that settled, why are you preoccupied about MRSA? It's not that it is new; it's been a big problem in hospitals for some time. Or shouldn't I ask?"

"You shouldn't ask!" Laurie agreed. "Not until I get more information. Then I'll sit you down for a convincing PowerPoint presentation."

"Why do I have a bad feeling about the goal of this supposed presentation?"

"Because you are worried I'm going to change your mind."

"Fat chance, Laurie, I'm having my knee fixed come Thursday."

"We'll see," Laurie said confidently. "Come on! I'll ride down in the elevator with you. I need to pick up some material I just had printed."

As they walked down the hall toward the elevator, Laurie asked Jack about his previous case, the last of the three homicides Lou was interested in. She'd heard Lou's description that morning about the detective sergeant's daughter and the baseball bat.

"It's a good one," Jack said, manipulating the crutches like a pro. "It was another opportunity for our PAs to shine. Steve Mariott noticed there were no footprints in the copious amount of blood on the floor. I mean, in and of itself, it doesn't mean a whole lot, but it made him look at the scene a little closer than he might have otherwise, which turned out to be key. The victim's forehead was bashed in, with even a bit of brain tissue extruding, but the overall shape of the wound wasn't concave like you'd expect a bat to cause. I made a mold of the injury, and its tramline."

"You mean it's more like having been caused by a sharp edge?" Laurie questioned as they boarded the elevator.

"Exactly," Jack said, grabbing both crutches in one hand so he could press the button for the basement. Laurie leaned over and hit the button for the first floor. The OCME printer was in the computer room, which was part of the administration area.

"Steve had noticed a bit of blood on the cast-iron edge of a granite coffee table. He'd even taken a picture of it, as well as the bat. I think Satan Thomas, in a drunken, drug-addled stupor, fell while trashing the apartment and hit his forehead on the edge of the coffee table. To prove it, I've sent one of the daytime PAs back to the scene to get a mold of the table's edge."

"That's terrific," Laurie said. "Lou is going to be pleased."

"I think the girlfriend is going to be the most pleased."

The door to the elevator opened. Laurie gave Jack a quick hug and thanked him for volunteering to do her case.

"I'll think of a way you can pay me back," Jack said with a wink and a smile.

After the elevator door closed, Laurie hustled down the main corridor toward the office printer in the computer room. She was determined to take advantage of this unexpected free time. With the hospital records of Riva's two cases, she planned on working more on her matrix by creating more categories and filling in the boxes she could. What Laurie was interested in was finding some hidden commonality among the cases, which could explain the sudden cluster.