Critical (27 page)
"We never thought of tailing Ponti!" Carlo said, knocking his forehead with the heel of his hand. "How come we were so stupid? I mean, we tried everything else."
"Maybe this little episode will have an unexpected payoff," Louie said, not knowing how prophetic his comment would turn out to be.
"When should we start?" Carlo asked.
"My mother, God rest her soul, always said, 'Don't put off until tomorrow what you can do today'..."
"Yeah, yeah," Carlo said. "Because today is yesterday's tomorrow."
Brennan, Arthur, and Ted smiled wanly. Like a lot of Louie's pet sayings, they'd heard both of the proverbs one too many times.
"Time is money," Louie said, raising his eyebrows teasingly. He knew his minions found his adages sappy.
"All right!" Carlo said. "We'll have to do this in shifts. I'll start. Who wants to come along?"
"I'll come," Brennan said.
"Keep me posted," Louie said.
10
APRIL 3, 2007 4:45 P.M.
Armed with yet another MRSA case from Chet, Laurie retreated to her office, still marveling that a series of infections were occurring despite the fact that it was impossible for them to be doing so, and it made her wish she'd studied more epidemiology during her training. Silently, she reiterated to herself the primary reason it couldn't be occurring. First off, the patients were all seemingly healthy, and healthy people usually could deal with a small number of staph being introduced into their nose or mouth. Ergo, for primary pneumonia to occur, there would have had to have been a large enough dose of staph introduced in a relatively short time to overcome the patients' natural defenses. But as Laurie had learned that very day, the HVAC systems of the Angels Healthcare hospitals were designed so that such a scenario could not happen. Above and beyond the fact that staph cannot be aerosolized, it was impossible for there to be a sudden surge of airborne bacteria in a room whose air intake was through a HEPA filter, whose air was changed every six minutes, and whose occupants were tested clean for MRSA, and who were all wearing surgical masks.
From an epidemiological and scientific perspective, Laurie became progressively concerned that the MRSA problem in the Angels hospitals could not be caused naturally, and that understanding led her to the more unsettling notion that the outbreak had to be deliberate. Then suddenly Laurie had an idea. There was one person in the OR who could conceivably manage to cause the pneumonias, and that was the person giving the anesthesia. With control of the airway and often ignored, the anesthetist or the anesthesiologist could conceivably manage in some devilish fashion to introduce secretly enough viable staph deep into the respiratory tree to cause the fatal pneumonia.
With a sense of urgency, Laurie snapped up her matrix and was immediately relieved. The matrix was at an early stage, but even with the small number of entries she had, she saw that there were different anesthetists and different anesthesiologists. But then she had another thought. What if it wasn't a single person but rather a cabal of anesthetists or anesthesiologists who were involved in some sort of vicious contract dispute with Angels Healthcare? But the second she'd conceived the conspiracy theory, she dismissed it as the product of how desperate she was to find an explanation. She even mocked herself for entertaining such a ridiculous, paranoid hypothesis, and she immediately vowed not to confess to anyone, especially Jack, that she had thought of such a thing. And after she'd returned to rationality, she realized the hypothetical bad guys couldn't be anesthetists or anesthesiologists because a number of the cases were not primary necrotizing pneumonia but rather fulminant surgical-site infections resulting in toxic shock syndrome.
Having run out of ideas, Laurie went back to expanding her matrix and filling in the blanks. When she'd first walked into her office, there was a note from Cheryl stuck on her monitor screen that indicated that most of the records Laurie had requested from the various Angels hospitals were in her e-mail inbox and that the rest should arrive the following day. Laurie had also found the packages sent from the ME offices in Brooklyn and Queens containing the files of their six cases and, in a separate envelope, the case files of the two missing cases of Besserman and Southgate, which had not been in their office when Laurie had gotten the four others.
Laurie went into her e-mail and scrolled through all the hospital records Cheryl had amassed for her. One by one, she queued them up and sent them to the printer down in administration. For ease of reading, she wanted hard copies. Next, she organized the cases by hospital. Considering case files and hospital records, she had a lot of information, which made her wonder if she should computerize her matrix. Although the idea had merit, she decided to stick with the simple legal-pad variety for the time being.
When she thought she'd allowed enough time to pass she made a rapid trip down to the computer room and retrieved the stack of printed hospital records.
On the way back up in the elevator, she noticed it was nearing five, and wondered if and when Jack would be returning. As she got out on the fourth floor to stop in and see Agnes in the microbiology lab, she pulled out her cell phone to make sure it was turned on in case Jack called. It was conceivable he might be closer to home than to the OCME on his field trip, as Chet had called it, and head home afterward rather than return to the office.
"We're making headway," Agnes said. Laurie had caught her in the process of putting on her coat to go home. It had been another of her normal ten-hour days. Agnes went over everything she had done, which included reaffirming that all the cases in Laurie's series were definitely methicillin-resistant staphylococcus aureus. She then ticked off where she had sent David Jeffries's samples for more definitive subtyping: the state reference lab, the CDC, and Ted Lynch in the OCME DNA lab. She advised Laurie that the CDC would be more efficient than the state reference lab and that Laurie could expect to hear from them in two to three days -- four, tops.
Agnes's comment about the CDC reminded Laurie that she had meant to call Dr. Ralph Percy about Chet's case, but a glance at her watch suggested she might be too late. After quickly thanking Agnes for everything she was doing, Laurie dashed up a flight to save time. Since she'd not gotten the number from Chet, she had to call directory assistance for the main CDC switchboard. When the CDC operator connected her to the doctor's line, Laurie got voice mail.
"Damn!" she murmured before Dr. Percy's outgoing message had terminated. The doctor had already left for the day, and Laurie was irritated at herself for not having called the moment she'd returned from Chet's. After the beep, Laurie gave her name, her direct-dial number, the patient's name, and the fact that she was interested in the MRSA typing he'd done for Dr. Chet McGovern. Then, as an afterthought, she mentioned she was a medical examiner and a colleague of Dr. McGovern.
"What's going on?" Riva asked. She'd returned to the office while Laurie had retrieved her printed documents and had overheard Laurie's voice-mail message.
"It's been one busy day," Laurie complained. "I wanted to talk to someone at the CDC, but he's left for the day."
"There's always tomorrow," Riva said.
"I hope you are not trying to aggravate me," Laurie said. Such a patronizing comment reminded Laurie of her mother.
"Oh, no. If anything, I was trying to calm you down. You look frazzled. I know you've been preoccupied most of the day."
"That's an understatement," Laurie said. She then told Riva what she'd been up to all day and why she wanted to talk with the doctor from the CDC.
"What about the woman at the CDC I dealt with?" Riva suggested. "Did you call her?"
"I did. She was helpful and said she'd get back to me."
"Why not try her? I'm certain she'd have access to Chet's case."
"Good idea," Laurie said. She had Silvia Salerno's number on a Post-it stuck to the edge of her monitor. As the direct-dial connection went through, she glanced at her watch. It was now significantly after five. Once again, she got voice mail. On this occasion, she didn't leave a message since the woman had already agreed to call her back. Laurie hung up the phone and shook her head.
"Two for two!" Riva said lightly. "They must have a curfew at the CDC!"
Laurie laughed. Riva's comment about the world-renowned CDC amused her, as unlikely as it was, and laughing for possibly the first time all day made her realize how tense she was.
Riva stood up and took her coat from behind the door. "I think I will follow the CDC's example and head home. Working with Bingham this morning on the police custody case exhausted me."
"Oh, yeah!" Laurie said. "As preoccupied as I've been, I forgot to ask you what the outcome was."
"Not good for the police or the city," Riva said, "although it could turn out to be a windfall for the family. The hyoid bone was fractured in several places, so there was obviously excessive force."
"The only good part is that Bingham will take over the inevitable political and legal fallout."
"That's true," Riva said. "We pathologists can only say it was a homicide. Whether justified will be up to a jury."
With her coat on, Riva said good-bye, but before she left Laurie asked, "If there are any more MRSA cases over the next week while you're assigning cases, would you give them to me?"
"I certainly will," Riva said before leaving.
Laurie turned back to her desk with the three stacks of case files from the three Angels Healthcare hospitals and the stack of printed hospital records. Over the next three minutes, she combined the case files with their hospital records. There were still a few hospital records missing, as Cheryl had indicated.
Putting her matrix in front of her, Laurie picked up David Jeffries's hospital record and began reading. As she read, she filled in the boxes that she'd not been able to do without the hospital record. Since she still felt the operating room had to be where he was infected, she read through the anesthesia record, paying attention to the detail. When she did so she came up with some additional categories that she had not thought of earlier, namely the OR room number, how long the operation took, duration of time spent in the PACU, and which drugs were given in the PACU. Reading through the nurses' notes, she found the names of the scrub nurse and the circulating nurse. With a ruler, she made more vertical lines to create boxes for this additional information.
When she finished with David Jeffries's hospital record, she reached for another. It happened to be one of Paul Plodget's patients: a forty-eight-year-old man named Gordon Stanek. Like Jeffries, he was a patient of Angels Orthopedic Hospital. And as she'd done with Jeffries, she used the hospital record to fill in the boxes of her matrix. As she'd noticed earlier with Riva's two cases, the anesthesiologists were different. Unsurprisingly, she recorded that the other people involved with the patient, including the surgeon and the nurses, were also different, as was the operating room itself. Even the anesthesia was different. Although both patients had general anesthesia, the agents employed were different. There was also a difference in the way the anesthesia was administered. Jeffries had had an endotracheal tube, while Stanek had had a laryngeal mask airway.
Laurie sat back and glanced first at her matrix, then at all the case files and hospital records. It was going to be a long process. In the end, what she hoped to find was some kind of commonality they all shared.
Laurie was about to pick up another hospital record when a rhythmic thumping coming from the hallway caught her attention. It was low in pitch and distant, and had the building not been as quiet as it was, since it was after five, Laurie might not have heard it. Straightening up in her chair, Laurie cocked her head to try to hear better. Although the beat stayed the same, it was becoming progressively louder. It was as if someone was beating on the floor with a rubber mallet and coming closer and closer.
Irrational fear spread through Laurie like a jolt of electricity. The thought of jumping up and slamming and locking her door flashed through her mind, yet she was frozen in place.
"Hey, sweetie," Jack said as he appeared in the doorway and proceeded into Laurie's office on his crutches. Leaning over, he gave her forehead a kiss. "You'll never guess what I've been up to." He leaned his crutches up against Riva's file cabinet and sat down in her chair. "I've been having a ball," he added and started to explain but then stopped in mid-sentence when he looked closer at Laurie's expression. He leaned forward and waved his hand in front of her face. "Hey! Hello! Anybody home?"
Laurie batted his hand away. "As quiet as it is around here, you and your crutches scared me," she said, not sure for the moment if she was more relieved or miffed.
"How did I do that?" Jack asked with confusion.
"Because ..." Laurie started to say, but then realized with some embarrassment how ridiculous it was for her to have been frightened by the sound of Jack's crutches on the corridor's vinyl floor. She guessed it was a symptom of how overwrought she was.
"I'm sorry," Jack said.
Laurie reached out and gave his knee a pat. "You don't have to apologize. If anybody is to blame, I am. I've had one hell of a day."
