Death Rounds (2 page)

“Bullshit!” Michael said, loud enough for anyone in the station to hear. A young medical student looked up from her computer screen, but no one else paid him any mind. He immediately lowered his voice, but not his intensity. “If a radiologist says that film suggests anything more than what you called it, he’s a liar. No one could predict that little mark was brewing into what she had today, certainly not without a previous film to compare it to—which, by the way, makes me wonder why she came here to St. Paul’s instead of the staff health service at University Hospital.”

“She was on vacation, St. Paul’s was closer to her home, and she said she didn’t like everybody at work knowing her business anyway,” I answered, only giving part of the reason. In fact she had phoned in ahead of time and found out I was on call. “I work with his wife,” she’d announced at triage, putting everyone on the defensive. She’d increased the level of discomfort even further by proclaiming, “And my son’s the chief technician for the labs at her hospital.” By the time she’d done the same routine with the resident who’d initially assessed her—browbeating him into ordering more tests than he might normally have asked for—anyone who went near the woman resented her. I only learned all this from the clerks and nurses after I’d sent her home. But I’d already taken my own dislike to Phyllis Sanders.

“I know Janet, Dr. Garnet,” had been her greeting when I’d appeared at her bedside to review her case with the resident.

Dr. Janet Graceton is my wife, an obstetrician at University Hospital. I met people all the time who announced they knew her, had had their children delivered by her, thought the world of her, but this had been different. I felt I’d had my chain yanked.

“I’ve heard so much about you as well,” she’d continued in a high whiny voice. Sitting up in her hospital gown, her arms crossed in front of her chest, her gray hair pulled tightly back into a bun, she’d seemed rigid, held in. She’d forced a smile, but it had looked like a reproach as her forehead frowned while her lips turned up. All the while her eyes seemed to say
Are you going to disappoint me too?

I’d resented her immediately and had been particularly repulsed by her attempt to use her acquaintance with Janet to manipulate me.

When she’d told me her son’s position and then added, “He’s worked with your wife too, you know,” I’d barely kept the irritation out of my voice. Go do your wheedling for special treatment in someone else’s ER, I’d been thinking while explaining she’d nothing much wrong with her.

“How long did you say she’d been sick?” Michael asked, snapping me back from my thoughts.

“Only a day,” I answered, trying to keep my words steady and not sound defensive. “She’d had a slight headache when she woke up that morning, then the temperature and diarrhea.”

“It doesn’t sound like much to bring a nurse into ER. I wonder if she chose Saint Paul’s over her own staff health service because they had her number there and knew she was a malingerer?”

“Maybe,” I answered, not admitting that was exactly what I’d suspected as I’d firmly insisted she could go home. “Obviously she wasn’t malingering this time.”

Michael gave me a smile and clapped his hand warmly on my shoulder. “You made a solid call. Earl, given what was there. Hey! After all your years in the pit, you of all people should know you can’t beat yourself up over every disease that turns nasty.” He finished signing off his part of today’s resuscitation, handed Sanders’s chart back to me, and added, “When this case is reviewed, everyone will agree with me.” He then strode briskly out of the station and over to where a new ambulance case had been rushed into triage.

He’d meant to support me, but the mention of a case review unleashed once more the sense of dread I’d been trying to control. All unexpected return visits trigger investigations to identify possible slipups. I’d instigated the mandatory checks myself when I’d first become chief over eight years ago. But not all physicians at St. Paul’s Hospital had appreciated my setting up an arena where their errors were dissected and laid bare for critical scrutiny. Whenever I had a case on the schedule, more than a few of these doctors turned up hungry to settle old scores. This time they might have a point. As I signed off my own notes, my memory of yesterday’s encounter kept playing over and over. Had my resentment toward the woman made me miss something?

Chapter 2

I spent the next five minutes trying to make sense of a rambling history given by an earnest medical student about an old man who seemed to hurt everywhere. I ended up suggesting he discuss the patient with Michael.

“Dr. Garnet,” called the ER clerk from her work area on the other side of the station. “It’s bacteriology on line three, about Mrs. Sanders.”

I grabbed the desktop telephone beside me and punched the third button. “Garnet here.”

“Dr. Garnet,” said the technician, his voice obviously excited, “it’s staph. Clusters and clusters of gram-positive cocci on the Gram stain of her sputum.”

“You’re sure?” I questioned, surprised. “It’s not just strands of pneumococci heaped together?”

While both these organisms are gram-positive cocci, that is, when treated with Gram stain reagents they stain blue and appear round under a microscope, pneumococcal bacteria line up in strands and pairs whereas staphylococci tend to occur in clumps and resemble bunches of grapes. I’d been expecting pneumococci.

“It’s out of a textbook,” he replied, “like a goddamned vineyard. I’m keeping the slides for our teaching file. All the other cultures are being plated out now.”

He was as excited as a kid with a new toy. Staph pneumonia was unusual, and bacteremia from staph pneumonia was outright rare. In all his enthusiasm he seemed to have overlooked that he’d just given Mrs. Sanders a one-in-three chance of dying.

“Do you know if it’s a hospital- or community-acquired infection?” he asked eagerly.

It was a good question despite the macabre exuberance. Hospital-acquired staphylococcus was apt to be resistant to the antibiotics we’d given her. One strain in particular, called MRSA, or methicillin-resistant staphylococcus aureus, responded only to vancomycin.

“She’s a nurse at University Hospital,” I replied. “I suppose we’ll have to assume resistance until we get your culture and sensitivity results.”

“Thanks for the great case, Doc!” he said before hanging up.

I was left shaking my head.

I called ICU and informed the charge nurse about the Gram stain result. She told me ID still hadn’t seen Sanders, so I ordered vancomycin—just in case.

“Do we stop the erythromycin?” she asked, not unreasonably. If the pneumonia was caused by staph, erythromycin wouldn’t add anything to the treatment already in place, except an increased chance of side effects.

But I hesitated.

“Dr. Garnet?” asked the nurse, after a few seconds of silence.

Something still didn’t fit. I couldn’t pin it down, but one thing I’d learned not to ignore in ER was an uneasy feeling that I was missing something.

“No,” I answered slowly, “leave it until ID sees her, and have them call me here when they do. They’ll probably change all my orders anyway. By the way, has anyone talked to the family yet?”

“There’s no answer at the woman’s home. Her chart from yesterday says she’s widowed—Sanders’s her maiden name—but the next of kin is her son, a Harold Miller, with the same phone number. Did he send her in?”

“No, according to the ambulance sheet a neighbor found her this morning and dialed 911.” I hesitated before giving my next suggestion. But it had to be done. “Her son’s in charge of lab technicians at University Hospital. You might try for him there. Tell him he can reach me in ER.”

After I hung up, I glanced around the department, confirming that Michael and the residents still had things under control. I stepped over to a set of corner shelves where we kept reference texts. While most of the residents used the computer to access material on any given topic in emergency medicine, I still preferred the written page. As chief of the department, I could assure we had both.

Despite the Gram stain result identifying staphylococcus, there were simply too many features of this case that seemed unusual. I pulled the middle volume of a medical text published by
Scientific American—
a large three-ring-binder format that was updated monthly—and found the section on pulmonic infections.

Looking at the differential diagnosis of pneumonias in a systematic outline relaxed me. The bits and pieces of various syndromes suggested by Sanders’s symptoms suddenly seemed to settle into an organized pattern. The thickness of her sputum and the presence of blood was indeed consistent with the more common pneumococcal infection that I’d been expecting to find, but pus was also a hallmark of how staph infections released toxins that destroyed tissue and, in so doing, created abscesses. The bloody sputum could have been the result of noncardiac pulmonary edema—a condition in which shock and sepsis break down the membranes lining the tiny air sacs through which oxygen normally passes into the blood. The result is a leaky-lung syndrome in which these same little sacs are flooded with blood-tinged serum.

The article reiterated that staph organisms were carried in the nostrils of up to fifty percent of hospital personnel, a well-known statistic, and that this was the most common nosocomial, or hospital-acquired, source of this infection with elderly or immunocompromised patients. In the update, however, was a new statistic. The incidence of serious drug-resistant organisms in U.S. hospitals, namely, MRSA or VRE, was now up to forty percent.

This creepy piece of data made my skin crawl. I immediately felt the urge to wash my hands.

But the next chapter, while reassuring about my personal safety, reinforced my suspicion there was something strange about Sanders’s being infected at all. Healthy adults only developed pneumonia from staphylococcus after some event, like an influenza infection, made the lung susceptible. The expected pattern was a flulike illness for at least five days and then the classic symptoms of life-threatening pneumonia we’d seen in Sanders today. The one-day prodrome she’d presented with yesterday wasn’t part of the picture.

Peering at the small print through the bottom part of my glasses, I suddenly realized the yellow droplets from Sanders’s sputum were still dried on the lenses. “Shit!” I exclaimed. The same medical student who’d overheard Michael’s profanity gave me a disapproving look. “Sorry,” I muttered, and rushed out of the nurses’ station. Illogically, I held my breath while running to a utility room. There I whipped on a pair of gloves, dropped my glasses into the deep sink where mops were cleaned, and emptied half a container of concentrated cleaner on them. My eyes were red with the fumes by the time I finished rinsing them off. On returning to the nurses’ station, I smelled like a recently scrubbed toilet.

“Phew!” said Michael, who was standing over the open book I’d abandoned on the counter. The section on pneumonias must have caught his eye. “What are you using for aftershave?” he kidded, but his laugh sounded a little nervous.

“Smart-ass!” I stepped by him to put away what I’d been reading.

“Hold it,” he cautioned, and pointed to a section I hadn’t looked at yet.

There, in a succinct paragraph, was exactly the prodrome I’d been looking for.

The pneumonia is preceded by a one day history of myalgia, malaise, and a slight headache after an incubation period of 2 to 10 days. Gastrointestinal complaints, especially diarrhea, may be present, and orthostatic dimness has been reported. The cough is initially nonproductive.

I looked up to the title of this section. It was Legionnaires’ disease.

* * * *

Little Gary Rossit, the chief of our infectious disease department, was the biggest son of a bitch in the hospital. Whenever he could use his considerable knowledge about communicable illnesses to humiliate his fellow physicians, he did so with relish. Perhaps it was his way of paying back the rest of the world for being taller than he was. I always suspected he simply enjoyed being mean. That his considerable skills also helped desperately ill patients get better was why most of us put up with him.

“Look, Earl, just because you booted the case yesterday, don’t think overdiagnosing the same symptoms today and ordering every antibiotic you can think of is going to let you off the hook.”

I felt my face flush with anger. We were outside the isolation cubicle in ICU, a well-lit glassed-in room located against a back wall of the department. He’d just finished pulling off his cap and other protective wear after seeing Mrs. Sanders, and his wavy black hair was sticking up in tufts. I had to resist grabbing one of them and lifting him off the floor by it.

“I’ve ordered the lab to test for
Legionella,” I
told him, gritting my teeth to help me keep my temper. Special culture and staining techniques that could take up to three days were required to isolate the hard-to-detect organism. Even then, none of the tests was one-hundred-percent sensitive.

“Where’s your reference to justify even thinking of those tests,” he asked belligerently. “There’s no literature on Legionnaires’ preceding staph pneumonia.”

“Show me literature on staph pneumonia and bacteremia after a twenty-four-hour prodrome in an otherwise healthy adult,” I shot back at him.

We glared at each other for a few seconds. The resident in charge of ICU who’d been listening from a few feet away started to fidget.

Then Rossit shrugged. “No wonder we’re way over budget,” he muttered as he walked over to a large desk near the central nurses’ station where he began writing his consultation note. Behind him were dozens of monitors and screens arranged on a wide curved console—a flashing array of fluorescent tracings, blinking numbers, and squiggled readouts. Every now and then an alarm bell would softly sound and get the attention of a nurse. Sometimes she’d readjust the monitor. Other times she and her colleagues would rush into one of the many curtained cubicles that lined the room and perform some procedure on a patient, out of sight. Occasionally there would be a cry or moan, but ICU was generally a quiet place where conversations were hushed and pain was monitored, measured, and medicated until it was endured without a whimper. Somewhere on the blinking wall of screens in front of me were the numbers that documented Mrs. Sanders’s agony.