Death Rounds (12 page)

“Good God!” he exclaimed, stepping back from the cloying stench that rose out of the open cavity, staggering all of us, even with our masks.

Swallowing and trying not to gag, 1 peered at the right lobe. The surface, already blackened by years of cigarette smoking, was blistered with abscesses—some of them open and draining. The entire organ was floating in a yellow pool of debris similar to what I’d suctioned out of her airway two days ago. The left lung appeared much the same, with the exception of the top half of the upper lobe.

“She must have been breathing and oxygenating through that until she died,” pronounced Len, pointing at this partially spared segment. His voice lost its practiced neutrality. He spoke slowly, clearly shaken.

The extent of the spread of the infection and the degree of tissue damage we stared at was truly alarming. Len nevertheless picked up his scalpel and proceeded to prepare the trachea, lungs, heart, and esophagus for removal en bloc. Identifying each major vessel and structure as he cut, he freed, then lifted this large dripping assembly from the chest cavity and placed it on an adjacent smaller table equipped with a drain. As he went to work on her right lung, removing it from the rest of the dissection, I swallowed a few more times and managed to ask, “Have you ever seen an infection this aggressive before?”

“No,” Len answered quickly, then added, “except...well, at least not recently, not in patients who weren’t immunocompromised somehow, and even then, not as completely unchecked as this...” His voice trailed off, and the lines in his forehead formed into deep vertical furrows as he looked up from his work. “But I saw cases somewhat similar during my residency in the early seventies, when methicillin-resistant staphylococcus first emerged, before vancomycin became the treatment of choice. Those pneumonias went fast too.” He looked back down and resumed his cutting. “But you had this lady on vancomycin, didn’t you?”

“Among other things,” I stated quietly, glancing at Rossit. I hoped the mere mention of what I’d ordered wasn’t enough to start him on another diatribe about my use of antibiotics.

“Any signs of resistance so far, Gary?” Len asked without looking away from the incisions he was making.

Rossit darted his eyes my way, then just as abruptly looked back across the table. “The organism in her sputum was coagulase positive, confirming staph aureus, and the preliminary disc diffusion screen suggested methicillin resistance,” he admitted to the top of Len’s head. The way he coldly rattled off the technical terms indicated he resented being made to reveal that vancomycin seemed to have been the right choice after all.

Well, well, I thought, feeling a flash of satisfaction. Rossit would be forced to put his attack against my prescribing patterns on hold, at least until we received confirmatory tests.

He admitted as much when he added, “But that procedure isn’t as accurate as the minimal inhibitory concentration method using a full twenty-four hour incubation and broth dilution.” This mouthful of terms made him pause for breath. “Any
intelligent
comment about Dr. Garnet’s choice of therapy will have to wait until tomorrow,” he concluded sarcastically, finally looking at me.

“Yeah, yeah, Rossit,” I shot back, “and heaven help me if the
minimal inhibitory concentration method
doesn’t validate the use of vancomycin! Get a grip, Gary! You’ll probably end up having to admit it was a reasonable call.”

‘The erythromycin, even rifampin—was there any antibiotic you
didn’t
think of?” he retorted.

Len was ignoring our spat.

“...slicing through the hilum, severing the main stem bronchus, pulmonary artery, and divisions of the pulmonary vein, thereby completing the removal of her right lung...”

He lifted the sodden organ, placed it on several pieces of paper towel, then cradled it in his gloved hands and set it on a balance for weighing. After recording the reading, he sliced open each of the lung’s three lobes, spreading the meaty halves and inspecting their interior. His hands moved slowly, so as not to spray any organisms into the air.

Suddenly his running commentary ended in midsentence. He stood frozen, transfixed by what he saw.

His unexpected reaction immediately made Rossit and me shut up, and we both strained forward to see what he’d found.

Across from me I heard Len whisper, “Holy shit!” Rossit muttered something else on my right. But my eyes were fixed on the horror in Len’s hands.

The inside of the lung was virtually destroyed. Its entire central structure—arteries, veins, and airways—had been converted into a brownish black mush. No circulatory pathways remained that might have carried antibiotics to the sites of the infection. But even if they had, the destruction of tissue visible to the naked eye meant the airways leading to alveoli, the microscopic sacs where life-giving oxygen passed into the blood, were no more. What little tissue had survived was confined to the periphery of each lobe. It had a reddish color—the sign of diffuse inflammation—and was coated with blood-streaked bubbles, a result of the leaky lung syndrome I’d suspected during her resuscitation. In the middle section of the lobes were more dark cavities where the abscesses we’d seen penetrating the lung’s surface first developed. Any remnants of tissue still intact around these holes had a coating of yellow slime.

I stood mesmerized by what I saw and didn’t realize at first that Len had resumed speaking.

“. . . the congested tissue appears diffusely inflamed and exudes a serous sanguineous fluid in the outer segments. Slightly deeper is extensive evidence of early cavitation. Most of the central parenchyma and vascular structures, however, have been replaced by liquefied necrotic debris—”

His voice wavered, and he stumbled over the dry terminology, which, while accurate, belied the enormity of what had happened to Phyllis Sanders.

“The debris gives the appearance of two infectious processes, one causing a diffuse lobar pneumonia, the other a more consolidated infection, with evidence of phagocytic tissue destruction more typical of staphylococcal organisms—Jesus Christ! What the hell’s going on here?” he finally broke off and simply stood staring down at what defied his attempt at a cold clinical description.

For a few seconds no one spoke.

Then I realized what I’d heard—
two processes.

“Could it be
Legionella,
Len, followed by staph?” I blurted out, clearly startling him out of his fugue. I glanced at Rossit. He was simply standing there, repeatedly swallowing, with his eyes riveted on the open lung.
Two processes.
Try and rip into me for mentioning
Legionella
now, Rossit, I thought, almost giddy with the possibility of suddenly turning the tables on the obnoxious little man.

“It’s something plus staph,” Len replied grimly after a few more seconds. “It’ll take a microscopic examination of tissue samples to determine the exact sequence for sure.” He paused, looking back down at the grisly specimen he still held. “But one thing’s certain,” he went on, his voice regaining its usual authority, “staphylococcus wouldn’t get this big a toehold on an intact lung, even a smoker’s lung, without some process first attacking the pulmonary tree and making breaks in the lining through which the staph could penetrate.”

“Like
Legionella?”
I repeated.

“Really, Garnet,” interrupted Rossit, “will you drop your obsession with bizarre scenarios—”

“I think
Legionella
is a hell of a good clinical suggestion, Gary,” declared Len, placing the lung in one of the plastic containers, then stepping around from his side of the table and coming to stand over a considerably startled looking Rossit. “Dr. Garnet was incredibly astute to recognize from the beginning we might be dealing with two separate organisms here,” he continued, his usually taciturn voice rising. “And as for ‘bizarre scenarios,’ this case is already bizarre!” he bellowed.

I could see Rossit’s chin flutter overtime under his mask— whether trying to swallow or find words, I couldn’t tell. His forehead and neck flushed an even deeper crimson than when he’d first seen me at the start of the autopsy. He made a few more attempts behind his mask at whatever he was trying to do with his mouth, then spun around and strode from the room.

Len stood with his hands on his hips, somehow looking bigger as he watched the vanquished little man disappear between the swinging doors. “Like I told you, Rossit,” he muttered, “here you’re on my turf, and this is my case!”

“I wish I’d done that,” I said cheerfully, stepping up and patting him on the back. “Just watching you felt terrific.”

“Oh, Earl,” he exclaimed, turning and looking at me, as if he’d forgotten I was in the room. “Sorry for the outburst.”

“I want to thank you for standing up for me,” I told him. “I was beginning to fear I might not get a fair hearing. Rossit’s been on my case big time since I...well...” I paused and looked over at Phyllis Sanders’s corpse. Staring at her eviscerated trunk with the severed rib ends bent outward, I felt a sudden letdown and realized whatever petty little battle I’d won here just now with Rossit hadn’t really mattered, because no matter what else Gary Rossit might try to pin on me, what I had to answer for in Death Rounds wouldn’t change.

“...since I sent her home,” I finally said, trying to keep my voice from betraying how morose I felt, putting my guilt into words. Her disfigured body made me remember how she had stared at me in ER.
Look at what you’ve done!

Len stepped back to the autopsy table. There was a great deal of work to be done yet.

“Don’t worry,” he answered, beginning to cut free the left lung. ‘That little bastard won’t use me, this department, or Death Rounds to railroad you or anyone else if I can help it. That’s why I put him on the spot—a reminder that questions about the management of this case could be asked of him as well as by him. If we’re right and there are two major infectious processes here, he’s not only going to have to explain why he didn’t catch on but why he was haranguing the one physician who did. And if our tissue samples confirm
Legionella,
you’re going to come out of this looking like a genius,” he declared enthusiastically as he carefully placed the left lung on his scale.

A genius with a dead patient, very possibly a murdered patient. Dare I tell Len?

All I had were Janet’s remarkable observations and a creepy tale about a figure in the dark. In medicine we called such evidence anecdotal. Interesting and sometimes considered, it usually didn’t count for much.

Better stick to the plan, I thought. Get into University Hospital as soon as possible and find some real proof. An idea suddenly occurred to me. “Is this infection unusual enough for us to warn UH about it right away?”

He didn’t answer immediately. “It’s the possible combination of organisms that’s strange here,” he finally replied. “I’ve seen
Legionella
by itself kill in twenty-four hours, and staph pneumonia can certainly be lethal within forty-eight hours, but having them together? I never heard of it.”

“But should we warn UH about what we found now?” I repeated, hoping that an alert about two such serious organisms would force University Hospital to allow Michael to add people—including me—to his investigation.

Len stared over at the right lung lying in one of the Tupperware containers. “Not right away,” he said at last. “At least not until we get full culture and sensitivity results, and not until I see tissue samples under a microscope. If we are dealing with MRSA or
Legionella
or both, then immediately state health gets involved, and they’ll be jumping all over UH and St. Paul’s in a big way. To raise all those alarms with everyone just on the appearance of her lungs . ..” He shrugged, then added, “But I’ve got to admit—so much tissue damage so fast...” He shook his head and went back to slicing off the different specimens he’d need to solve the riddle.

Damn! Maybe I should haul Michael in here myself, I thought, force him to look at the telltale organs, and let them frighten him into listening. But the gory things weren’t finished with me yet. A terrifying question shot through me like a chill. Was this what the person who’ d come padding toward me in the dark had intended for me? Or Janet, if I hadn’t come looking for her? Might her lungs have ended up like the specimens in front of me, infected and devoured from within?

I wanted out of the autopsy room. I wanted to get away from Phyllis Sanders’s remains and call Janet. Maybe she shouldn’t even be at UH working until we had figured out what was going on or unmasked whoever was prowling around in the subbasement. Then I remembered all three nurses became ill while away from the hospital and felt even more at a loss what to do.

But I slowed my breathing and forced myself to focus instead on a final question I had meant to ask Len. It had nothing to do with Janet, but I still wanted to know.

“How did Rossit get you to give this case such an early date in Death Rounds?” I asked him point-blank.

He looked up from his cutting, an annoyed frown underlined by the top of his mask. “For Christ’s sake, give us some credit. Earl!” he ordered gruffly. “Rossit didn’t. He knew we wouldn’t go along with him, so he convinced somebody else whom we had to listen to.”

“What do you mean?” I asked, truly puzzled.

“Hey, I’m supposed to be the guy around here with no political smarts, but even I could figure that one out.”

“Len, what the hell are you talking about?”

“There’s one other person in this hospital who was hot to put you on trial for this case, and Rossit knew we couldn’t refuse him.”

“Who’s that?” I asked, my mouth going dry.

“Your good friend Paul Hurst, our acting CEO. Hurst ordered us to put Sanders on Death Rounds for Monday.”

Chapter 8

“It’s only a presumptive diagnosis, Janet, until we get confirmation by culture results,” I told her over the phone. I’d gone back to my office after the autopsy and finally tracked her down between deliveries in the UH birthing center. “But Len Gardner is certain there was a preliminary infection prior to the staphylococcus, and
Legionella’s
a good bet.”