“It’s terrifying,” Jack said. He grabbed Laurie’s officemate’s chair, pulled it over to Laurie’s desk, and sat down. “This is just what I’ve been worrying about. This could be a real epidemic. What have you learned about this index case?”
“Not much,” Laurie admitted. “He’d been admitted Saturday evening with a fractured hip. Apparently he’d had a brittle bone problem; he’d had a whole string of fractures over the last few years.”
“Fits the pattern,” Jack said.
“What pattern?” Laurie asked.
“All the index cases from these recent outbreaks have had some sort of chronic illness,” Jack said.
“A lot of people who are hospitalized have chronic illnesses,” Laurie said. “In fact, most of them. What does that have to do with anything?”
“I’ll tell you what’s on his paranoid, sick mind,” Chet said. Chet had appeared at Laurie’s door. He stepped into the room and leaned against the second desk. “He’s got this thing about AmeriCare and wants to see conspiracy behind all this trouble.”
“Is that true?” Laurie asked.
“I think it’s less that I want to see conspiracy than it’s staring me in the face,” Jack said.
“What do you mean by ‘conspiracy’?” Laurie asked.
“He has this notion that these unusual illnesses are being spread deliberately,” Chet said. Chet summarized Jack’s theory that the culprit was either someone at AmeriCare trying to protect its bottom line or some crazy person with terrorist inclinations.
Laurie looked questioningly at Jack. Jack shrugged.
“There are a lot of unanswered questions,” Jack offered.
“As there are in just about any outbreak,” Laurie said. “But really! This is all a bit far-fetched. I hope you didn’t mention this theory to the powers that be over at the General.”
“Yeah, I did,” Jack said. “In fact I sort of asked the director of the lab if he was involved. He’s rather disgruntled with his budget. He immediately informed the infection-control officer. I imagine they’ve let the administration know.”
Laurie let out a short, cynical laugh. “Oh, brother,” she said. “No wonder you’ve become persona non grata around there.”
“You have to admit there’s been an awful lot of questionable nosocomial infection at the General,” Jack said.
“I’m not even so sure about that,” Laurie said. “Both the tularemic patient and the patient with Rocky Mountain spotted fever developed their illnesses within forty-eight hours of admission. By definition, they are not nosocomial infections.”
“Technically that’s true,” Jack admitted. “But…”
“Besides, all these illnesses have been seen in New York,” Laurie said. “I’ve done some recent reading myself. There was a serious outbreak of Rocky Mountain spotted fever in eighty-seven.”
“Thank you, Laurie,” Chet said. “I tried to tell Jack the same thing. Even Calvin has told him.”
“What about the series of cases coming from central supply?” Jack asked Laurie. “And what about the rapidity with which the patients with Rocky Mountain spotted fever developed their illnesses? You were questioning that just this Saturday.”
“Of course I’d question those things,” Laurie said. “They’re the type of questions that have to be asked in any epidemiological situation.”
Jack sighed. “I’m sorry,” he said. “But I’m convinced something highly unusual is going on. All along I’ve been worried that we might see a real epidemic crop up. This outbreak of meningococcus may be it. If it peters out like the other outbreaks, I’ll be relieved, of course, in human terms. But it will only add to my suspicions. This pattern of multiple fulminant cases, then nothing, is highly unusual in itself.”
“But this is the season for meningococcus,” Laurie said. “It’s not so unusual.”
“Laurie’s right,” Chet said. “But regardless, my concern is that you’re going to get yourself into real trouble. You’re like a dog with a bone. Calm down! I don’t want to see you fired. At least reassure me you’re not going back to the General.”
“I can’t say that,” Jack said. “Not with this new outbreak. This one doesn’t depend on some arthropods that aren’t around. This is an airborne problem, and as far as I’m concerned, it changes the rules.”
“Just a moment,” Laurie said. “What about that warning you got from those thugs?”
“Now what?” Chet questioned. “What thugs?”
“Jack had a cozy visit from some charming members of a gang,” Laurie said. “It seems that at least one of the New York gangs is going into the extortion business.”
“Somebody has to explain,” Chet said.
Laurie told Chet what she knew of Jack’s beating.
“And you’re still thinking of going over there?” Chet asked when she was through.
“I’ll be careful,” Jack said. “Besides, I haven’t exactly decided to go yet.”
Chet rolled his eyes to the ceiling. “I think I would have preferred you as a suburbanite ophthalmologist.”
“What do you mean, ophthalmologist?” Laurie questioned.
“Come on, you guys,” Jack said. He stood up. “Enough is enough. We’ve got work to do.”
Jack, Laurie, and Chet did not emerge from the autopsy room until after one in the afternoon. Although George had questioned the need to post all the meningococcal cases, the triumvirate had insisted; George relented in the end. Doing some on their own and some together, they autopsied the initial patient, one orthopedic resident, two nurses, one orderly, two people who’d visited the patient, including the nine-year-old girl, and particularly important as far as Jack was concerned, one woman from central supply.
After the marathon they all changed back to their street clothes and met up in the lunchroom. Relieved to be away from the mayhem and a bit overwhelmed by the findings, they didn’t talk at first. They merely got their selections from the vending machines and sat down at one of the free tables.
“I haven’t done many meningococcal cases in the past,” Laurie said finally. “But these today were a lot more impressive than the ones I did do.”
“You won’t see a more dramatic case of the Waterhouse-Friderichsen syndrome,” Chet said. “None of these people had a chance. The bacteria marched through them like a Mongol horde. The amount of internal hemorrhage was extraordinary. I tell you, it scares the pants off me.”
“It was one time that I actually didn’t mind being in the moon suit,” Jack agreed. “I couldn’t get over the amount of gangrene on the extremities. It was even more than on the recent plague cases.”
“What surprised me was how little meningitis was involved,” Laurie said. “Even the child had very little, and I would have thought at least she would have had extensive involvement.”
“What puzzles me,” Jack said, “is the amount of pneumonitis. Obviously it is an airborne infection, but it usually invades the upper part of the respiratory tree, not the lungs.”
“It can get there easily enough once it gets into the blood,” Chet said. “Obviously all these people had high levels coursing through their vascular systems.”
“Have either of you heard if any more cases have come in today?” Jack asked.
Chet and Laurie exchanged glances. Both shook their heads.
Jack scraped back his chair and went to a wall phone. He called down to communications and posed the same question to one of the operators. The answer was no. Jack walked back to the table and reclaimed his seat.
“Well, well,” he said. “Isn’t this curious. No new cases.”
“I’d say it was good news,” Laurie said.
“I’d second that,” Chet said.
“Does either of you know any of the internists over at the General?” Jack asked.
“I do,” Laurie said. “One of my classmates from medical school is over there.”
“How about giving her a call and seeing if they have many meningococcal cases under treatment?” Jack asked.