Robin Cook - Critical

Thinking in this vein about Michael, Angela couldn't help but reflect for a moment about herself. As a realist, she knew that she too carried some emotional baggage from her past, and her current life was far from serene. As she boarded the elevator, she wondered if she too had a tragic flaw that could explain how she had gone from a very idealistic first-year medical student to where she currently was: begging for money from a man she despised to prop up a nascent financial empire.

Laurie couldn't remember the last time she had been so keyed up. Moving quickly she left Paul Plodget's office after speaking with him and Edward Gonzales. She'd again hit pay dirt. The first time had been a half-hour earlier with George Fontworth, an ME who'd been with the OCME for almost as long as Arnold and Kevin. He'd provided her with four MRSA cases he'd had over the last three months. And now she'd learned Paul had also seen four MRSA cases over the same time period, and Edward one. Although one of Paul's cases was from Manhattan General, a tragic case of a previously well five-year-old girl who'd developed rapidly fatal necrotizing pneumonia from a boil-like lesion obtained at a local playground, all the others were from an Angels Healthcare hospital. First, there was a Jonathan Wilkinson, who'd died of necrotizing pneumonia after a triple coronary bypass; second was Judith Astor, who died of toxic shock-like syndrome after a facelift; and third was Gordon Stanek, who died of necrotizing pneumonia after a rotator-cuff repair. Edward's case was Leroy Robinson, who passed away from necrotizing pneumonia after the repair of an open wrist fracture.

Walking quickly enough to briefly skid on the highly waxed vinyl floor, Laurie stormed into her office. After sitting down, she pulled herself toward her desk and reached for her rapidly expanding matrix to add Paul's and Edward's cases.

"Remind me, if asked, never to do another case with our beloved chief," Riva said, turning around toward Laurie. It was a common joke around the OCME to express such sentiments after working with Bingham. Riva had come up to the office between cases to make a few work-related calls. For a moment, she watched Laurie diligently work, wondering why her office mate hadn't even greeted her. It was so unlike Laurie.

"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.