Critical (18 page)

Freddie merely laughed.

“Is it that bad?” Lou asked.

“Vinnie made hay right after Paulie got sent up, especially with drugs. The Vaccarros want their old territory back.”

“What about the Asians, Hispanics, and Russians?”

“They are getting to be a pain in the ass for everyone.”

“All three groups.”

“Mainly the Asians bringing in drugs from the East rather than South America.”

“It was rumored there was an apparent hit last night,” Lou said, finally getting around to the point. “Do you know anything about it?” He purposefully didn't want to give any of the details.

Freddie's eyes flicked over toward the restaurant door in a nervous fashion, which for Lou was a giveaway. From his years of experience, he guessed skinny Freddie knew something.

“I don't know anything about no hit,” Freddie said unconvincingly.

“Come on! Don't make me threaten, and don't make me call Vinnie for old times' sake.”

“Okay, I know there was a hit last night, but that's all I know about it.”

“Please! Don't drag this out.”

“I don't know who it was, honest. All I know, it was some guy who was going to rat.”

“What was the victim going to rat about and to whom?”

“Who knows?”

“Are you pulling my chain here or what?”

“Honest, I'm telling you all I know, which is close to zilch. Vinnie's upset about something, but I have no clue. He doesn't talk about such things, except to Franco Ponti.”

Lou eyed the hopeless kid-turned-man. In one sense, he felt sorry for him, because Lou was sure he was going to end up in a Dumpster some night. He'd been playing two ends against the middle but wasn't intelligent enough to carry it off over the long haul. In another sense, Lou was angry with him because like all these other misfits, the shithead was abetting a tiny group of people who made all Italian Americans look bad.

“All right,” Lou said after a pause. “I want you to find out who this guy was who got whacked. I don't want a war breaking out between the Lucia and Vaccarro factions, which is what I'm worrying about.”

“There's no way for me to find out any such thing. Vinnie is tight-mouthed. If I asked him anything, he'd know something was screwy.”

“Don't ask him, ask Franco.”

“That would be worse than asking Vinnie. You know the guy's crazy.”

“Figure out a way,” Lou said. He reached across Freddie and opened the door.

L
aurie's eyes were glazed over as she stared blankly out of the taxi's side window as it raced northward on Second Avenue. She was totally preoccupied with her MRSA series, which had started out as a possible way of convincing Jack to postpone his knee surgery but which had morphed into something else entirely. She still intended to use the issue with Jack, but now she sensed there was a wider significance, and the possibility electrified her. Her conception of the role of the medical examiner was to speak for the dead to help the living. Suddenly, she saw her current series as a means to do just that. If she could figure out why these MRSA deaths were occurring in such a cluster, she could presumably save potential victims.

Thinking in such a vein had a disheartening aspect. Why hadn't the OCME picked up on the problem sooner? Laurie pondered the question for a moment before guessing the reason: a low index of suspicion, which Laurie assumed would have influenced her, too, concerning David Jeffries, had the personal aspect not intervened. Laurie knew that as many as ten percent of all patients entering the hospital come away with a hospital-acquired infection, meaning about two million patients a year, resulting in nearly ninety thousand deaths in the United States alone. Of these infections, about thirty-five percent were staph, many of which were MRSA. In short, the problem was just too common to cause much of a stir, especially with bacteria on the rise.

A sudden crash jolted Laurie from her reflections. Had she not had her seat belt on, her head would have hit the ceiling.

“Sorry!” the cabbie said, glancing at Laurie in his rearview mirror to see if she was okay. “Potholes from the winter.”

Laurie nodded. She appreciated the apology, as unexpected as it was, but not the driving style.

“Maybe you could slow down,” she suggested.

“Time is money,” the turbaned driver answered.

Knowing the futility of trying to influence the taxi driver's mind-set, Laurie went back to her musing. She was on her way to the Angels Orthopedic Hospital, which was sited on Fifth Avenue on the Upper East Side, and surprisingly enough, approximately directly across Central Park from where she and Jack lived. Over the previous two hours she'd been frantically busy, and, despite a mild fear for her life in the cab, she appreciated the forced respite and time to organize her thoughts that the ride offered. She'd finally been able to meet with Arnold Besserman and Kevin Southgate, and had gotten the names of their six cases and four of the six case files and hospital records. Arnold had even given her the personal monograph he'd written on MRSA, which Laurie had quickly read.

Laurie now knew more about the bacterium than she'd ever known, even more than she had just before taking her forensic pathology boards, for which she had crammed in her old collegiate style, with all sorts of esoteric facts, including some about MRSA and other staph organisms. As Agnes had said, staphylococcus aureus was an extraordinary and versatile pathogen.

With the accession numbers of Arnold's and Kevin's cases plus those of George Fontworth, Laurie had relayed them all to Agnes Finn. Laurie wanted Agnes to retrieve their frozen samples for culture and subtyping just as she was already doing with Laurie's case that morning and Riva's cases. Laurie thought it was important to see how closely they all matched.

Laurie had then made some important phone calls with the numbers Cheryl had gotten for her. First, she called Loraine Newman at the Angels Orthopedic Hospital. Laurie found her as accommodating as both Arnold and Cheryl had described. The woman graciously agreed to a meeting that very afternoon at two-thirty.

Next, Laurie had called a woman at the CDC by the name of Dr. Silvia Salerno, who was associated with the CDC's national library of MRSA strains that had been formed to identify genetic patterns in the subtype, in hopes of influencing prevention and control strategies. In addition, she was part of the CDC's Web-based National Healthcare Safety Network and had been the person to whom Riva had been referred. It was she who had had Riva's isolates subtyped.

“If I am not mistaken, they were a community-acquired MRSA, or what we call CA-MRSA,” Silvia had said when Laurie had asked if she remembered the cases. “Let me look it up. Okay, here it is. CA-MRSA, USA four hundred, MWtwo, SCCmecIV, PVL. Now I remember it very clearly. That is a particularly virulent organism, maybe one of the most virulent we've seen, particularly with the PVL toxin.”

“Do you recall Dr. Mehta mentioning that her two cases came from two separate hospitals?”

“I don't. I assumed it was the same institution.”

“It was definitely two hospitals. Does that surprise you?”

“It suggests the two individuals knew each other or they each knew a third person.”

“Meaning you believe these were not nosocomial infection?”

“Technically, for an infection to be considered nosocomial, the patient has to have been in the hospital for more than forty-eight hours.”

“But that's only a technical definition. I mean, the patients could have gotten them from the hospital.”

“Of course. The definition is more for statistical reasons than scientific, but getting such an infection within twenty-four hours of admission would suggest to me that they were part of the patient's own flora.”

Laurie described her series, all of whose victims had died of MRSA within twenty-four hours and, of those whose subtyping was available, had died of community-acquired MRSA, which Silvia said backed up her contention that the bacteria were most likely brought in by the patients. Regardless, Silvia had specifically said she was interested in the cases and had been surprised not to have heard of the cluster. Offering to help in any way she could, she took Laurie's direct-dial office number, and promised to get back to her after she'd asked around to see if anybody at the CDC had heard about the outbreak. She'd also promised to have a second look at Riva's samples to determine if they were the exact same strain or merely close.

Finally Laurie had called the Joint Commission on Accreditation of Healthcare Organizations. Cheryl had not been able to get her a specific person to talk with, and after Laurie had been switched around numerous times, each time being given the name of someone else who could supposedly help her, she had given up, defeated for the moment by the bureaucratic mind-set.

Arriving at her destination, the taxi pulled up to the curb and stopped, and Laurie handed over the fare and the tip. As she climbed from the cab, she looked up at an impressive, modern high-rise of green-tinted glass held in place by vertical ribs of green granite. The name, Angels Orthopedic Hospital, was inscribed into a pediment-shaped marble lintel over the front doors. A liveried doorman stood on the sidewalk. A sloping driveway led to a receiving dock, a service entrance, and a multistory parking garage in the rear.

The interior was even more impressive. It was more like walking into a Ritz-Carlton than a hospital, exactly as Jack described that morning. The floor was a mixture of hardwood and marble, and the information booth looked like a concierge desk, with two uniformed men sitting side by side in suits and ties. But what caught Laurie's eye more than the décor was the lack of people. There was no hustle and bustle like a normal hospital. Other than the two men at the information booth, there were only two people in the large lounge area sitting opposite each other on opposing, elegantly upholstered couches.

Laurie went up to the information booth and received the full attention of both gentlemen. She asked for Loraine Newman, mentioning her name and that she had an appointment.

“Certainly, ma'am,” one of the men said. He picked up the phone, and after a brief conversation directed Laurie to a pair of interior doors to the left of the bank of elevators. “Miss Newman is waiting for you in administration.”

Laurie followed the directions and pushed through the designated doors. The administration area was more utilitarian than the lounge area but still sumptuous compared to any hospital Laurie had ever been in. It was a wide, long room with glass-enclosed offices on either side, each fronted by individual secretarial desks. Most all the desks were occupied, but it didn't appear that much work was being done. Only a few of the secretaries were typing into their monitors, while most were chatting in subdued tones.

One of the secretaries caught sight of Laurie and asked if she could help her, but before Laurie could respond, a glass door to an office opened and an energetic woman wearing a white coat over a brown turtleneck sweater and skirt called out to her. She introduced herself as Loraine Newman before ushering her inside.

“Let me have your coat!” Loraine said. She was Laurie's height and build and even approximate age but had different coloring compared to Laurie's blond complexion. “Please take a seat,” she said, as she placed Laurie's coat on a hanger and hung it inside a small closet.

Laurie sat down, and Loraine went behind her desk and did the same.

“I've never met a medical examiner,” Loraine said with a smile. “I'm awed by what you guys do.”

“We don't get out much,” Laurie said. “Most of our scene work is done by our forensic investigators.” She inwardly winced, recognizing Bingham would surely not appreciate what she was doing.

“How can I help you?” Loraine asked. “I suppose you are here because of yesterday's unfortunate MRSA death.”

“That and more,” Laurie answered. “I did the autopsy on Mr. Jeffries this morning. The extent of his infection was dramatic, to say the least, especially how quickly it consumed him.”

“You have no idea how upset we are, and not only about the tragic loss of a life of an otherwise healthy man but also because it has occurred despite our making maximum effort to prevent it.”

“I heard from one of my colleagues the efforts that you have been making. I imagine it must be discouraging, especially since you have apparently had eleven such cases.”

“
Discouraging
is not a strong enough word. Did you find out anything at autopsy that might help us? When you called, I was hoping that was going to be the case.”

“I'm afraid not,” Laurie admitted.

“Then why did you come over?”

Laurie squirmed in her chair. Although the tone of the question was far from hostile, Laurie found herself questioning exactly why she was compelled to make the visit, and for a moment felt foolish.

“I didn't mean to put you on the spot,” Loraine said, sensing Laurie's discomfiture.

“It's okay,” Laurie said. “After I did the autopsy this morning, I found out essentially by accident about all the other cases occurring over the last three and a half months. I just felt I had to do something. I'm afraid the OCME has let you and the rest of the city down by not being aware of the outbreak. It's part of our job not to let something like this fall through the cracks.”

“I appreciate your sense of responsibility, but in this case I don't think it matters. We certainly have been aware, and believe me, we have done everything possible. And when I say everything, I mean everything, including the hiring of a full-time infection-control professional. And as the chairperson of this hospital's interdepartmental infection-control committee, I personally jumped on the problem from day one. We've had input from everyone, including our medical staff, nursing, engineering, laboratory, you name it. Our committee has met just about every other week since the first MRSA case. We even shut down our ORs for a time and halted all surgery and invasive procedures.”

“So I heard,” Laurie said. “I don't have much training in epidemiology, but there are several things about this outbreak that bother me.”

“Such as?”

Laurie took a moment to organize her thoughts. She was afraid she might sound naïve, since she truly only had the basics in epidemiology. “For one thing, it has continued despite all your efforts at control; secondly, many of them are, like Jeffries, primary pneumonias, which I believe is unique for staph; third, they have apparently been occurring in only Angels Healthcare facilities. You do know that your sister hospitals are experiencing cases as well?”

“Of course. I've had multiple meetings and frequent communication with my counterparts at our heart hospital and at our cosmetic surgery and eye hospital. I was also the one who strongly encouraged Angels Healthcare's CEO, Dr. Angela Dawson, to hire the M.D./Ph.D. infection-control professional to coordinate our efforts, specifically because the problem was happening in all three of our institutions.”

“Is that Dr. Cynthia Sarpoulus?”

“That's correct. Why do you ask?”

“I recall one of my ME colleagues mentioning her name. He spoke to her a month or so ago.”

“She's one of the leaders in our specialty, and coauthored a major text on hospital-infection control programs. I was sure that, when I heard she'd been hired, we'd be out of the woods.”

“But it hasn't happened.”

“It hasn't happened,” Loraine agreed.

“Well, back to my amateur concerns,” Laurie said.

“I'd hardly call you an amateur, doctor,” Loraine said with a smile. “Please, continue!”