Critical (20 page)

“That's the condensate pan down there,” Loraine shouted, while pointing over Laurie's shoulder to the base of the machine's innards.

Laurie nodded. She was interested because she knew air-conditioning condensate pans were a frequent source of airborne outbreaks, such as Legionnaires' disease. She turned her head downstream into the mouth of the efferent duct, where she could see a mesh screen. “Is that a filter?” Laurie yelled.

“There are two,” Loraine answered. She closed the door to the coils, and it snapped shut. She took several steps forward. There were two vertical slitlike openings. She pointed to the two of them with both index fingers. “The first is a standard filter for relatively large-sized particles. The second is a HEPA filter for particles down to the size of viruses. And to anticipate a question, we have on multiple occasions tested the HEPA filters for staph. Only twice did we get a positive result.”

“Was it CA-MRSA?” Laurie questioned.

“It was, but it was not meaningful.”

“Why?”

“Because the HEPA filter stopped it.”

“What's that access door beyond the HEPA filter?”

“That's the clean-out port of the efferent duct. We have all the ducting cleaned once a year.”

After about six feet, the efferent duct split like the tentacles of a squid into multiple smaller ducts, each going to a separate OR, the PACU, and surgical lounge. Laurie could tell because each was labeled with an incised Formica plaque. Same as the main duct, each had a clean-out port. “When were the ducts cleaned last?”

“When the ORs were shut down.”

Laurie nodded. Looking down toward the end of the walkway between the equipment, she saw another door. “Where does that door lead?”

“Another HVAC room, pretty much the same as this one except that it also houses our electrical generators. Beyond that is a doorway into a vestibule with a pair of service elevators and a back stairwell.”

Laurie nodded again, and then walked back to the other side of the air handler that served the ORs. Similar to the efferent side, there was a clean-out port for cleaning the return duct. She then looked back at Loraine and shrugged her shoulders. “I can't think of any more questions. It's a very impressive system. And thanks for the lecture on air handlers. You seem to know your stuff.”

“Part of our training in hospital infection control included learning more than we wanted to know about heating and ventilation,” Loraine yelled. She then pointed back the way they'd come.

As soon as the heavy insulated door closed behind the women, the silence of the seemingly empty hospital enveloped them like an invisible blanket. Laurie tried to fix her hair, which at the moment gave her the appearance she'd been out riding in a convertible.

“I'd like to see a patient room,” Laurie said. “Provided you have the time. I don't want to monopolize your afternoon.”

“With as few patients as we have currently, I certainly have the time.”

“How about David Jeffries's room.”

“I think it's being thoroughly cleaned. We can look in, but I'm sure housekeeping will be there.”

“Then another room will be fine.”

Five minutes later, Laurie stood in one of the standard rooms. In keeping with the five-star hotel décor in the lounge area, the room was equivalently decorated and furnished. The bed and the rest of the furniture were hardly the usual hospital issue. The television was a flat-screen model, which was set up without extra charge to have blue-ribbon cable service as well as Internet access. There was even an upholstered couch that unfolded into a bed in case a family member wanted to stay over. But what impressed Laurie the most was the bathroom. “Oh, my goodness,” she said as she glanced in. It was done in marble and had a second flat-screen TV. “Do you have trouble getting some patients to leave?”

“It's far better than my bathroom. I can assure you of that.”

With no specific reason to visit the room, Laurie made a mild show of inspecting the position of the vents in the room for the HVAC system. There were several high near the ceiling and several low near the baseboard. It was the same in the bathroom.

“I guess that's it,” Laurie said.

“Any other part of the hospital you'd like to see?”

“Well…” Laurie said hesitantly. Having had her rather vague but pet theory that the MRSA victims were being infected in the OR trashed by a combination of the presence of the HEPA filter and even more so by learning the patients undergoing general anesthesia never breathed ambient air, Laurie was convinced her site visit was a complete bust from the standpoint of solving the mystery of the MRSA outbreak. She certainly hated wasting any more of Loraine's time, even though the woman was graciously accommodating, even to the point of seeming to enjoy giving the tour. Laurie could tell she was proud of the institution.

“You are not keeping me from anything,” Loraine said, guessing the reason for Laurie's hesitation.

“If that's the case, then I suppose I wouldn't mind seeing the OR area, particularly one of the ORs itself.”

“We'll have to change into scrubs.”

“I do it every day.”

As they retraced their steps back toward the elevators, Laurie noticed the paintings lining the walls were real oils and not prints. While they waited for an elevator, Laurie glanced at the nearby nursing station. Behind it was a bank of high-tech flat-screen monitors, enough to serve every room. All were dark. Four nurses and an orderly were relaxing at the station: Three were in desk chairs, the other two sitting on the desk itself. There was intermittent laughter.

“They are acting as if there are no patients on this floor,” Laurie said.

“There aren't,” Loraine responded. “That's why I brought you here.”

“Knowing how expensive it is to run hospitals, I'd hazard that the CFO, whoever he or she is, must be sweating bullets.”

“That I don't know. Luckily, it is not my responsibility, and I don't often talk with the bigwigs.”

“Has anyone lost their job?”

“I don't believe so. A number of people have taken a voluntary leave of absence, but the administration is counting on the low census turning around immediately. Our ORs are all back online.”

“Except the OR David Jeffries was operated on in.”

“It wasn't open for today while it's being thoroughly cleaned, but it will be open tomorrow.”

Laurie was tempted to ask if the morrow's patients scheduled for that particular OR would be told of David Jeffries's fatal experience, but she didn't. It would have been a provocative question, to which Laurie already knew the answer. Too often, patients were denied information that they had the right to know if the concept of informed consent was to be truly honest.

The décor of the OR floor and the OR suite itself, except for the doctors' lounge, looked to Laurie as she expected a NASA building to look: aseptically functional. It was also like the hall above: all white, with the same composite floor. The walls, however, were tile. In contrast, the doctors' lounge was mostly soothing green, and also in contrast to the rest of the hospital, there was a lot of activity in the OR area, because the day shift was leaving and the evening shift arriving.

The women's locker room was equally lively. Loraine gave Laurie a set of scrubs and directed her to a locker. While both women changed, Laurie overheard a short conversation Loraine had with an acquaintance who was going off duty. Loraine asked her if there'd been many cases that morning.

“It was slim pickings,” the woman said. “I'm afraid everyone is getting a bit bored with all the sitting around. We were only running two out of the five rooms.”

Five minutes later, Laurie and Loraine pushed into the OR and the double doors swung closed behind them, cutting off the chatter from the surgical lounge.

To Laurie's left was a blank OR scheduling blackboard, which suggested there were no cases under way. To Laurie's right was the OR desk, fronted by a chest-high countertop, behind which Laurie could see just the tops of two hooded heads. Beyond the OR desk was the open doorway into the PACU. The central corridor stretched out approximately eighty feet to a far wall.

Loraine advanced to the desk, and the two women seated behind looked up. “Dr. Sarpoulus!” Loraine said. She was surprised to see her infection-control superior. “I didn't know you were here.”

“Is there some reason you should know?” Cynthia questioned, with an edge to her voice.

“Well, no, I suppose not,” Loraine responded. She switched her attention to the other woman, whose nametag read:
Mrs. Fran Gonzales, OR Supervisor.
“Fran, I have a guest here who wanted to take a peek at our OR.” Loraine motioned for Laurie to step up to the counter, and Loraine introduced her as a New York City medical examiner.

Before Fran could respond, Cynthia's head popped back up. She'd returned to studying the OR scheduling log, which she and Fran had been busily doing before Laurie and Loraine had appeared. “You are a medical examiner?” she questioned, with even more edge to her voice than when she'd spoken with Loraine.

“I am,” Laurie confirmed.

“What the hell are you doing here?”

“I'm ah…” Laurie began, but hesitated. She was taken aback by Cynthia's tone and challenging glare. Laurie couldn't help but remember Arnold's description of the woman as not being terribly cooperative, as well as defensive, and essentially telling him to butt out. The last thing Laurie wanted was some sort of a confrontation, knowing she was, to a certain extent, overstepping her bounds by making the site visit. Steve Mariott, the evening PA, had visited the hospital the night before, after Jeffries's death had been called into the OCME.

“Well?” Cynthia questioned impatiently.

“I autopsied a case this morning of a patient who'd been operated on yesterday here at Angels Orthopedic Hospital and who had died of an exceptionally aggressive MRSA infection.”

“We are well aware of that, thank you very much,” Cynthia snapped.

Laurie glanced briefly at Loraine, who appeared as surprised as Laurie. “When I canvassed my colleagues, I discovered you'd had a number of similar cases. I thought it was appropriate to come over here, and see if I could help.”

Cynthia laughed cynically. “And just how did you think you could help? Have you been trained in epidemiology, infection control, or even in infectious diseases?”

“My training is in forensic pathology,” Laurie said defensively. “My exposure to epidemiology has not been extensive, but my understanding is that in an outbreak of this sort, one of the first things that should be done is to accurately subtype the organisms.”

“I'm board-certified in internal medicine with a subspecialty in infectious diseases and have a Ph.D. in epidemiology. As far as your comment about subtyping, you are correct but only if such information is needed to decide on a targeted method of control. In our situation, it wasn't needed, since our CEO insisted that we use a global control strategy. Our interest was not in saving money by restricting ourselves to a target approach. I spoke with one of your colleagues a number of weeks ago after he'd autopsied one of our MRSA cases. I assured him we were well aware of the problem and aggressively engaged in solving it, and thanked him for the call.”

“That's all well and good,” Laurie said, with her own dander rising. “Having had the dubious honor to autopsy the unfortunate individual this morning, I can say with some conviction that you have been unsuccessful in your control efforts.”

“That might be the case, but we surely don't need interference. Your job is to tell us cause of death and anything else we might not know pathologically. The fact of the matter is that we are well aware of both the cause and mechanism of death, and we are doing everything humanly possible to control this unfortunate outbreak. What is it you wish to accomplish by visiting the operating room? What do you want to see?”

“To be totally honest, I don't know,” Laurie said. “But I can assure you that there have been thousands of times that site visits have either helped or been crucial in a forensic investigation. Mr. Jeffries is officially a medical examiner's case, and I am duty-bound to investigate it fully, which in this case means viewing the scene of his proximate cause of death. Odds are, he was exposed to the bacteria that led to his demise in the operating room where he'd had his surgery.”

“We'll see about that,” Cynthia said, getting to her feet. “I'll have you talk with someone with considerably more authority than I. I insist you wait outside in the surgical lounge. I will be right back.”

Without another word or even a glance over her shoulder, Cynthia walked quickly to the double doors and departed.

Laurie and Loraine exchanged another surprised and confused glance.

“I'm sorry,” Loraine said. “I don't know what's come over her.”

“It's certainly not your fault.”

“She is under a lot of pressure,” Fran, the OR supervisor, said. “She's been intense from the first, and it's only gotten worse. She's taking the whole problem very personally, so try not to do so yourself, Dr. Montgomery. She's even been at my throat on occasion.”