Error in Diagnosis (3 page)

DECEMBER EIGHTH

The Island of Nevis, West Indies

NUMBER OF CASES: 823

Dr. Jack Wyatt's plan to spend a relaxing week at a plush Caribbean hideaway had fallen well short of his expectations. After a punishing two-hour tennis lesson with a fanatic pro, he limped back to his oceanfront casita. Dumping his gear on the floor, he resisted the temptation to collapse on the canopied four-poster bed in favor of watching another spectacular sunset.

With one brief stop to pluck a chilled imported beer from the refrigerator, he made his way out onto the veranda and flopped into a wicker love seat. With his angular legs outstretched and the fading warmth of the
afternoon sun on his freckled arms and shoulders, he gazed out to sea. A couple hundred yards from the beach, two WaveRunners with their engines whining sliced across the water in tandem.

Since his divorce nine months earlier, Jack had done little to kick-start a new social life. It had been a process, but he finally admitted to himself that his wife had stopped loving him long before she'd asked him to move out. The ink had barely dried on their divorce decree when she packed up her belongings and their daughter and moved to France, where she had been born and raised. He never pined for her, but he missed Nicole terribly.

He had never given serious thought to vacationing alone, and it was only at the insistence of a few concerned friends that he needed some time off that he finally caved in and booked the trip. Unfortunately, the change of surroundings did little to improve his emotional indifference.

A few days after he arrived, he gave serious consideration to cutting his vacation short and returning to Columbus. But his grueling schedule of teaching and patient care as chief of neurology at the medical school left him precious little time off. In spite of the disappointment with his vacation, the meager two weeks he could manage each year were far too precious to give up.

It wasn't long before the rigors of his tennis lesson, the premium beer and the light tropical wind levied their full effect. With the droning of the WaveRunners disappearing to the north, Jack closed his eyes and yielded to the inevitable.

It wasn't more than a few minutes later, when the shrill alert of his phone snapped his eyes open, that his tranquil nap came to an abrupt end.

“Hello,” he muttered, assuming it was the concierge confirming his dinner reservation.

“Jack. It's Mike. I'm sorry to bother you on vacation but something's happened to Tess.” Jack pulled his legs in and shook the fuzz from his head. “She's pretty sick. The doctors put her in the intensive care unit at Southeastern State.”

Jack was unaccustomed to the trepidation in his best friend's voice. Having grown up in Fort Lauderdale across the street from each other, Jack and Mike had been inseparable from their first day of kindergarten until high school graduation in spite of diametrically opposed personalities. Even though they had attended different colleges, time and distance had done nothing to erode their friendship. They spoke frequently and still shared an inviolate golf trip to Arizona every September.

“Was she in an accident?” he asked Mike with a mixture of alarm and uncertainty.

“No, nothing like that. I got a call yesterday that she had passed out during her spinning class. Her instructor called nine-one-one and the paramedics took her to Southeastern State.”

“Is she still unconscious?”

“No . . . not exactly. I . . . I guess you'd call it more like a daze. Her eyes were going crazy, so they called in a specialist. As soon as he saw her, he had her admitted to the intensive care unit.”

“Is the baby okay?”

“They told me she's okay . . . but I'm not sure anybody . . .” Mike paused for a few moments. “I need you to come up here, buddy. I'm scared shitless. I guess I didn't realize how bad things were until a few hours ago. The ICU doctor told me she's . . . she's not sure Tess is going to make it.”

“I'll call the airlines as soon as we get off the phone,” Jack said, pushing his sunglasses atop his head. “I'll be there tomorrow.”

“Don't bother calling the airlines. I'll fly down tomorrow and get you. Just come to the general aviation center at the Saint Kitts airport at around ten.”

“Has Tess had an MRI or CT scan of her head?”

“Both,” he answered. “Look, I'm calling from Dr. Helen Morales's office. She's the dean of the medical school. She can fill you in a lot better than I can.”

Although they had never met, Jack recognized the name immediately. Helen Morales was a trained radiologist but for the past fifteen years, she had been a nationally recognized innovator in medical education. Two years ago, she had left her position at Dartmouth to become dean of Southeastern State University's medical school.

It wasn't hard for Jack to connect the dots why Mike was calling from her office. In addition to Tess and Mike being alumni of Southeastern State, they both had an undying passion for philanthropy. Mike was a dorm-to-empire techno-genius. By the time he was thirty, he had made his fortune designing and producing video games. Last year he had been named to Southeastern State
University's board of trustees. Soon after the appointment, he pledged five million dollars toward construction of the new business school, an architectural marvel that would bear his name.

“Dr. Wyatt?” came a pleasant voice. “This is Helen Morales. Let me begin by adding my apology to Mike's for disturbing you on vacation, but we're all very concerned about Tess.”

“Mike and Tess are family, Dr. Morales. You're not disturbing me.”

“He obviously feels the same way about you. As Mike mentioned, Tess was brought to ER early yesterday morning with a major alteration in her mental status. We ran two complete urine and blood toxicology panels thinking she might have accidentally ingested something, but they were completely negative. She's had both an MRI and a CT scan of her brain, both of which were normal.” Even as she spoke, Jack was racking his brain trying to recall any neurologic illness that fit Tess's symptoms. “So, as you can see, in spite of a rather extensive evaluation, we don't have a diagnosis.”

Jack was well aware that Dr. Morales's call was a courtesy briefing only. Being a family friend and not a treating physician, he was mindful not to step across the line of professional ethics by making any suggestions regarding Tess's care.

“It certainly sounds like you've done everything by the book,” he told her.

“Coming from a neurologist of your preeminence, I'll take that as a compliment. All of us here are quite familiar
with your outstanding work on elusive neurologic diagnoses. Your book chapters and scientific publications are required reading for our neurology residents.”

“That's kind of you to say.”

“As I'm sure you're aware, we consider Tess and Mike extremely important members of the Southeastern State family. When Mike mentioned to me that you two were extremely close friends . . . well, I encouraged him to call you. I understand your main reason for coming here tomorrow is to support Mike, but I was hoping I might be able to persuade you to make your visit a little more formal. I'd like to extend you an invitation to serve as a visiting professor of neurology at Southeastern State. That way you'd be able to formally consult on Tess's case.”

Jack was quite familiar with visiting professorships. It was a common practice amongst medical schools to invite faculty members of other schools to spend time with their residents and students in order to expose them to different medical insights and perspectives. Over the years, Jack had been invited to serve as a guest professor on many occasions. His schedule permitting, he always accepted. But Dr. Morales's invitation was a bit different. Serving as a guest professor at Southeastern State would directly involve him in the care of his closest friend's wife, which was a touchy situation at best and one fraught with a host of potential problems. But his concerns paled in comparison to his friendship with Mike, which meant that turning down Helen Morales's invitation was not an option.

“I would be happy to accept your invitation,” he said.

“That's excellent, Jack. I'll make sure the staff's prepared to familiarize you with the details of Tess's hospitalization as well as with the other cases.”

A little puzzled by Helen's comment, he inquired, “The other cases?”

“We've admitted several other women with the exact same symptoms as Tess. Our information's still pretty sketchy, but it seems there are numerous other hospitals in the country which are also treating women with the same illness.”

Planting his bare feet firmly on the teak deck, Jack stopped the love seat from rocking. He stroked the three-day stubble that roofed his straight jaw and said, “You'll have to excuse me but I've been cut off from the world for the past few days.”

“Specific details of the illness haven't been widely publicized as yet, but I'm sure it won't be long until the media gets wind of things.”

“I suspect I'm repeating what the physicians at Southeastern State have already suggested, but if there are multiple patients with the same symptoms, wouldn't the diagnosis be more likely a contagious disease rather than a primarily neurologic one?”

“That's exactly what we thought at first, but that doesn't seem to be the case. Hopefully, you'll be able to help us figure this out,” Helen responded.

“I'll be happy to help in any way I can,” he said. “I should give Dean Hutchins at Ohio State a call just to let him know that—”

“I hope you won't consider it too presumptuous of
me, but I already called Hutch to make sure he'd have no objection. Fortunately, there have been no reported cases in Ohio or I'm sure he would have already summoned you back. He asked me to tell you to stay as long as we need you.” Jack thought to himself that there weren't too many people in the country who called Eric Hutching, the venerable dean of the Ohio State University College of Medicine, Hutch. “Mike would like to speak with you again. I'll put him back on. I look forward to meeting you tomorrow.”

Jack stood up and walked over to the railing where he spent the next ten minutes trying to calm his friend down. Mike had a litany of questions, very few of which Jack was able to answer with any authority or certainty. Nobody was more aware than he that patience was not one of Mike Ryan's virtues. Regrettably, at the moment his need for answers that simply weren't there stoked the fires of his frustration.

Watching as the last bit of daylight dissolved into the temperate night, Jack made the short walk to the beach. He strolled along the water's edge, staring at a massive freighter steaming to the south with its running lights flickering off the water. Taking a few steps back, he reached dry sand. He thought about Tess. Ever since Mike had started dating her in high school, she and Jack had been close friends. She was one of the most even-tempered, caring people he'd ever met. She was as devoted to Mike as he was to her. As innovative as he was, she founded a company that specialized in event planning for major children's charities. The corner of his mouth creased into
a hint of a smile when he thought about how often he had kidded Mike that he was lucky he'd met Tess first.

Trying to make sense out of everything Helen Morales had said, he sat down and pulled his knees up to his chest. With a growing sense of trepidation regarding the days to come, he continued to watch the huge freighter until it dwindled to a speck on the horizon and then finally vanished into the darkness.

In spite of his efforts to force it from his mind, he was left with one chilling thought. Even if the cause of this strange new disease could be discovered, there were no guarantees it could be cured.

DECEMBER NINTH

James S. Brady Press Briefing Room,
the White House

NUMBER OF CASES: 1,265

With a measure of reluctance, Dr. Renatta Brickell approached the lectern for her nine
A.M.
press briefing. Ill at ease in front of a microphone, the surgeon general tightened her fist around the gold butterfly charm her father had given her for luck the day she'd graduated from medical school. She had never held a press conference in the White House, nor to the best of her knowledge had any of her predecessors. It was at the suggestion of the president, Kellar, that the briefing take place there.
Renatta waited a few seconds for the last of the journalists and other media correspondents to find their seats.

“Ladies and gentleman, before I take your questions, I have a brief statement,” she began with her signature smile conspicuously absent. “I'd like to summarize what we know to this point regarding the outbreak. Beginning approximately two days ago, a large group of otherwise healthy women began contracting a severe illness. The disease attacks the nervous system and, to the best of our knowledge, has never been seen before. What is particularly disturbing is that all of the women are at least twelve weeks pregnant. The disease has been identified in twenty-two states across the country.” She paused briefly to pull the microphone a few inches closer to her lips. “We are calling this illness GNS, which is an acronym for Gestational Neuropathic Syndrome.” She flipped her legal pad back to the first page and looked up. “That concludes my statement. I'll be happy to take your questions.” The room was filled with a sudden flurry of hands. Brickell had a good idea which reporters had an argumentative, bulldog style. At least for the first few minutes, she would intentionally avoid recognizing them. Scanning the audience for a few seconds, she pointed at a wiry man wearing a sweat-stained white dress shirt seated in the front row. “I'll begin with Ben Halpern from the AP.”

“Have there been any deaths to either the mothers or their babies?”

“None that have been officially reported.”

“What about brain damage or other permanent injuries?”

“We have no way of knowing for sure, but considering the impaired mental status of these patients . . . well, frankly, it would be impossible to completely rule out the possibility.” An instant murmur filled the room. Brickell raised her hand. “I would, however, like to point out that the consensus amongst our perinatologists is that the babies are stable.”

“Have you been able to determine for certain if the fetuses are suffering from the disease—or is it only affecting the mothers?”

“Unfortunately, at this point, we have not been able to determine that.”

Brickell next recognized Melinda Casey, a health care analyst for C-SPAN.

“In his remarks earlier today, the president said he considers this disease to be a significant threat to the public health of this country and that he would make every conceivable resource available to find the cause and a treatment. Can you provide us with some of the specifics?”

“Of course. The Centers for Disease Control in Atlanta has been working around the clock investigating this outbreak. Hundreds of physicians and medical researchers have been assembled from a wide variety of specialties to participate in the GNS project. A select group will be part of a presidential task force. The most up-to-date equipment and support services have been placed at their fingertips. With over a thousand women already affected, I expect this investigation will become as comprehensive and far-reaching as any medical inquiry the Centers for Disease Control has ever embarked upon.”

“Has there been any progress at all with respect to finding the cause?” Casey asked.

“Not so far, but we are pursuing any and all plausible leads.”

Not wanting to entertain any further follow-up questions from Casey, Brickell hastily shifted her eyes to the opposite side of the room. She gestured at John Versellie, from the
Boston Globe
.

In a high-pitched voice, he inquired, “Do you have any idea at all how the disease is being transmitted?”

“Not at this time.”

“According to the information released by your office, many of these women are in their final trimester, yet none of them has gone into labor or delivered. Can you tell us why?”

“The simple answer to your question is, no, I can't. What we do know is that none of our patients is beyond thirty-two weeks, which means none has reached her expected delivery date. Another possibility is the disease itself may be delaying the onset of labor. We know that certain neurologic conditions such as multiple sclerosis and spinal cord injuries can do that.” Versellie again raised his notepad, but instead of recognizing him, Brickell said, “In anticipation of your next question, John, we don't know why women in their final few weeks or those in their first trimester seem to be immune to GNS.”

Brickell next called upon Maggie Fitzsimmons from MSNBC, a physician who had resigned from her internal medicine residency at the University of Miami five years earlier to pursue a career as a medical correspondent.

“Generally, a baby born at thirty-two weeks would have an excellent chance of survival. Has any consideration been given to either inducing labor or performing a cesarean section to see if ending the pregnancy will cure the illness?”

“Yes, we have considered that possibility. The problem is that delivering these babies could be extremely dangerous and perhaps even fatal to both mother and baby. The stress of labor and the administration of anesthetic drugs are all unknowns in patients with GNS. The other issue is that these infants might be highly contagious and even using the most sophisticated isolation techniques, they might represent an enormous risk to other infants and their caretakers.”

“If it is determined that ending the pregnancy will halt the disease, will President Kellar address the possibility of recommending termination for those women whose babies are too premature to be delivered?”

“I don't speak for the president, but as a rule, the chief executive doesn't make medical recommendations.”

“But wouldn't the president and his administration consider this more of a moral question than a medical one?”

Brickell raised her hand above the murmur.

“Ladies and gentlemen, we have a serious problem on our hands. For the moment, our goal is to quickly isolate the cause of GNS and to formulate an effective treatment plan that will lead to a cure. That's what we all need to stay focused on.”

As Dr. Brickell expected, the reporters were relentless,
and for the next thirty minutes she continued to field one difficult question after another. Finally, she leaned forward and placed her hands on either side of the lectern. Her eyes found a persistent young man who had moved into the aisle. With a nod and a gesture, she recognized Tony Williamson, a new correspondent from Reuters whom she had met at her last press conference. It was immediately obvious to her then that whatever he lacked in experience he more than made up for with his instincts and talent.

“With an epidemic of this magnitude has the president given any consideration to—”

“Excuse me for interrupting, Tony, but GNS is not an epidemic. An epidemic, by definition, is a dramatic rise in the expected number of cases of an established disease with a known epidemiological history. Since GNS has never been seen before, this present situation can't technically be classified as an epidemic.”

Regarding Brickell through unconvinced eyes, Williamson said nothing for the moment. It wasn't hard for her to read his thoughts. Her comment was evasive, making her look as if she were sidestepping a tough question by providing a piece of information that was true but at the same time totally irrelevant.

After a forced smile and a slow nod, Williamson renewed his question, “Irrespective of what we call this . . . this outbreak, the fact remains our nation's facing a disease that's spreading to the tune of roughly five hundred new cases a day. Can you give us some sense of what the CDC and our other key government health care agencies are
recommending to thousands of pregnant women and their families who are becoming increasingly more terrified with each passing day?”

Brickell wasn't surprised by the question. Before she'd even walked up to the lectern, she'd expected someone would ask it. She took a few seconds to gather her thoughts before responding.

“We are working closely with local, state and national medical societies, public health organizations and physician groups to help us educate and inform all pregnant women and those who are considering becoming pregnant of the present situation. We've created a telephone hotline and an interactive website for doctors. I assure you, we are critically aware of the rising anxiety across the country. But until we have more specific information about this illness, it would be irresponsible of us to make any recommendations beyond general cautionary measures.”

Brickell glanced to the side of the room. Urging her to wrap things up, Julian Christakis gave her his most subtle
cut
sign.

“I have time for one more question,” she said. Before she could recognize anybody, an uninvited voice asked, “Is there any possibility GNS is an act of biological terrorism?”

Her eyes found the young woman in the center of the room who had asked the question. Brickell had no clue who she was, but she didn't feel she could use her refusal to follow proper protocol as a way of dismissing the extremely valid question.

“All possibilities will be carefully evaluated,” she
answered cautiously. “But at this time, we have no evidence that GNS is the result of a biological weapon.” Brickell took two short steps backward. “I'm sorry. I'm going to have to stop here. I encourage all of you to refer to our website for the exact date and time of our next briefing.”

She turned away from the lectern, and with Julian in tow, she quick-walked out of the briefing room.

“Excellent job,” he told her. “Especially that last question.”

“Excuse me?”

“Your responses were honest and on point. I'm sure they helped to diminish the anxiety of an impending crisis.”

Brickell was well aware that part of Julian's job was to contain prickly situations and curry favor with her regardless of how difficult the situation seemed. But today, his fairy-tale optimism was over the top.

“Julian, we're dealing with a potentially devastating disease that's spreading out of control. To make matters worse, it's selectively attacking pregnant women, one of any society's most vulnerable groups.” She looked at him as if he should know better. “What did you call it—‘an impending crisis'? This crisis is hardly impending. It has a large gray fin, is finished circling, and just about ready to bite us all on the ass.”

“I understand, Dr. Brickell but we—”

She waved her hand, which prompted his immediate silence.

“This is an enormous problem, which isn't going to
go away by simply sprinkling a little pixie dust on it. It's probably only a matter of days, maybe hours until we start seeing fatalities. Americans are a resilient people, but I don't think they're ready to see helpless pregnant women and unborn babies die.”

Just at that moment, a young man tapped on the door. Julian waved him forward.

“I have a message for Dr. Brickell.”

Julian took the note and handed it to her.

“We haven't even begun to hear the outcry from the conservative and religious organizations,” she said, unfolding the note. “Every government agency having anything remotely to do with health care is being barraged with thousands of frantic calls. Families are desperately looking for answers, and our only response is to tell them to remain calm and give us more time. And in case you didn't get the memo, Christmas is three weeks away, so the timing of this disaster couldn't be worse.” She shook her head as she read the note. “Great,” she muttered, crumpling it in hand. “C'mon, we have to get back to the office. We have a lot of prep work to do.”

“What's going on?”

“The president's cutting his trip short. He arrives at Andrews at seven forty-five tonight. He wants to meet with us at soon as he gets to the White House.”

Leading the way out of the room, Brickell wondered what new information she could gather in the next ten hours that might help her respond to the tough questions President Kellar was sure to pose. At the moment,
the only thing she could tell him was that if the task force she'd assembled didn't figure out how to stop this outbreak pretty damn soon, they would have to brace for what would likely be the worst national health crisis since HIV.