Death Benefit (34 page)

Suddenly Pia turned back around. “You know what we know the most about?”

George shrugged.

“We know the most about Rothman and Yamamoto’s illness even without the autopsy results and even without seeing their charts. I was in the lab when it presented, I saw them in the hospital, I talked to the doctor who was treating them, I examined Rothman myself, I diagnosed new symptoms, I spoke with the department head involved.”

“Good, yes,” George said. They had gone over all this before but under the circumstances, George was happy to do it again. Pia tore the sheets she had written on off her legal pad, crumpled them into a ball, and threw the ball in the general direction of the trash basket. She missed. Pia began writing again, more slowly this time.

“Okay,” she said while she worked. “We do have a timeline of the infection. The onset was extremely rapid. Rothman or Yamamoto pressed the panic button and there was a medical team in the lab almost at once. I saw them arrive. Rothman and Yamamoto knew what to look out for, so from the first symptom to the medical team arriving may have been only ten minutes, at the outside. Springer showed up, and he went into the lab. Then he stayed and talked to the staff while Rothman and Yamamoto were taken directly up to the infectious disease floor and put in isolation, and treatment was started. I’d say they were there in five or six minutes. And Springer told us it was classic typhoid fever—high temperature, delirium, and so on, so it was diagnosed immediately. No delays. They got antibiotics within an hour of the initial symptoms.”

Pia had the pad on her knee.

“So Rothman and Yamamoto got all the symptoms straight off. It apparently wasn’t the usual sequence where a patient gets one symptom initially and then another a few hours later. It happened like a bolt of lightning. As far as I know, that’s not the way typhoid fever develops. Then the patients got the more ominous rebound tenderness by that evening. It’s all so speeded up.”

“You said this was a particularly virulent strain,” George said.

“True. One of the zero-gravity strains. The alpha strain. But still.”

“And you also said that Rothman’s own sensitivity studies suggested that the strain should have been knocked out by the antibiotic he was given.”

“That’s right, the chloramphenicol and later the ceftriaxone.”

“So what are you saying? Are you suggesting that it can’t have been that strain of salmonella?”

“No, I’m not. The strain had to be involved since Koch’s postulates were satisfied.”

“Meaning that they managed to grow the culture from samples taken from the patient.”

“Or by using more modern DNA techniques, yes.”

“Pia,” George complained, “you’re confusing me. What’s the bottom line here? What are you trying to say?”

“I suggested to Springer that there might be a second bacteria involved, a bacteria or a virus that was actually more virulent than the salmonella typhi and that was resistant to the antibiotics. It could explain the shockingly fast clinical course Rothman and Yamamoto experienced.”

“What was Springer’s reaction to your suggestion?”

“He went bonkers on me,” Pia said with disgust. “That was the end of the interview because he went out and called in reinforcements, meaning the dean.”

Pia put down her pad and pen back on the desk.

“So you think there might have been two bacteria involved,” George said.

“Right at this moment that’s the only thing I can think of. The clinical course was just too fast, especially in the face of two antibiotics given within hours of initial symptoms and known to handle salmonella. I know it’s contrary to recognized diagnostic rules, the major one being that one should look for a single causative agent even with seemingly multiple symptoms. But it’s the only way I can explain what we’ve seen with Rothman and Yamamoto.”

She turned back to her desk and read from her notes.

“We have all the symptoms right here: fever, delirium, prostration, temperature elevation, sweating, low white cell count known to be associated with salmonella, all leading up to abdominal rebound tenderness. From intestinal perforation and finally death.”

George got up from the bed and headed into the bathroom. Pia was overwhelming him. He was amazed she remembered Koch’s postulates from second-year microbiology. He certainly didn’t. He put some of the ice that was melting in her sink into a fresh towel, rolled it up and brought it to her desk. He exchanged it for the first one he’d made. Pia was staring at the paper, her back to him.

“Here’s some more ice,” he said.

Pia swiveled around in her chair, and George winced when he saw her jaw at such close quarters.

“How’s it feel?”

“It’s not too bad. A bit better with the ice.”

Pia took the fresh towel and held it to her face. An image flashed into her mind: Rothman lying on his deathbed, sweating into his pillow, delirious . . . Suddenly she stared directly up into George’s eyes with a fierce intensity that made George look away.

“The hair loss!” Pia said slowly, with emphasis. “What about the hair loss?”

 

 

P
ia got up from her chair, put the ice-filled towel down on the desk, and started pacing her room, circling George. First he’d been unnerved by the intensity of Pia’s stare when she had her epiphany, whatever it was; now she was stalking around the room like a cat closing in on a mouse.

“What hair loss?” George questioned.

“Rothman’s! Remember I saw there was some hair on his pillow before we found the rebound tenderness.”

“Yes, I remember. You pointed it out to the resident, and, as I remember, she suggested it might have been due to the chloramphenicol.”

“Exactly,” Pia said.

She stood still. “Can I use your computer?” Pia’s laptop was old and slow; the year before George had invested in a new Dell with a much faster processor.

“Sure. Let’s go!” George picked up the wet towel from Pia’s desk and gestured toward her with it. Pia shook her head. George took the towel into the bathroom while Pia changed from her pajama pants into sweats. She also quickly downed more Advil.

Gathering up her notes and heading for the door, Pia paused and looked back. She’d experienced a flash of anxiety. Although her room was where she’d been attacked, she still felt safer there than outside. Her attackers were lurking out there somewhere. Perhaps they really were watching her, as they’d threatened. George sensed her trepidation and put an encouraging hand on Pia’s shoulder and squeezed lightly. They exchanged a reassuring glance. Pia breathed deeply and walked out of the room, shutting off the light as she went.

“Let’s take the stairs,” Pia said, and she and George descended the four flights, walked along the corridor, but then stopped in front of George’s door. Both had the same thought: If they knew about George, they probably knew his room number.

“What do you think?” he asked. It wasn’t crazy to imagine that the two men might have it in their mind to pay George a visit too.

“Now I think we’re being paranoid,” Pia said.

“But as you correctly said, even paranoid people have real enemies. Wait there!” George unlocked the door and pulled it fully open. He and Pia were prepared to flee if anything looked amiss. Nothing did. George entered his room, making sure nothing had been disturbed before throwing open the bathroom door. “All clear,” he said with a sigh of relief.

“Let’s get to work,” Pia said.

George booted up his laptop and checked the wireless signal before giving up his desk chair to Pia. He went and sat on the bed. His room was a mirror image of hers.

Pia quickly went online, typed “hair loss” and “chloramphenicol” into the search engine and scrolled through the results for a few minutes. “There’s nothing that lists hair loss among chloramphenicol’s side effects. Actually, there are some alternative healers who sell chloramphenicol to reverse hair loss. Wow, De Silva was so wrong when she said chloramphenicol might be the cause of the hair loss.”

Pia continued surfing. “Springer attributed it to fever and stress,” she said as she read. “It seems that stress can cause hair loss. But I don’t think it could be involved in this case. I mean Rothman and Yamamoto were certainly being stressed with their fevers and all, but for stress to cause hair loss I think it has to be over a period of months, not hours.”

Pia continued her search. George couldn’t see the screen from his vantage point, but he could see the light flickering on Pia’s face as page after page flashed by. Suddenly there was a steady light, and Pia leaned forward in her chair. “Yeah, here we are. Hair loss and stress. Yup, I was right.” Pia read out loud: “‘Unless the stressed patient is pulling his own hair out, severe stress merely changes the hair follicle from an active state to a resting state. The hair doesn’t fall out immediately but rather over a period of months.’ ”

Pia looked over at George. “Clearly Springer’s suggestion wasn’t much better than De Silva’s.”

“So what are you thinking?”

“Since I’ve never heard of salmonella causing hair loss, we have to think of something else to explain it, bringing us back to the second-agent idea, like another bacteria or a virus. But if there was another microbe involved, it would have to be one whose clinical symptoms mimic typhoid fever because all the other symptoms were consistent with typhoid fever. Are you following me?”

“I think so.”

“I’m saying that we have to come up with an agent that mimics typhoid fever symptomatically but which also causes hair loss and can kill in hours in the presence of chloramphenicol and possibly ceftriaxone. Of course, without access to the charts, I can’t be sure they ever got the ceftriaxone, but for the sake of argument, let’s assume they did.”

“You know what I wish?” Pia said after a few minutes of silence. “I wish that we examined Yamamoto as well as Rothman. Just to be sure he was suffering from the same signs and symptoms.”

“Maybe we can ask Dr. De Silva’s opinion.”

“I don’t think she’s going to want to hear from me. Let’s keep going.”

Pia looked up at the corkboard on the wall behind George’s desk. A business card for a taxi service was tacked next to a picture of George’s mother and grandmother. There was a postcard from Hungary alongside it. Suddenly Pia snapped around again.

“What are the usual causes of hair loss besides what I’ve mentioned?”

“This sounds like internal medicine rounds, which I’d like to forget. That was one venue where I did not shine in the slightest.”

“Come on,” Pia said. “What causes hair loss?”

“Er, hormonal changes, alopecia areata, stress like you said.” Pia motioned for George to come up with more. He thought harder.

“Dermatological diseases of the scalp, particularly cicatricial diseases. Wow, that’s a good one. That’s the kind of response that would have gotten me kudos on rounds. Trouble is I always choked up.”

“What else?” Pia commanded. She waved her hand, indicating she wanted more.

“Okay, certain drugs.”

Pia nodded and looked expectantly at George, as if she knew the answer and was waiting for him to get it. It was like a game of charades.

George became impatient, ready to give up before he remembered something else.

“What about chemotherapy and radiation?” George sounded uncertain. Sure, they caused hair loss, but what could be the relevance?

“Right on!” Pia exclaimed. “Radiation! You saw people undergoing radiation when you were on oncology during internal medicine.”

George nodded.

“Chemotherapy and/or radiation destroys the hair follicles and the hair falls out immediately.”

“What are you getting at?” George noticed that Pia’s face had brightened considerably.

“I said I was wondering if Rothman could have been infected with another bug besides the salmonella, another bug that was not sensitive to chloramphenicol or the third-generation cephalosporin he was given.”

“Right, the ceftriaxone.”

“I suddenly don’t think there was another microbe,” Pia said. “Damn it, George, you said it yourself, remember? You said they had to autopsy the bodies the same day the men died because they were ‘hot.’ I thought at the time it was a strange word to use, but I think you were more right than you knew. I don’t think they were hot because they were full of bacteria. I think they might have been hot because of radiation.”

 

 

L
aurie Montgomery had been sitting in her office at the Office of the Chief Medical Examiner catching up with an old friend, Detective Captain Lou Soldano, when the phone rang. She saw it was her boss, apologized, and took the call. She was soon rolling her eyes, and Lou smiled.

Laurie Montgomery had been back at the OCME for eleven months, since the harrowing events of the infamous Satoshi Machita case, involving both the New York mob and the Japanese Yakuza, which led to the kidnapping of her infant son, John Junior. The story had been plastered all over the media for several days as the details of the case unfolded. After JJ’s rescue, Laurie had come back to work but only after she had found a live-in nanny, Paula, who immediately proved to be a godsend. With Paula looking after JJ, Laurie felt secure. Right now, her husband and fellow ME, Jack Stapleton, was working in the same building, and JJ was safe with Paula at the couple’s home on 106th Street. It didn’t hurt that she and her husband had friends like Detective Captain Lou Soldano either. Right after the kidnapping, he’d insisted on a twenty-four-hour security detail for the Stapleton home.

From Laurie’s side of the conversation and from knowing Laurie’s boss, Dr. Harold Bingham, Lou sensed he’d be in for a wait. He took his copy of the
New York Post
from his briefcase and flipped through it until he saw the story: IVY SPACE GERM DOCS DIE. He quickly reread the first few paragraphs. He had wanted to show the article to Laurie, which was one of the reasons he’d stopped by.