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  Immediately the local public health authorities feared that the virus might have been transported to Hawaii by a human carrier from another outbreak in Asia. But according to the CDC, there’d been no recurrences reported there or anywhere else on the planet since the initial case in Taiwan. “That means the source is probably here,” Julie advised a hastily assembled meeting of her own staff and a half dozen epidemiologists from Honolulu’s medical faculty. “We’ll have to visit every poultry coop in the Kailua district and draw off blood samples from anything that clucks, quacks, or chirps.”

  There were no arguments from anyone at the table, and within hours they mobilized a platoon of technicians and off-duty health care workers to do the job. The subsequent testing revealed that the source of the microbe had been a flock of infected chickens in a small farm next door to where Sandra Arness and Tommy lived. Tommy, they learned later, had sometimes walked over to feed and handle the chicks with his baby-sitter.

  The slaughter of poultry on the island of Oahu began.

  I

  Winter

  Chapter 1

  Thirteen Months Later New York City Hospital

  Dr. Richard Steele found today’s shift his worst ever in ER. Of course, Mondays were always bad compared to the rest of his week. More people arrived in emergency with heart attacks and every other kind of medical crisis on that day—a fact he knew well as a twenty-year veteran and longtime chief of the department. But this Monday’s marathon seemed particularly hard, and all afternoon he felt a step behind.

  One of the nurses slammed down the phone and sprinted toward the resuscitation room. “There’s a pre-code coming—a fifteen-year-old asthmatic!” she yelled over her shoulder the way a quarterback calls a play. Everyone within earshot leaped up to help her get ready, instantly understanding what would be demanded of them. Past an overflow of stretcher patients crammed into the corridor, they scrambled after her, briskly navigating the jumble of IV poles, bags, and lines that hung like webs from the ceiling.

  As he watched them go, Steele knew that not only the protocols for running a respiratory arrest would be flashing automatically into their minds. The patient’s age would pump their adrenaline levels higher than usual. The prospect of losing someone so young always exacerbated the fear of failure in ER. It would be his job to make sure that the extra anxiety didn’t affect his team’s performance. At one time he accepted this added burden as simply another part of his role. These days he found himself dreading it. While his abilities as a resuscitator were as sharp as ever, his people skills had become nonexistent. “Put the MI who’s still in resus near the head of the line!” he called after them, making himself heard above the noise of a department already loud from overcrowding.

  He grabbed the nearest receiver and punched in the numbers for the cardiac care unit. In no time two nurses raced back from the resuscitation room pushing a gurney that bore a frightened-looking elderly woman attached to an armada of portable monitors, intravenous tubes, and a tank of oxygen. By then he’d at least managed to bully the covering cardiologist into giving the woman a bed upstairs, where they could treat her heart attack properly. Years of cost-cutting had made such fights into another of his “routine” duties, but this time the argument left him feeling drained and sweaty.

  A low rumble of protest broke out from those who were also waiting for beds when the nurses wheeled the woman past their convoy of stretchers and parked her at the front. “Christ, it’s warm in here,” he complained in an overloud voice to no one in particular, continuing to scribble his clinical notes in her chart. “Would someone call maintenance again and tell them to turn down the goddamned heat? It’s too bloody hot to work!”

  One of the nearby clerks, already wearing a sweater, gave him a curious glance. The cardiac lady, despite being so sick, skewered her face into an expression of disapproval, pulled her covers up around her neck, and muttered loudly enough for everyone in the nursing station to hear, “I’m lucky to make it out of this zoo before I freeze to death.”

  The ambulance attendants rushed in with a tall adolescent who had blue lips, a gray face, and such respiratory distress that beneath his open shirt the muscles between his ribs sucked inward each time he attempted to breathe. Even though they’d given him oxygen, he kept pulling off the mask, frantically rolling his eyes and straining his head in every direction, the way a man trapped in an airless chamber might cast about trying to find a final puff of breath.

  As Steele followed the stretcher between the rows of patients lining the way, he huddled with his resident. “What’s your immediate course of action here?” he demanded.

  “Albuterol, by aerosol, to dilate his bronchi?” she replied timidly.

  “No! At least not first off. This guy’s bronchi are clamped so tight that he can’t inhale air, let alone medication. What are you going to do about that?”

  “Give him IV steroids?” she said hopefully.

  “Again, later. Right now you’re going to intubate him before he arrests on you.”

  She flushed from the neck of her clinical jacket to the tips of her earlobes. “I’m sorry, Dr. Steele, I knew that. It’s just that you’re making me nervous—”

  “Knowledge at the ready, Doctor, is the best and only antidote around here for being nervous,” he snapped. With a wave at the boy, he added, “And your apologizing for not having that knowledge isn’t exactly going to cut it with him!”

  Her eyes welled up with tears.

  Shit, he thought, what an asshole he’d become! He hadn’t always been so impatient and sarcastic when he taught. The woman on the verge of weeping in front of him appeared young enough to be his daughter, and so far during her rotation she’d proved herself no better or worse than the thousand other novice doctors whom he’d guided through the shoals of ER over the years. With a pang of loss he remembered the heady days when he’d actually adored taking them under his wing and building their confidence. Teacher of the Year, they’d repeatedly voted him before he lost all capacity for the joy of it. Now the phrase made him wince: If any resident had said it of him over the past eighteen months it could only have been in sarcasm. He knew that the sole reason they still put up with him was the skills he could impart. A rotation under his temperamental watch had become known as a trial by fire—a passage to be endured and survived, and then joked about over beer—one of the horror stories that all training programs generate. But causing his charges to cry was a new low, even for him. And if he didn’t make it right with her, she could report him for it. Shit, she probably should, he thought, disgusted with himself. “So how do we do a crash induction?” he asked her a tad more gently.

  “Administer IV midazolam for short-acting sedation, give an antifasciculation dose of pancuronium, then paralyze him with succinylcholine . . .”

  The answers poured out of her now that he’d adopted a less frightening tone. As they hurried into the resuscitation room, he gladly let her talk. The brisk pace left him out of breath. Damn cigarettes, he thought, wondering if he’d ever regain the courage to quit.

  The nurses converged around the teenager, plying him with pressure cuffs, stethoscopes, IV lines, and monitor leads.

  “BP ninety over fifty. Pulse fifty-five.”

  “O-two sat—eighty-seven.”

  “Respirations labored at fifty; minimal air entry at the bases!”

  As they measured his agony by the numbers and the resident ordered the meds she’d rattled off before, Steele moved to the head of the bed.

  The boy’s eyes were blue rims around pupils wide with terror. He attempted to talk, but issued little more than a barely audible squeak.

  “It’s okay, son,” the physician said gently, easily offering the professional comfort he so readily gave to frightened patients but withheld from others around him. With a pang of guilt, he thought of his own child, who was nearly the same age, to whom he’d repeatedly uttered those same words, but never with the conviction that he offered daily to strangers. “We
’re going to sedate you and have you breathing right in no time. Just nod yes or shake your head no to my questions. Is your asthma usually this bad?”

  The youth shook his head. No.

  “Do you use your pumps regularly, the steroids as well as the bronchodilators?” If he’d been properly taught how to administer his medication and manage his problem, Steele knew, he’d understand the distinction. If not, he’d been poorly trained, and poor control would be his norm.

  The youth nodded. Yes!

  Various screens lit up around them, and beeping sounds filled the tiled echo chamber. Oxygen hissed out the side vents of the patient’s large green mask, which the nurses had substituted for the one he’d arrived with. Quick terse orders bounced around the room.

  “. . . get his bloods . . .”

  “. . . do an arterial gas . . .”

  “. . . a portable chest film . . .”

  Through the din Steele thought he heard a small wheezing sound emanating from the boy’s throat each time he breathed in as well as out. His own pulse rocketing, he announced, “He’s also got stridor!” That meant an obstructed upper airway as well as bronchospasm, and a big jump up in the league of trouble they were dealing with. Upper airway obstruction sometimes required a tracheotomy—the act of cutting a hole through the front of the windpipe. Even in the most skilled hands, as an emergency procedure it could be a tricky maneuver. “Were you stung?” Steele demanded, his mind leaping to the most common causes of such a severe reaction.

  No.

  “Do you have food allergies?”

  The boy vigorously nodded.

  “To nuts?” The most common culprit.

  More head bobbing.

  “You ate something with nuts?”

  The boy immediately protested, shaking his head back and forth.

  The trouble with nut allergies, Steele knew, is that people can ingest the allergen unknowingly when it’s ground up and used as flour in baked goods or added in minute pieces to salads or dips. He also knew that it didn’t matter anyway at this point how the nuts got into his patient. Having recognized the possibility of their ingestion, he quickly added a third enemy to the list of what they might be battling— anaphylactic shock, or the vascular collapse unique to an extreme allergic response. A glance at one of the monitors confirmed the teenager’s pressure dropping like a stone. “Give him a half milligram bolus of epi,” he ordered, adrenaline being the drug of choice.

  “I’ve got it!” somebody said.

  “Ready for the intubation,” declared the resident at his shoulder, a laryngoscope in her gloved hands and an array of endotracheal tubes in different sizes spread out on a tray beside her.

  Steele found himself giving her full credit for being willing to step up and attempt the job despite his abysmal treatment of her. Feeling even more ashamed of himself, he told her quietly, “Good for you, Doctor.”

  In no time the medication she’d ordered took hold, and with a few twitches, the boy fell paralyzed from head to toe. The resident easily scissored his slack jaw open with her fingers. “Oh, my God, look at this!” she exclaimed while sliding the illuminated blade down the side of a tongue swollen as big as a Polish sausage.

  Steele watched intently from behind, ready to move in at the slightest sign of a problem.

  “And the pharyngeal walls are edematous as well,” she reported, pushing the tip of the light through the swells of pink mucous membranes that kept bulging around her instrument and obscuring her view.

  “Pulse fifty. Pressure sixty-five over forty,” intoned the nurse who’d taken charge of recording the boy’s vitals.

  Everyone in the room knew that the slowing heart rate resulted from apnea, or his not breathing, and that it compounded the shock of his allergic reaction. They stood in silence now, waiting for the resident to get the airway, knowing that if she didn’t succeed fast, they’d be treating a cardiac arrest as well as his respiratory problems.

  “Can you see the cords?” asked Steele in the cool tone he saved for the tightest situations.

  “Not yet,” she replied, her voice shooting an octave higher. She nevertheless persisted, steadfastly continuing to dab into the swollen orifice with a suction catheter, drawing off pooling secretions of saliva while cautiously advancing the light.

  The nurses exchanged uneasy, knowing glances, and Steele got ready to take over.

  “Wait, I think I see them,” she announced excitedly.

  Steele bent down and confirmed the sighting just in time to see her lay aside the suction device and deftly slip the tip of an endotracheal tube through the V of the patient’s vocal cords. “Now repeat the bolus of epi IV, give him the bronchodilators by aerosol, and run in the IV Solu-Medrol over twenty minutes,” she commanded with authority while beaming a triumphant smile at Steele.

  He nodded his approval, then watched as she expertly fixed the airway in place, hooked up a ventilation bag, and pumped it hard.

  He left the room knowing that in the years to come he’d be the deserving butt of her jokes as she regaled friends with tales about the day she’d stood up to an ogre in ER at New York City Hospital. As he passed a mirror over the sink, sunken sockets ringed by baggy dark circles returned his gaze, making him appear a decade older than his forty-five years. “God, I’ve let myself go,” he muttered angrily as he returned to the nursing station. “And why is it still so hot in here? Christ, I’m sweating like a pig.”

  As he wrote a note on the boy’s chart, he had to pause and rub his left wrist. It had been hurting him lately, and being a southpaw, he’d attributed the pain to one of the repetitive movement injuries that plagued people who worked on computers or had to write a lot. That’s all I need, he thought, acutely aware that an ER doctor who couldn’t quickly record the hundreds of written notes and orders wouldn’t be able to work emergency at all.

  “Excuse me, Dr. Steele, but the boy’s mother, a Mrs. Armstrong, is here,” interrupted one of the nurses.

  He stepped into the corridor to greet her. A thin, straight-haired blond woman who appeared to be in her early thirties stared at him with frightened blue eyes as he approached. She and her son had practically identical features, Steele noticed, and their resemblance stirred thoughts of another mother and son who’d been the image of each other. “Your boy’s all right,” he announced before he’d even reached her, and instantly he saw the fear leave her face.

  “Thank God,” he heard her whisper as she let out a long breath and dropped her shoulders a notch.

  As they headed toward resus, threading their way through the stretchers, he prepared her for what she’d see. “He’s intubated and sedated, but the worst is over. He should recover quite speedily and be back breathing on his own by tonight. But he had a close call, and from now on should carry a syringe of adrenaline at all times. He must have inadvertently eaten some nuts.”

  “No, Doctor,” she protested, stopping in her tracks. “It couldn’t have been that. He’s meticulous about avoiding them. His friends called me at work and told me what happened. They were having veggie burgers at a local health food store. Besides, the owners know him there, and are as careful with his food as we are.”

  “Soya!” exclaimed Steele.

  “Pardon?”

  “It’s a major ingredient in so-called vegetarian substitutes for meat and is soaring up the list of food allergies over the last couple of years, especially for people allergic to nuts. No one has definite proof, but suspicions run high in the scientific community that the rise stems from the genetic manipulation of the soya plant itself, in particular the insertion of DNA from a species of Brazilian nut tree to increase its hardiness. To make matters worse, people like your son who are at risk can’t avoid this modified version because it isn’t labeled as such. I’m afraid there’s no alternative but to eliminate all soya-containing products from his diet. . . .”

  As Steele explained the heightened vigilance that would be the lot of her son and virtually everyone involved in h
is care from now on, the pain in his wrist increased to the point where he found it difficult not to wince. Back at the nursing station it further hampered him while he attempted to complete his clinical notes. Already the head nurse stood at the door, summoning him for yet another ambulance case. “It’s a man bleeding from both ends who’s shocky, probably from an ulcer. We’ve started O 2, IVs, and bloods, but it’s not enough. . . .”

  Her words suddenly droned into the background. He tried to listen more carefully, but the sound of her voice remained tinny and far away. He felt dizzy, then nauseated. The pain in his wrist crept up his arm.

  His respirations quickened, and a weight settled on his chest. Despite it all being exactly as he’d heard patients describe it over the years, he still tried to deny it. He got to his feet, determined to walk it off. The darkness came over him like a wave, and he didn’t even feel the crack of his skull hitting the linoleum floor. His last thoughts as his heart sputtered to a standstill and he slipped toward death were for Luana, his greatest love, and loss, in life.

  Chapter 2

  He felt no rising above his body, no hurtling toward a light, no encountering heavenly figures. Just white explosions inside his skull that, even in his clinically dead state with no pulse or respirations, his brain correctly interpreted as countershocks. And, of course, some idiot was pounding on his chest. Next would come the hose down his throat as they intubated him, he thought, and was right about that as well. What struck him most was how little he cared which way things went. The voices around him, far away yet familiar, all seemed so needlessly frantic.

  “. . . get a blood gas . . .”

  “. . . give him epi . . .”

  “. . . stand clear . . .”

  Why were they bothering?

  Another white explosion seared through his head.

  Then they left him alone.