Death Rounds Read online

  “Dr. Garnet,” said the technician, his voice obviously excited, “it’s staph. Clusters and clusters of gram-positive cocci on the Gram stain of her sputum.”

  “You’re sure?” I questioned, surprised. “It’s not just strands of pneumococci heaped together?”

  While both these organisms are gram-positive cocci, that is, when treated with Gram stain reagents they stain blue and appear round under a microscope, pneumococcal bacteria line up in strands and pairs whereas staphylococci tend to occur in clumps and resemble bunches of grapes. I’d been expecting pneumococci.

  “It’s out of a textbook,” he replied, “like a goddamned vineyard. I’m keeping the slides for our teaching file. All the other cultures are being plated out now.”

  He was as excited as a kid with a new toy. Staph pneumonia was unusual, and bacteremia from staph pneumonia was outright rare. In all his enthusiasm he seemed to have overlooked that he’d just given Mrs. Sanders a one-in-three chance of dying.

  “Do you know if it’s a hospital- or community-acquired infection?” he asked eagerly.

  It was a good question despite the macabre exuberance. Hospital-acquired staphylococcus was apt to be resistant to the antibiotics we’d given her. One strain in particular, called MRSA, or methicillin-resistant staphylococcus aureus, responded only to vancomycin.

  “She’s a nurse at University Hospital,” I replied. “I suppose we’ll have to assume resistance until we get your culture and sensitivity results.”

  “Thanks for the great case, Doc!” he said before hanging up.

  I was left shaking my head.

  I called ICU and informed the charge nurse about the Gram stain result. She told me ID still hadn’t seen Sanders, so I ordered vancomycin—just in case.

  “Do we stop the erythromycin?” she asked, not unreasonably. If the pneumonia was caused by staph, erythromycin wouldn’t add anything to the treatment already in place, except an increased chance of side effects.

  But I hesitated.

  “Dr. Garnet?” asked the nurse, after a few seconds of silence.

  Something still didn’t fit. I couldn’t pin it down, but one thing I’d learned not to ignore in ER was an uneasy feeling that I was missing something.

  “No,” I answered slowly, “leave it until ID sees her, and have them call me here when they do. They’ll probably change all my orders anyway. By the way, has anyone talked to the family yet?”

  “There’s no answer at the woman’s home. Her chart from yesterday says she’s widowed—Sanders’s her maiden name—but the next of kin is her son, a Harold Miller, with the same phone number. Did he send her in?”

  “No, according to the ambulance sheet a neighbor found her this morning and dialed 911.” I hesitated before giving my next suggestion. But it had to be done. “Her son’s in charge of lab technicians at University Hospital. You might try for him there. Tell him he can reach me in ER.”

  After I hung up, I glanced around the department, confirming that Michael and the residents still had things under control. I stepped over to a set of corner shelves where we kept reference texts. While most of the residents used the computer to access material on any given topic in emergency medicine, I still preferred the written page. As chief of the department, I could assure we had both.

  Despite the Gram stain result identifying staphylococcus, there were simply too many features of this case that seemed unusual. I pulled the middle volume of a medical text published by Scientific American—a large three-ring-binder format that was updated monthly—and found the section on pulmonic infections.

  Looking at the differential diagnosis of pneumonias in a systematic outline relaxed me. The bits and pieces of various syndromes suggested by Sanders’s symptoms suddenly seemed to settle into an organized pattern. The thickness of her sputum and the presence of blood was indeed consistent with the more common pneumococcal infection that I’d been expecting to find, but pus was also a hallmark of how staph infections released toxins that destroyed tissue and, in so doing, created abscesses. The bloody sputum could have been the result of noncardiac pulmonary edema—a condition in which shock and sepsis break down the membranes lining the tiny air sacs through which oxygen normally passes into the blood. The result is a leaky-lung syndrome in which these same little sacs are flooded with blood-tinged serum.

  The article reiterated that staph organisms were carried in the nostrils of up to fifty percent of hospital personnel, a well-known statistic, and that this was the most common nosocomial, or hospital-acquired, source of this infection with elderly or immunocompromised patients. In the update, however, was a new statistic. The incidence of serious drug-resistant organisms in U.S. hospitals, namely, MRSA or VRE, was now up to forty percent.

  This creepy piece of data made my skin crawl. I immediately felt the urge to wash my hands.

  But the next chapter, while reassuring about my personal safety, reinforced my suspicion there was something strange about Sanders’s being infected at all. Healthy adults only developed pneumonia from staphylococcus after some event, like an influenza infection, made the lung susceptible. The expected pattern was a flulike illness for at least five days and then the classic symptoms of life-threatening pneumonia we’d seen in Sanders today. The one-day prodrome she’d presented with yesterday wasn’t part of the picture.

  Peering at the small print through the bottom part of my glasses, I suddenly realized the yellow droplets from Sanders’s sputum were still dried on the lenses. “Shit!” I exclaimed. The same medical student who’d overheard Michael’s profanity gave me a disapproving look. “Sorry,” I muttered, and rushed out of the nurses’ station. Illogically, I held my breath while running to a utility room. There I whipped on a pair of gloves, dropped my glasses into the deep sink where mops were cleaned, and emptied half a container of concentrated cleaner on them. My eyes were red with the fumes by the time I finished rinsing them off. On returning to the nurses’ station, I smelled like a recently scrubbed toilet.

  “Phew!” said Michael, who was standing over the open book I’d abandoned on the counter. The section on pneumonias must have caught his eye. “What are you using for aftershave?” he kidded, but his laugh sounded a little nervous.

  “Smart-ass!” I stepped by him to put away what I’d been reading.

  “Hold it,” he cautioned, and pointed to a section I hadn’t looked at yet.

  There, in a succinct paragraph, was exactly the prodrome I’d been looking for.

  The pneumonia is preceded by a one day history of myalgia, malaise, and a slight headache after an incubation period of 2 to 10 days. Gastrointestinal complaints, especially diarrhea, may be present, and orthostatic dimness has been reported. The cough is initially nonproductive.

  I looked up to the title of this section. It was Legionnaires’ disease.

  * * * *

  Little Gary Rossit, the chief of our infectious disease department, was the biggest son of a bitch in the hospital. Whenever he could use his considerable knowledge about communicable illnesses to humiliate his fellow physicians, he did so with relish. Perhaps it was his way of paying back the rest of the world for being taller than he was. I always suspected he simply enjoyed being mean. That his considerable skills also helped desperately ill patients get better was why most of us put up with him.

  “Look, Earl, just because you booted the case yesterday, don’t think overdiagnosing the same symptoms today and ordering every antibiotic you can think of is going to let you off the hook.”

  I felt my face flush with anger. We were outside the isolation cubicle in ICU, a well-lit glassed-in room located against a back wall of the department. He’d just finished pulling off his cap and other protective wear after seeing Mrs. Sanders, and his wavy black hair was sticking up in tufts. I had to resist grabbing one of them and lifting him off the floor by it.

  “I’ve ordered the lab to test for Legionella,” I told him, gritting my teeth to help me keep my temper. Special culture and stai
ning techniques that could take up to three days were required to isolate the hard-to-detect organism. Even then, none of the tests was one-hundred-percent sensitive.

  “Where’s your reference to justify even thinking of those tests,” he asked belligerently. “There’s no literature on Legionnaires’ preceding staph pneumonia.”

  “Show me literature on staph pneumonia and bacteremia after a twenty-four-hour prodrome in an otherwise healthy adult,” I shot back at him.

  We glared at each other for a few seconds. The resident in charge of ICU who’d been listening from a few feet away started to fidget.

  Then Rossit shrugged. “No wonder we’re way over budget,” he muttered as he walked over to a large desk near the central nurses’ station where he began writing his consultation note. Behind him were dozens of monitors and screens arranged on a wide curved console—a flashing array of fluorescent tracings, blinking numbers, and squiggled readouts. Every now and then an alarm bell would softly sound and get the attention of a nurse. Sometimes she’d readjust the monitor. Other times she and her colleagues would rush into one of the many curtained cubicles that lined the room and perform some procedure on a patient, out of sight. Occasionally there would be a cry or moan, but ICU was generally a quiet place where conversations were hushed and pain was monitored, measured, and medicated until it was endured without a whimper. Somewhere on the blinking wall of screens in front of me were the numbers that documented Mrs. Sanders’s agony.

  The resident hesitantly approached and asked, “Dr. Garnet, what do we do if he discontinues the erythromycin?”

  Erythromycin was the treatment of choice for Legionella.

  “Ignore him,” I answered none too quietly. “He’s only a consultant giving an opinion.”

  I watched the little man flinch, sign off his brief entry with a flourish of his pen, then rise and start back toward me. He was shaking his head and trying to smile, but it was his turn to look flushed.

  “At this stage. Garnet, I think she’s SOL, whatever we do. Our next discussion about her will probably be at Death Rounds, when we’ll have the benefit of an autopsy and not have to endure some cock-and-bull scenario cooked up by you to assuage your own guilt. And by the way, chum, you did miss something yesterday that justified keeping her.” He abruptly wheeled about and walked swiftly toward the exit. As he hit the metal disk that activated the sliding doors, he glanced back at me. His bristly mustache, stocky body, and short legs usually reminded me of a video game character, but there was nothing comic in the triumphant glare he gave me before he stalked from the room.

  Looking embarrassed, the resident was tugging at her stethoscope. “Excuse me. Dr. Garnet, but I have to round on the other patients,” she said nervously, then rushed off to one of the cubicles.

  I exhaled, trying to release the knot mat was quickly tightening in my stomach again, and forced myself to go over to the desk where Rossit had left the chart. Cursing the little man’s hostility, I quickly reviewed the notes from yesterday’s visit, yet couldn’t find what he’d inferred—and what I’d been dreading—that I’d missed something basic. I was about to dismiss the accusation as a cheap shot when my eye fell on a circled passage in the nurse’s notes.

  2 P.M. Patient discharged home by Dr. Garnet. Reported feeling dizzy on standing but complaint passed when sitting. Patient taken to front door in a wheelchair and helped into a taxi.

  Orthostatic dizziness—the nurse should have recognized it was significant and taken the woman’s pressure standing. We would probably have picked up a drop and known she was becoming unstable. At the very least we would have started her on an IV to rehydrate her and observed her vital signs. We would have had her here when she decompensated, and earlier administration of antibiotics would definitely have increased her chances of survival.

  Sanders herself must have known the dizziness was of concern. Had she protested, insisting that someone should take her pressure again, but only increased the antagonism of her nurse? Had she been ignored and hustled out the door in a wheelchair?

  In any ER, the attitude of the chief sets the tone. Kidding and teasing aside, I knew my staff usually took their lead from me. Even though we’d all found Sanders tiresome, it was up to me to make sure my own attitude and dislike of the woman hadn’t implicitly signaled that the patient was a crock and that her complaints weren’t to be taken seriously.

  Rossit was right. I’d missed a key sign of orthostatic hypotension that was clearly there to be found. Worse, I’d probably assured no one else would find it either.

  I literally fled from ICU.

  Chapter 3

  Seeing patients was going to be difficult. As I headed down the stairwell from the third floor, I thought of signing out to Michael until I felt more collected, but the idea of sitting around and dwelling on things unnerved me even more.

  When I arrived in ER I took Susanne to a quiet corner and explained what I’d learned. The expression on her face quickly registered the same anxiety I was feeling.

  She groaned. “Oh no. Who was the nurse?”

  In my confusion upstairs I hadn’t bothered to notice.

  “Sorry, but if you go over the chart, her note is now plenty obvious. Rossit was kind enough to circle it.”

  “You’re kidding!”

  “You know how he is. Nailing the mistakes of others is a blood sport to him, and I’m afraid he can’t wait to wipe the floor with me over this one. The trouble is, in his eagerness to have my hide, he’s likely to smear everyone else in the department who went near Sanders.”

  “Chiefs make for especially good hunting, do they?” she asked harshly, obviously angered by the prospect of Rossit’s legendary troublemaking hitting so close to home. “Christ, the man’s a menace. He makes everyone in the hospital want to cover up mistakes instead of learning from them.”

  I gave a little laugh. “That’s exactly what some physicians think about my mandatory reviews of unexpected return visits.”

  I must have sounded as miserable as I felt.

  Her eyes widened in surprise. “Earl Garnet!” she exclaimed. “How can you even think of yourself in the same category as a louse like him. You’re fair in those reviews, and everyone knows it, even, I suspect, the ones who resent having to look at their own errors. You help physicians be better doctors, Earl. Rossit doesn’t care about that. He’s vicious, pure and simple, and everybody knows that, too!”

  Susanne hardly ever called me Earl, except when we happened to meet at a social function outside the department. At work, even after all these years, she insisted the chain of command be evident and clear to all our staff. The practice was one of the many fundamentals she adhered to that ensured we ran a tight ER. Realizing the damage Rossit could cause had obviously rattled her.

  Still, I appreciated the spontaneous outburst of support. “Thanks Susanne,” I said, trying to sound a lot less worried than I was, but her frown deepened.

  “Are you sure you want to work? It’s not that busy, and you could do the light cases.”

  “Sanders had been a light case,” I muttered without thinking.

  Susanne started, then slowly nodded. “Yeah,” she said quietly, “I know what you mean.”

  In ER, the so-called little cases were the sleepers—the ones that occasionally hid something rare but lethal. For most competent physicians, the sicker the patient, the more straightforward the treatment. The already dead—a cardiac arrest—were the most routine cases of all.

  “The shape I’m in right now, Susanne, I’m probably safest in resus.” I left her standing there with a doubtful look on her face as I headed toward the triage desk to find the sickest patient we had.

  For the next twenty minutes, a bad asthmatic in severe respiratory distress kept me busy enough to push away any thoughts of Sanders and Rossit, but when I got to more routine cases, those thoughts, always present at the back of my mind, came to the fore. Each time I began listening to a person’s complaint and attempted to seem empathet
ic, I felt like a fraud. I kept imagining Sanders’s eyes. Remembering her expression. Are you going to disappoint me too ?

  Then her son phoned.

  I’d been sewing up the lip of a five-year-old girl who’d been dancing on a slippery staircase in her stocking feet.

  “Dr. Garnet,” the clerk had summoned, poking her head in the door of our minor surgery room. “There’s a Mr. Harold Miller from University Hospital on line three inquiring about the Sanders woman.”

  “I’ll be right there,” I said, tensing.

  I finished my suture and got to a phone. “Mr. Miller, it’s Dr. Earl Garnet. No doubt you’re calling about your mother?” I kept swallowing, but my mouth was dry.

  “Dr. Garnet! I was in the medical library at the university, and our lab secretary reached me only a few minutes ago. A nurse from your ICU called and said you’d admitted Mother with a diagnosis of pneumonia and septic shock?” His speech was fast and clipped. He sounded tense, but I couldn’t tell if he was also angry.

  “I’m afraid she’s very ill, Mr. Miller. I’m glad you’re on your way,” I said as evenly as I could. I hated having these conversations on the phone, especially this one. Without seeing the face of the person I was talking to, I couldn’t fully judge the impact of my words. I wasn’t going to lie, but neither did I want to let something slip out that would hand my head to his lawyer.

  “But Dr. Garnet, what happened? I talked with her around ten last night She said that she saw you yesterday afternoon and you told her everything was okay, that it was just the flu.”

  “You saw her last night? And she was all right?” I’d assumed she must have deteriorated from the time she left ER. If she was still apparently not too sick after ten, she must have gone septic in less than twelve hours.

  “No, I didn’t see her,” he answered. “I phoned her at home from the hospital. I was on call for the night. She sounded like you said, like she had the flu.”

  Then wham, the kind of virulence we shouldn’t see in an otherwise healthy woman in her fifties. I suddenly felt more compelled to explain that riddle than to try to avoid being sued. Perhaps I’d do both.