Critical (9 page)

“All that is supposed to be done before seven-thirty,” Bingham snapped.

“Yes, sir,” Laurie said, not interested in arguing. Unlike Jack, Laurie generally followed rules reflexively. However, the one mandating that autopsies start at seven-thirty sharp she generally ignored, since it conflicted with her belief that it was more important to know the case prior to doing the post. In an attempt to preclude any more conversation with Bingham about the issue, Laurie stepped directly up to Jack's table and asked loudly how his case was going.

“Stellarly,” Jack quipped, “except the inconvenient fact that the patient died. The only bad side is that it has been dragging on. We'd have made significantly more progress if there was any decent help around here.”

“Screw you!” Vinnie said. “If you two old windbags hadn't carried on like you've been doing, we could be up having coffee by now.”

“Gentlemen,” Bingham's voice called out. “I'll have no disrespect, nor profanity, in the autopsy room.”

Lest she incite any further comments from Jack and subsequent retorts from Bingham, Laurie quickly headed toward Marvin and her own case. As she passed Bingham's table, she cringed for fear of being called over, but luckily Bingham had been distracted by what he called a “catastrophic mistake” on Riva's part as she dissected the neck.

“Are you going to need anything special?” Marvin asked as Laurie came up abreast of the fifth table. As prepared as Laurie was, she generally knew in advance when special needs were required for a case.

“A good supply of culture tubes,” Laurie said as she surveyed David Jeffries's corpse. For fifty-one years of age, the man appeared to have been in good physical condition. There was no excess fat. In fact, his muscles, particularly the pectorals and quadriceps, had the definition of a much younger man.

Laurie grimaced behind her plastic face screen. Besides the obvious infection at the surgical sites on either side of the right knee, there was a sprinkling of small pustules all over his body, which given the time would have turned into abscesses or boils. Even more striking were areas of desquamation, particularly on his pelvis, with the skin sloughing in relatively large sheets.

“Are you looking at his hands?” Marvin asked.

Laurie nodded.

“What caused his skin to peel off like that?”

“Staph makes a lot of toxins. One of them causes skin cells to separate from their neighbors.”

“Ugh,” Marvin said.

Laurie nodded again. She'd seen staph infection before, but this was the worst.

“Anyway, to answer your question about culture tubes,” Marvin said, “I got plenty.”

“Did you get a good supply of syringes as well?”

“Yup.”

“All right, let's do it,” Laurie said, as she pulled down the suspended microphone.

“Want to check out the X-ray? I put it up just in case.”

Laurie stepped over to the view box and gazed at the film. Marvin followed and looked over her shoulder.

“Our X-rays are mainly for foreign bodies and fractures,” Laurie said. “Even so, you can certainly appreciate the pneumonia and how diffuse it is. It looks like the lungs are filled with fluid.”

“Hmmm,” Marvin said. X-rays were a mystery to him. He couldn't understand how doctors could see what they did in the foggy image.

Laurie went back to the body and completed the external examination. After making sure the endotracheal tube was where it was supposed to be in the trachea, she pulled it out. It had been placed by the doctors to ventilate him when he had begun to have trouble breathing. She cultured the bloody mucus adhered to it. Turning to the multiple IV lines, she made sure they were also properly placed and, after doing so, pulled them out and cultured them as well. Medical examiners insisted such tubes be left in place to be sure that they played no role in the patient's death. She also cultured the pus issuing from the surgical site.

Once the external exam had been finished and dictated, Laurie began the internal with the standard Y-shaped incision starting at both shoulders, meeting at the midline, and then extending down to the pubis. She worked quietly, shunning the usual banter she normally exchanged with Marvin, who was an eager learner.

For a time, Marvin stayed quiet as well, correctly sensing Laurie's awe at the virulence of the microbe that had played such havoc throughout David Jeffries's body. It wasn't until Laurie lifted out the heart and lungs and put them in the pan he was holding that he broke the silence. “Shit, man,” he commented. “This baby weighs a ton.”

“I noticed,” Laurie said. “I think we'll find both lungs full of fluid.” After she removed the lungs and weighed each separately, she made multiple slices into them. Like fully soaked sponges, a mixture of edema fluid, blood, necrotic tissue, and pus emerged.

“Ye gods!” Marvin said. “That's ugly.”

“Have you heard of the term
flesh-eating bacteria
?”

“Yeah, but I thought people only got that in their muscles.”

“This is a similar process, but in the lungs and much more lethal. Its official name is necrotizing pneumonia. You can even see beginning abscesses.” Laurie pointed to minute cavities with the tip of the knife.

“You guys look like you are having way too much fun,” Jack said, after silently coming up along Laurie's right side.

Laurie let out a short, sarcastic laugh that was enough to briefly fog her face screen. She gave a quick glance at Jack before holding up the exposed cut surface of the lung for him to see. “If you call seeing the worst case of necrotizing pneumonia fun, then Marvin and I are having a blast.”

Jack used his gloved index finger to assess the turgidity of the lung section. “Pretty bad, I'd have to admit. Shows you what can happen if you smoke too many Cuban cigars.”

“Jack,” Laurie said, ignoring his attempt at humor, “why don't you stay with us for a few minutes? I think you should see the full extent of this postoperative infection. This poor individual was being literally and rapidly digested from the inside out. This might be the worst or best advertisement for not having elective surgery I've ever seen.”

“Thanks for the invite, but I've got two more cases to do before Lou conks out,” Jack said. “Besides, I know how your mind works, especially with your not-so-subtle reminder the victim had surgery, meaning I know you have an ulterior motive for your kind invitation vis-à-vis my Thursday plans. So I'll let you two have all the fun.” With a little wave, he started to leave.

“What about your first case?” Laurie asked, mindful of Lou's interest. “What did you find?”

“Not a whole bunch. We recovered the twenty-two-caliber slug, for whatever that's worth. Lou says it's a Remington high-velocity hollow-point, but he could just be trying to impress me. The thing's a bit mangled from penetrating the guy's skull. There were also some abrasions and indentations on his legs, suggesting he'd been chained, perhaps attached to a weight. I think he was supposed to sink, which suggests he was thrown overboard out of a boat, not dumped into the water on shore. Lou thinks that's important. Otherwise, the guy was healthy except for a slight cirrhosis of the liver.”

After Jack limped off, Marvin asked what Jack had meant about her having an ulterior motive.

“We're having a disagreement about when he gets his knee repaired,” Laurie said without elaborating. “Now, let's get back to work.”

“What have you got?” Arnold Besserman asked. Working at the next table, he'd overheard Laurie and Jack's conversation. Arnold had been at the OCME longer than any of the other medical examiners. Although Jack dismissed him as long in the tooth, outdated, and haphazard, Laurie was friendly with him, as she was with most everyone else.

“Do you mind me interrupting?”

“Certainly not,” Laurie said sincerely. His stepping over to her table was what made working in the communal autopsy room enjoyable and stimulating for her.

“Quite an amazing case,” Laurie said. “Take a peek at this lung. I've never seen such dramatic nosocomial necrotizing pneumonia, and it apparently developed over less than twelve hours.”

“Impressive,” Arnold agreed as he looked at the cut surface of David Jeffries's lung. “Let me guess: It's a staph infection. Am I right?”

“You hit it on the nose.” Laurie was impressed.

“I've had three similar nosocomial cases over as many months, with the last one about two weeks ago,” Arnold said. “Maybe not quite as bad, at least not all of them, but bad enough. Mine were from a methicillin-resistant strain coming from outside the hospital but which apparently had hybridized with bacteria coming from within the hospital.”

“That's exactly what my case apparently is,” Laurie said, even more impressed.

“The strain is called community-acquired MRSA, or CA-MRSA, to distinguish it from the usual nosocomial, hospital-acquired MRSA, or HA-MRSA.”

“I remember reading about it,” Laurie said. “Someone had a case five or six months ago, of a football player who picked it up in the locker room and had an infection that ate away a lot of his thigh.”

“That was Kevin's case,” Arnold said. Kevin Southgate was another senior ME who'd joined the OCME only a year after Arnold had. As the old guard, Arnold and Kevin stuck together like a team, although opposites in their politics. Both were infamous around the office for constantly conspiring to take as few cases as possible. It was like they were working half-time full-time.

“I remember when he presented the case at Thursday conference,” Laurie said. Other than the informal but effective give-and-take in the autopsy room, the formal Thursday conference with its required attendance was the only other opportunity for all of the city's nineteen MEs to share their experiences. Laurie, for one, lamented this situation because it hampered the OCME's ability to recognize trends. She had complained about it, but without coming up with a solution, the issue had died. With the OCME doing more than ten thousand cases a year, there wasn't time for more interaction, and there were no funds to hire more forensic pathologists than the one they had hired that year.

“The CA-MRSA bug is scary, as this case of yours aptly demonstrates,” Arnold said. “It's been a mini-epidemic outside the hospital, like Kevin's football player and even, tragically enough, some young, healthy children getting scrapes on the playground. Now it seems to be going back into the hospital. That's the bad side. The good side is that it is sensitive to more antibiotics, but the antibiotics have to be started immediately because, believe it or not, being more sensitive to antibiotics has given the strain added virulence. Not making the complete line of defensive molecules for antibiotics like the HA-MRSA strains, these community-acquired strains are able to spend more time and effort making a soup of powerful toxins to enhance their virulence. One of them is called PVL, which I'm sure has played a role in your case here. PVL toxin chews up the patient's cellular defenses, particularly in the lungs, and initiates an overwhelming and perverse release of cytokines, which normally help the body fight infection. Do you realize that as much as one-half of the destruction you are seeing in the lung sections you are holding comes from the victim's own completely overstimulated immune system?”

“You mean like the cytokine storm they are seeing with people dying from H5N1 bird flu?” Laurie asked. The thought went through her mind that she would have to suggest to Jack that he might need to adjust the opinion he had of Besserman. He was embarrassing her by how much more he knew about MRSA than she.

“Exactly,” Arnold said.

“I'm afraid I'm going to have to do some serious reading about all this,” Laurie admitted. “Thanks for all the information. How is it that you are such an expert?”

Arnold laughed. “You're giving me too much credit. But a month or so ago, Kevin and I got interested in the issue because of several cases we each had. We kinda challenged each other to learn about it. It's a good example of the genetic versatility of bacteria and how quickly they can evolve.”

Laurie struggled to rein in her mind, which was bouncing from one topic to another. She looked down at the turgid, nearly solid slice of lung she was holding. She knew pathological bacteria were making a comeback, but what she was facing in terms of pathogenicity seemed beyond the pale.

“So the cases you mentioned earlier were necrotizing pneumonia?” she asked. “Just like this case appears to be.”

“That would be my guess, but I'd be even more certain if I looked at the microscope section of your case. I'd be glad to take a peek.”

Laurie nodded. “And Kevin's cases were the same as yours?”

“Very much so.”

“Were his nosocomial also?”

“Of course. They were nosocomial but also involved the community-acquired strain, the same as mine.”

“Why didn't you bring this up at Thursday conference?”

“Well, frankly, it was not that many cases, and everyone is aware of the burgeoning problem of staph, particularly antibiotic-resistant staph.”