Critical (21 page)

One of the secretaries caught sight of Laurie and asked if she could help her, but before Laurie could respond, a glass door to an office opened and an energetic woman wearing a white coat over a brown turtleneck sweater and skirt called out to her. She introduced herself as Loraine Newman before ushering her inside.

"Let me have your coat!" Loraine said. She was Laurie's height and build and even approximate age but had different coloring compared to Laurie's blond complexion. "Please take a seat," she said, as she placed Laurie's coat on a hanger and hung it inside a small closet.

Laurie sat down, and Loraine went behind her desk and did the same.

"I've never met a medical examiner," Loraine said with a smile. "I'm awed by what you guys do."

"We don't get out much," Laurie said. "Most of our scene work is done by our forensic investigators." She inwardly winced, recognizing Bingham would surely not appreciate what she was doing.

"How can I help you?" Loraine asked. "I suppose you are here because of yesterday's unfortunate MRSA death."

"That and more," Laurie answered. "I did the autopsy on Mr. Jeffries this morning. The extent of his infection was dramatic, to say the least, especially how quickly it consumed him."

"You have no idea how upset we are, and not only about the tragic loss of a life of an otherwise healthy man but also because it has occurred despite our making maximum effort to prevent it."

"I heard from one of my colleagues the efforts that you have been making. I imagine it must be discouraging, especially since you have apparently had eleven such cases."

"
Discouraging
is not a strong enough word. Did you find out anything at autopsy that might help us? When you called, I was hoping that was going to be the case."

"I'm afraid not," Laurie admitted.

"Then why did you come over?"

Laurie squirmed in her chair. Although the tone of the question was far from hostile, Laurie found herself questioning exactly why she was compelled to make the visit, and for a moment felt foolish.

"I didn't mean to put you on the spot," Loraine said, sensing Laurie's discomfiture.

"It's okay," Laurie said. "After I did the autopsy this morning, I found out essentially by accident about all the other cases occurring over the last three and a half months. I just felt I had to do something. I'm afraid the OCME has let you and the rest of the city down by not being aware of the outbreak. It's part of our job not to let something like this fall through the cracks."

"I appreciate your sense of responsibility, but in this case I don't think it matters. We certainly have been aware, and believe me, we have done everything possible. And when I say everything, I mean everything, including the hiring of a full-time infection-control professional. And as the chairperson of this hospital's interdepartmental infection-control committee, I personally jumped on the problem from day one. We've had input from everyone, including our medical staff, nursing, engineering, laboratory, you name it.

Our committee has met just about every other week since the first MRSA case. We even shut down our ORs for a time and halted all surgery and invasive procedures."

"So I heard," Laurie said. "I don't have much training in epidemiology, but there are several things about this outbreak that bother me."

"Such as?"

Laurie took a moment to organize her thoughts. She was afraid she might sound naive, since she truly only had the basics in epidemiology. "For one thing, it has continued despite all your efforts at control; secondly, many of them are, like Jeffries, primary pneumonias, which I believe is unique for staph; third, they have apparently been occurring in only Angels Healthcare facilities. You do know that your sister hospitals are experiencing cases as well?"

"Of course. I've had multiple meetings and frequent communication with my counterparts at our heart hospital and at our cosmetic surgery and eye hospital. I was also the one who strongly encouraged Angels Healthcare's CEO, Dr. Angela Dawson, to hire the M.D./Ph.D. infection-control professional to coordinate our efforts, specifically because the problem was happening in all three of our institutions."

"Is that Dr. Cynthia Sarpoulus?"

"That's correct. Why do you ask?"

"I recall one of my ME colleagues mentioning her name. He spoke to her a month or so ago."

"She's one of the leaders in our specialty, and coauthored a major text on hospital-infection control programs. I was sure that, when I heard she'd been hired, we'd be out of the woods."

"But it hasn't happened."

"It hasn't happened," Loraine agreed.

"Well, back to my amateur concerns," Laurie said.

"I'd hardly call you an amateur, doctor," Loraine said with a smile. "Please, continue!"

"An hour or so earlier, I talked with a doctor at the CDC. She'd had the opportunity to subtype the staph from two of your cases that occurred more than a month ago at different hospitals. Using rather sophisticated genetic typing, they proved to be the same. She promised to confirm that with tests of even higher specificity and get back to me. To my informally trained epidemiological brain and contrary to what she thinks, it suggests to me a carrier is involved: a carrier who visits both hospitals. Do any of the Angels Healthcare personnel regularly visit all your hospitals?"

"Wow," Loraine remarked. She laughed in a fashion that indicated she was impressed. "Are you teasing me about not having epidemiologic training?"

"Just the required exposure for my pathology residency," Laurie said.

"We have definitely considered a carrier to be the source of the problem. In fact, so much so that we have repeatedly cultured everyone: medical staff, service personnel, and particularly those individuals who regularly visit all three of our hospitals. One of the ways that our CEO founder conceived of keeping expenses down was to have centralized services like laundry, engineering, laboratory, nursing, and food service. Each service has a department head whose office is at Angels Healthcare's central office but who travels on a regular schedule to all three hospitals. These people have been tested repeatedly for the exact reason you've suggested."

"Has anybody tested positive?"

"Absolutely About twenty percent positive, which is what one would expect in the normal population. In fact, slightly more on the medical staff. And everybody who tested positive has been treated with mupirocin until they tested negative."

"Did any of them test positive for the community-acquired MRSA?"

"Oh, yeah. Quite a few."

"Do you know if the subtype was the same as what killed your patients?"

"Our subtyping was by a VITEK system and only for antibiotic resistance, and yes, some were the same."

"Antibiotic resistance is not particularly sensitive in terms of differentiating substrains."

"I'm aware of that, but since we treated anyone positive for staph, we didn't think it mattered."

"Maybe so," Laurie said. "Did you have any of the isolates typed by the CDC?"

"No, we didn't."

"Why?"

"That was a decision made by the home office. I suppose because we were treating everyone who was positive, as I said, so that characterizing it more served no purpose. Also, we were already instituting every known infection-control procedure."

"Did you let the CDC know you were experiencing this MRSA outbreak?"

"We did not."

"How about the Joint Commission on Accreditation of Healthcare Organizations? Did you notify them?"

"No, we didn't. The JCAHO only needs to be notified if our overall infection rate goes above four percent over our designated surveillance period."

"Which is what?"

Laurie watched Loraine hesitate as if Laurie had asked a state secret. "You don't have to tell me if you feel uncomfortable," Laurie added. "I don't even know why I'm asking."

"And I don't know why I'm hesitating. Anyway it is a year interval."

"But your rate could be above four percent if you considered the last three months."

"It's possible," Loraine agreed. "But I've not stopped to figure it out."

"How about the New York City Board of Health?" Laurie asked. "I presume you let them know."

"Of course," Loraine said. "And the city epidemiologist, Dr. Clint Abelard, has made several site visits. He was impressed with everything we were doing and didn't have any suggestions, which is not surprising, since we had tried everything."

"Very interesting," Laurie commented. She felt better about coming for her visit, since Loraine hadn't ridiculed her about any of her thoughts. At the same time, she was reluctant to mention any of her more outlandish ideas. "How about a tour. Your hospital is truly elegant, and not like any other I've ever seen."

"Sure," Loraine said without hesitation. "We all are quite proud of it, especially since we are all owners."

"Really?" Laurie questioned. "How so?"

"Our CEO, Dr. Dawson, gave all the employees a little stock when we signed on. It's not much, but there is a certain symbolic value. Actually, that might change for the better in the near future. The company is scheduled to go public in a few weeks. If all goes well, our tiny amounts of stock could actually be worth something."

"Well, I'll say a little prayer for the IPO."

"Thanks," Loraine said. "The rumor is that it is going to do very well."

"Can we do the tour now?" Laurie asked.

"Certainly," Loraine said. She stood and opened the door leading to the area occupied by the secretaries. Laurie followed.

"What is it you'd like to see?" Loraine questioned as they left the admin area and emerged into the main lounge. "It's fancier than other hospitals but otherwise basically the same."

"But no emergency room."

"Right, no emergency room. We're a surgical hospital. We don't want beds taken up with medical patients."

"How about an intensive-care unit?"

"Not an intensive-care unit per se. If that kind of care is needed, we can isolate part of the PACU, or post-anesthesia unit. If the PACU is too full, we send patients to the University Hospital. It saves a lot of money."

"I'm sure it does," Laurie agreed, but the idea of a surgical hospital not having a full-fledged ICU bothered her.

They paused out in the main lobby area, standing in front of the elevators.

"I cannot help but notice how quiet it seems to be," Laurie said. "There are so few people."

"That's because our census is very low, which has been progressive since the MRSA problem began. Of course, the worst was when the ORs were completely shut down. During that period we had the entire hospital staff, including the president, disinfecting everything."

"But the ORs are open now?"

"Yes, they are open now except for the OR where Mr. Jeffries was operated on."

"Was he the only case done in the room yesterday?"

"No, he wasn't. There were two others after Mr. Jeffries."

"And they are well."

"Perfectly fine," Loraine said. "I know what you are thinking. It has us baffled as well."

"Since your census is low, does that mean some of your staff doctors are choosing to do their surgery elsewhere?"

"I'm afraid so."

"What about Dr. Wendell Anderson?"

"He's one of the brave ones, or should I say loyal. He's still operating here on a regular basis."

Laurie nodded while fantasizing about tying Jack to the bed during his sleep Wednesday night. More than ever, she did not want him to have his operation.

"What is it you'd like to see?" Loraine repeated.

"How about starting out with your HVAC system?"

Loraine did the equivalent of a double take. "Are you joking?"

"I'm serious," Laurie said. "Are the operating rooms and the PACU on a separate system from the main part of the hospital?"

"Absolutely," Loraine said. "This is a state-of-the-art facility. The HVAC for the operating rooms is designed to change each OR's air every six minutes. There would be no need to do that for the whole hospital. Even the laboratory area has its own system, although not with that kind of flow."

"I'd still like to see it," Laurie said. "Particularly the OR system."

"Well, I don't see why not." They boarded a waiting elevator. Loraine pressed the button for the fourth floor. She explained that the second floor was for outpatient services, the third was the OR and PACU as well as central supply, and the fourth was for the laboratory and engineering. Engineering included HVAC and the supply of various gases for the ORs and bedside. All the floors higher than the fourth were for patient rooms. The very top floor was a special VIP section, which had slightly larger rooms and more expensive decor. The service, she insisted, was the same.

"Are all the Angels Healthcare hospitals similar?" Laurie asked.

"Essentially identical, as will be the six hospitals slated soon to be constructed: three each in Miami and Los Angeles."