Laurie replaced the textbook and scanned her shelf for a possible second source. Not seeing one, she repositioned herself at her monitor screen and Googled acanthamoeba. A large number of hits appeared in seconds. She chose a general one.
With a growing sense of urgency, Laurie scanned the first part of the article, which described the protozoa as one of the most common in soil and fresh water. It described some of its characteristics, including the fact that it was a free-living bacterivore but could on rare occasions cause infections in humans. The next paragraph elaborated this issue at length, and Laurie quickly skimmed it.
It was at that point that Laurie's eyes encountered the caption of the next paragraph: Acanthamoeba and MRSA! With a surge of adrenaline coursing through her body, Laurie read an elaboration of what Dr. Wylie had mentioned, namely, that MRSA had recently been shown to be able to infect acanthamoeba. But in addition to what he'd cited, the article stated that the MRSA that emerged from the amoeba was frequently more virulent. And then, experiencing a reaction akin to a bolt of electricity passing through her, Laurie read that acanthamoeba cysts infected with MRSA can act as a mode of airborne dispersal for MRSA!
Laurie rocked back in her chair and stared blankly at her monitor screen. She was stunned. She'd been confident that MRSA could not be aerosolized, but now she was aware it could be, so all potential scenarios concerning how the MRSA was spread were back on the table, particularly the idea that the Angels hospitals HVAC systems could be involved.
With some difficulty, Laurie tried to calm herself. She had to think, and with her pulse racing and ideas flying around inside her brain, it was difficult. She took a few deep breaths, and after doing so, she remembered another reason she'd dismissed airborne spread as a serious possibility: The patients never breathed room air after being inducted. It was always bottled air or cleaned and piped-in air.
Laurie thought about this stumbling point. It seemed so definitive, or was it? With a mounting fear that her concerns were legitimate, she snapped her phone off the hook. Even though a quarter to eight might have been the worst time to call an anesthesiologist, as all the seven-thirty cases were being inducted, Laurie called over to the Manhattan General Hospital. She'd worked on a case with the MGH's chief of anesthesia, Dr. Ronald Havermeyer, and he'd been extraordinarily helpful. Laurie was sure he, of all people, could reassure her about patients never breathing OR air and would be happy to do so. Additionally, his being chief meant that he was in a supervisory role and might be available.
Nervously tapping her fingers on her desktop, Laurie willed the connection to go through as quickly as possible.
"Dr. Havermeyer," a voice finally said.
Laurie quickly explained who she was and without explaining why, asked her question.
"It's true," Dr. Havermeyer said. "The patient never breathes room air after induction until they get to the PACU, and even there they are often maintained on piped-in sources."
"Thank you," Laurie said.
"Not at all. I'm glad I could help."
Laurie was about to hang up when Dr. Havermeyer asked why she wanted to know.
Quickly, Laurie sketched out her concern – namely, whether bacteria in the HVAC system could be responsible for postoperative nosocomial pneumonia.
"Are you talking about an extended period of breathing ambient air, or just three or four breaths over fifteen or twenty seconds?"
Laurie felt her throat go dry as she intuitively sensed she was about to hear something she did not want to hear.
"Because if it's the latter, there usually is a time," Dr. Havermeyer said. "When the surgeon gives the word and it's time to wake the patient up, or at least terminate the anesthesia, the anesthetist frequently flushes the system with pure oxygen in order to get a faster turnover time for the OR. During the flush, the patient might take two, three, or even four breaths. So it's possible." Laurie thanked the doctor and hung up.
Suddenly, her fears coalesced. MRSA could spread airborne if encysted with acanthamoeba, and patients having general anesthesia did, even if for only a few seconds, breathe ambient OR air. Laurie snapped up the paper on which she'd written the days of the week her cases had occurred. Her memory told her that orthopedic cases were on Monday and Thursday, and it was unfortunately true. It was also unfortunately true that it was Thursday that very day, the day Jack had to have his surgery.
With growing desperation, Laurie grabbed one of her cases' hospital charts. Frantically, she searched for the anesthesia record to check the time anesthesia commenced. Anesthesia time was one variable she'd not included in her matrix. To her horror, it was seven-thirty-five a.m. Literally tossing the record to the side, Laurie grabbed another: seven-thirty-one a.m. Swearing under her breath, Laurie grabbed yet another: seven-thirty-four a.m.
"Damn!" Laurie shouted. She got another: seven-thirty a.m.
With four cases out of twenty-five enough for Laurie to fear for the worst in relation to Jack, she ran from her office and beat the elevator down button in hopes of hurrying its arrival. She checked her watch as she waited. It was just after eight. Jack's procedure was supposed to take a little more than an hour, so she might make it if she got a taxi immediately. Luckily, First Avenue was a good place to get a cab in the morning because of the hospitals and other services in the area. What Laurie had decided was that she wanted to be in the Angels Orthopedic Hospital's engineering spaces above the OR as soon as possible to make absolutely certain no one else did.
AS MUCH AS Angelo thought he was depressed the previous evening, he now felt worse. They'd been waiting for almost two hours after arriving at six-fifteen, and still no Laurie Montgomery. Since she and her boyfriend had arrived the previous morning from 30th Street, he'd positioned the van so as to be able to see as far up the street as possible. Every time he'd see a taxi approach, his heart would speed up in anticipation, only to be disappointed again and again.
"I don't think she's coming to work today," Angelo growled. "Kinda looks that way," Franco said while licking his finger to turn the page of his newspaper. "As if you give a shit!"
Franco lowered his paper and glared over at Angelo, who'd turned to look back up 30th Street. He felt like lashing out at his partner in crime but didn't. It wasn't worth the effort. Instead, he started to go back to the paper when he caught sight of a figure bursting out from the OCME and descending the front steps as if being chased.
"It's her!" Franco yelled.
Angelo's head spun around. He started to demand where when he caught sight of Laurie. She was standing at the curb, holding open a taxi door so a passenger could disembark.
"Holy shit!" Angelo yelled. He reached behind his seat for the ethylene, but Franco grabbed his arm.
"There's no time," Franco asserted. "We've got to follow her. Start the damn car!"
They watched while Laurie's hand anxiously waved for the obese woman passenger to hurry. Laurie even resorted to giving the woman one of her hands and attempting to help by pulling, as if the woman were stuck. As soon as the woman was barely out of the way, Laurie threw herself into the cab and pulled the door shut. A moment later, the cab was off with a screech of rubber.