Laurie then took the next case file and hospital record and set to work. Not quite an hour later, the phone rang. As much as she'd been concentrating combined with the near-absolute silence of the deserted fifth floor, the phone's old-style raucous jangle totally startled her. She answered it in a panic before she'd even had a chance to guess who it might be. It was Jack.
"What time did you leave?" he asked.
"I'm not sure. It was three-fifteen when I got up."
"Why didn't you wake me? I missed you when I awoke a few minutes ago."
"I wanted you to get as much sleep as you could."
"Are you exhausted?"
"I've been exhausted for days. Luckily, I didn't have any trouble getting to sleep."
"I'm glad we talked again last night," Jack said, "even if I wasn't when we began."
"I'm glad, too."
"Well, I had better jump into the shower with my antibiotic soap. I'm supposed to be over there at six-fifteen, and it's already twenty after five."
"I forgot to ask: How long does this patella tendon graft take?"
"Dr. Anderson told me a little more than an hour."
"I'm impressed. That's fast."
"He does them so often, he's got it down to a science."
"I'll see you around noon," Laurie said.
"I love you."
"I love you, too," Laurie closed. She heard the click. It sounded so final. Slowly, she replaced the receiver. What was the day going to bring? she asked herself uneasily. She wished she'd hung up first, because she kept hearing the metaphoric disturbing finality of the click over and over in the depths of her brain.
Shaking off any morbid thoughts engendered by the phone, Laurie went back to her matrix, taking yet another case file and its accompanying hospital record from the slowly dwindling stack. To keep from thinking about anything other than the busywork of data entry, Laurie kept at her task compulsively, as if it were a life-or-death necessity. Close to seven, she had only two more to go when Riva arrived.
"What on earth are you doing here so early?"
"I couldn't sleep," Laurie said. "I thought I might as well work."
Riva looked over her shoulder at Laurie's nearly complete matrix. "Very impressive! Have you learned anything earth-shattering?"
"Hardly" Laurie said. She thought for a moment about telling Riva about the unknown and possibly infectious agent she'd found microscopically but then changed her mind. Riva would undoubtedly want to see it, and Laurie was intent on finishing her matrix.
"Are you still planning on a paper day today?" Riva questioned.
"Absolutely," Laurie said. "I want to finish what I'm doing and then go over to see Jack. He's having his surgery today."
"Oh, that's right," Riva said. "I'd forgotten. I don't have Jack to schedule, either. I'd better get down there and see what's come in overnight."
By seven-twenty-five, Laurie had finally made the last entry. She held the matrix up. It was quite extensive, with every known variable she had been able to conjure up to compare the cases.
Quickly she scanned the document, looking for gross, unexpected commonalities among the twenty-five cases that might suggest the how and the why the patients had gotten infected. But nothing seemed to jump out until she looked back at the column for date of surgery. Having always had a facility with mathematics and numbers in general, there seemed to be a pattern. Believing it was only some sort of coincidence, Laurie got out her daily calendar and translated the dates of her series into days of the week. To her surprise, there was a pattern in that all the eye or cosmetic cases were on Tuesday, the heart cases were on Wednesday or Friday, and the orthopedic cases were on Monday or Thursday. With her knowledge of statistics, Laurie immediately knew that twenty-five cases were not nearly enough to give any credence whatsoever to her finding, yet she found it curious.
Returning to the matrix and slowing down, she let her eyes pause at each entry in each of the categories, such as age, duration of the procedure, type of anesthesia, et cetera, but still nothing significant caught her attention. Coming to the end of the matrix, Laurie switched her gaze to the wall clock. It was seven-thirty exactly, and Jack's surgery was starting. Laurie could visualize the scalpel cut through the skin, and she winced at the thought. Looking back at her matrix, she felt sorry she had finished filling it in. The process itself had been effective in keeping her mind from thinking about what she preferred not to think about.
Suddenly, Laurie thought of something else she could do to avoid obsessing over what was happening to Jack. She thought of Dr. Collin Wylie in New Zealand and the possibility that he'd gotten the photomicrograph, and the possibility he'd had an opportunity to look at it, and if he had, whether he'd been able to recognize it and respond. There were a lot of ifs, but, undeterred, Laurie went to her e-mail. The main reason she'd not thought about doing so earlier was because the outgoing e-mail had been sent during the night, and she'd forgotten to factor in that New Zealand was on the opposite side of the world, meaning in Auckland it had been morning.
The moment after she'd clicked the appropriate icon and her e-mail opened, she saw it: [email protected]. Eagerly, Laurie opened it.
Dr. Montgomery: Greetings from Down Under I received the photomicrographs from Peter, and I have already duly chastised him for not recognizing an acanthamoeba polyphaga cyst, although I gave him some slack because of the location. I have never seen one in the lung. If you want to see it better, use an iodine stain. As for the evanescent nodularity Peter mentioned, I can only assume that it represents encasement of more of the same MRSA as is seen free in the microscopic field. It has been recently demonstrated in Bath, England, that MRSA can invade and multiply within acanthamoeba, similar to legionella, the cause of Legionnaire's disease. Since acanthamoeba normally eat bacteria, it is interesting to wonder how the MRSA and legionella have developed antiamoebic resistance, if you will, and how molecularly similar the process is to their antibiotic resistance. I will be back in the city on Monday. If I can be of any additional assistance please do not hesitate to contact me.
ALL THE BEST, COLLIN WYLIE
As astonished as she was about what she was reading, Laurie had read the e-mail without blinking, and she had to make up for it by squeezing her eyes shut and then blinking several times in a row. She knew next to nothing about amoebas in general or acanthamoeba in particular. Leaning over, she pulled her Harrison's Principles of Internal Medicine from the shelf and rapidly looked up acanthamoeba. The reference was short, and merely part of a general article about infection with free-living amoeba. It talked about acanthamoeba causing an encephalitis, but nothing about pneumonia. It also mentioned that the CDC had a fluorescein-labeled antiserum available for definitive diagnosis, which Laurie thought might be helpful to confirm Dr. Wylie's impression.
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!