"Is HUS ever fatal?" Kim forced himself to ask.

"Are you sure we should be talking about this aspect?" Kathleen questioned. "Remember the E. coli diagnosis has not been definitively made. I've just wanted to prepare you for its possibility."

"Answer the question, goddamn it!" Kim said hotly.

Kathleen sighed with resignation. She'd hoped Kim would be smart enough not to want to hear the disturbing details. The fact that he did, left her with no choice. She cleared her throat. "Between two hundred and five hundred people, mostly kids, die from E. coli 0157:H7every year," she said, "and it's usually from HUS."

Perspiration broke out on Kim's forehead. He was stunned anew. "Two to five hundred deaths a year," he repeated. "That's unbelievable, especially since I've never heard of HUS."

"As I said, these are CDC estimates," Kathleen said.

"With that kind of mortality, how come all this isn't better known?" Kim asked. Intellectualization had always been a coping mechanism for Kim in dealing with the emotional burdens of medicine.

"That I can't answer," Kathleen commented. "There's been a couple of high-profile episodes with this E. coli strain, like the Jack-in-the-Box outbreak in 'ninety-two and the Hudson Meat recall in summer 'ninety-seven. Why these and other episodes haven't raised general awareness and concern. I don't know. It is rather mystifying."

"I remember those two episodes," Kim said. "I suppose I just assumed the government and the USDA took care of the problems."

Kathleen laughed cynically. "I'm sure that's what the USDA and the beef industry hoped you'd believe."

"Is this mostly a problem with red meat?" Kim asked.

"Ground meat, to be precise." Kathleen said. "Ground meat that is not cooked through and through. But it's also true that some cases have been caused by such things as apple juice and apple cider and even unpasteurized milk. The key problem is contact with infected cow feces."

"I don't remember this problem as a child," Kim said. "I used to eat raw hamburger all the time."

"It's a relatively new situation," Kathleen said. "It's thought to have originated in the late seventies, perhaps in Argentina. The belief is that a shigella bacterium gave an E. coli bacterium the DNA necessary to make a shigella-like toxin."

"By bacterial conjugation," Kim suggested.

"Precisely," Kathleen said. "Conjugation is bacteria's answer to sexual reproduction, a method of genetic shuffling. But if conjugation was involved, it's curious since conjugation usually only happens within a species. But the truly surprising aspect is that once this new strain of E. coli was formed, it spread extraordinarily rapidly around the globe. Today it exists in about three percent of bovine intestines."

"Are the infected cows sick?" Kim questioned.

"Not necessarily," Kathleen said. "Although it can cause a bovine diarrheal disease, cows seem to be generally immune to the toxin, at least systemically."

"Strange!" Kim commented. "And ironic! Back when molecular biology was in its infancy, a doomsday scenario was envisioned that scared everybody: a researcher would give an E. coli bacterium the ability to manufacture the botulism toxin, and then bacteria would inadvertently get released into nature."

"It's a good analogy," Kathleen said. "Especially considering that with the emergence of E. coli 0157:H7nature probably didn't do it on its own. Man helped."

"How so?" Kim asked.

"I believe E. coli 0157:H7 has come from the intense farming techniques that are in use today," Kathleen said. "The need for cheap protein to feed the animals has resulted in creative but disgusting solutions. Cows are fed rendered animals, including themselves. Even chicken manure is being widely used."

"You're joking!" Kim said.

"I wish," Kathleen said. "And on top of that, the animals are given antibiotics. It creates a soup within the animals intestines that fosters new strains. In fact the E. coli 0157:H7was created when the shigella toxin DNA was transferred along with the DNA necessary for a particular antibiotic resistance."

Kim shook his head in disbelief. He was hearing about an issue of considerable interest, but then, all of a sudden, he remembered the case in point: Becky's situation. The realization was instantly sobering.

"The bottom line of all this is bovine fecal material particularly in ground beef," Kim said. His voice returned to its previous anxious intensity.

"I think that's fair to say," Kathleen said.

"Then I know how Becky got it," Kim said angrily. "She had a rare hamburger at the Onion Ring restaurant Friday night."

"That would be consistent," Kathleen said. "Although the incubation period for E. coli 0157:H7 is usually longer, sometimes as much as a week."

The door to the chart room banged open, causing both Kim and Kathleen to start. One of the nurses leaned in. She was flushed.

"Dr. Morgan!" she said urgently. "There's an emergency with your consult Rebecca Reggis!"

Kim and Kathleen raced out of the room and ran headlong down the corridor toward Becky's room.

NINE

Wednesday afternoon, January 21st

Kim came through Becky's door, he saw a nurse on either side of his daughter's bed. One was taking her blood pressure, the other her temperature. Becky was writhing in pain and whimpering. She appeared as pale as a ghost. Tracy was standing off to the side, with her back against the wall and a hand pressed to her mouth. She was almost as pale as Becky.

"What happened?" Kim demanded.

Kathleen came into the room behind Kim.

"I don't know," Tracy wailed. "Becky and I were just talking when suddenly she cried out. She said she had a terrible pain in her stomach and her left shoulder. Then she had a shaking chill."

The nurse taking the blood pressure called out that it was ninety-five over sixty.

Kathleen went around the left side of the bed and felt Becky's pulse. "Has Dr. Stevens been called?" she asked.

"Yes, immediately," one of the nurses said.

"Her temperature is one hundred and five," the other nurse said with dismay. Her name was Lorraine Phillips. Her colleague was called Stephanie Gragoudos.

Kim nudged Lorraine away from the right side of Becky's bed. Kim was frantic. It was like being stabbed in the heart to see his daughter suffering.

"Becky, what is it?" Kim demanded.

"My stomach hurts me," Becky managed amid groans. "It hurts me bad. Daddy, please!"

Kim pulled down Becky's blanket. He was shocked to see a swath of purplish subcutaneous bleeding on her chest. He raised his eyes to Kathleen. "Were you aware of this purpura?" he asked.

Kathleen nodded. "Yes, I saw it earlier."

"It wasn't there last night," Kim said. Kim looked back at Becky. "Tell Daddy where it hurts."

Becky pointed to her lower abdomen slightly to the right of the midline. She was careful not to touch herself.

Kim gently placed the tips of his index, middle, and ring fingers on Becky's abdomen where she'd pointed. He pressed in enough to barely dimple the skin. Becky writhed.

"Please don't touch me, Daddy," she pleaded.

Kim pulled his hand back sharply. Becky's eyes shot open and a cry of pain issued from her parched lips. Such a response was a sign Kim did not want to see. It was called rebound tenderness, and it was a strong indication of peritonitis, inflammation of the lining of the abdominal cavity. And there was only one thing that could cause such a catastrophe.

Kim straightened up. "She's got an acute abdomen," he yelled. "She's perforated!"

Without a moment's hesitation, Kim pushed up to the head of the bed and released the wheels. "Someone get the rear wheels," he yelled. "We'll use the bed for transport. We've got to get her to surgery."