Working too close to home
Elizabeth Hesse

I startled at the sound of knocking on my open office door. Although it was only nine in the morning, I have been in for two hours, and was so engrossed in the charts I was poring over that I forgot where I was.

I looked up to see Dr. Steven Howard, a young researcher new to the BSL-4 group at the United States Army Medical Research Institute for Infectious Diseases, or USAMRIID, as it was commonly called. “You look very professional today, Dr. Fontenot,” he said with a secretive smile as he took a bite of his bagel, looking more like he should be posing for a Gap commercial than preparing himself to wear a blue plastic “spacesuit” all day.

“I don’t have to be in the lab today. I can actually look professional,” I replied, suspicious that something was going on.

“Yeah… You’re needed in the lab, by the way,” Dr. Howard replied slowly, the smile stretching into a grin.

With a roll of my eyes, I pointed at the calendar next to I desk. “I’m on charts today, which means that I’m not supposed to be in the lab. Besides, I’m a pathologist who has not had the chance to cut anything up in over six months. If I wanted to be doing lab work all the time, I would have gone to grad school, and not had to sell my soul to the Army to pay for med school. I’m tempted to tell Jackson that I’m not going in there again until he finds me a body.”

The grin now from ear to ear, Howard said, “Did you know that we only have one Level 4 pathologist on at a time this week?”

I groaned as I tossed my pen aside. I was scheduled to have the weekend off and was planning on leaving early that day and spending some time relaxing with my husband and kids, possibly going camping in the nearby mountains. Autopsies in the BSL-4 lab, with the bulky spacesuits and dulled instruments, took an average of seven hours each. If there really was a body in the lab, there was no way I was leaving early.

“So what’s the story?” I asked with a sigh as I removed my wedding ring, one of the few pieces of jewelry I ever wore.

Howard shrugged. “All I know is that a team brought a body in via Level-4 isolation half an hour ago, and you, being an autopsy-happy pathologist and in the office today, gets to do the post.”

“It must be my lucky day,” I replied as we headed down the hall toward the lab. Standing in a hot, bulky suit with no food, drink, or bathroom breaks for hours always makes me feel lucky.

Throughout my career at USAMRIID, first as an officer in the Army and later as a civilian with the same job and much greater pay, I have seen many bodies decimated by many different diseases. I have opened the chest cavities of Ebola victims to see pools of blood after their organs became completely porous. I’ve removed skin samples of patients who died of group A strep, known as the flesh-eating bacteria. Yet every time, I’m always taken aback by the latest patient. I still get shocked and a little scared every time I saw how tiny bits of life—or in the case of viruses and prions, bits of non-life—could bring a person to my table.

This particular patient was different than most. First of all, she was Caucasian, which was rare, as most BSL-4 organisms attacked in tropical locations, such as the Caribbean, Africa, and South America. Second, her symptoms didn’t match anything I or Captain Michael Thomas, my pathology assistant, had ever seen before. Rather, it looked like a combination of everything we’ve seen before. Her skin was red and scaly, not unlike necrotizing fasciitis, the result of the flesh-eating Group A strep. Where her skin was broken, and from every orifice, caked blood indicated some sort of hemorrhagic disease. Near her mouth and nose, mucous was mixed with the blood, indicating some respiratory ailment.

I turned to Capt. Thomas and took a deep breath. “You ready for the external examination?” I asked loudly. Even with the built-in microphones in the suits, it still took effort in order to make myself heard above the constant flow of air in the suits. He nodded in reply and held up his camera as proof.
While he began taking pictures from every angle, I began dictating into the small microphone built into my spacesuit. “Patient is a Caucasian female, approximately 18-22 years of age,” I began. So young—about the same age as Nicolette, my eldest daughter.

We had been in the lab for three hours already, and were almost done with the external examination; all that remained was the hands. It had been a slow process that day, because the bright red rash made looking at the skin very difficult. External exams were always my least favorite part of the autopsy, and slowing going over every inch of skin with a hand lens did not make it any more fun.

“Whoa,” I said softly as I picked up the right hand. “Captain, did you get a picture of the right hand?”

“I believe so,” the young assistant replied.

“Then how did you miss this?” I asked sharply. I’m normally very easy going in the autopsy suite, or at least I like to think so, but I don’t handle mistakes very well.

I held up the right hand for Capt. Thomas to see, making sure to point out the small red bite marks on the middle finger. They weren’t blatantly obvious, not with the rash and post-mortem degradation, but a trained pathologist’s assistant like Thomas should have seen them immediately.

“Monkey?” he asked, hoping to make up for his mistake.

“I think so,” I replied thoughtfully. “A small monkey, if so. I’d like full pictures of this and a cast for the vets to look at. I think we might have found our mode of transmission.”

Thomas rushed to get the supplies while I dictated the findings. I’m sure he hoped I would get over the transgression quickly; level 4 autopsies were awkward enough without any added drama.

“Did you set samples aside for the CDC?” I asked as I slowly removed a dulled, threaded needle used to close the Y-incision, the incident of five hours ago long forgotten. Closing the chest was a useless procedure, because the body would never lie in a casket—incineration was the only option at this point—but it was standard protocol, and didn’t take much time.

“Yeah. What department did you want those to go to?” Thomas asked as he continued labeling vials.

I was about to tell him to send them to the Emerging Infectious Disease department, which was standard procedure, when I thought of the nature of the disease. Usually I have a fairly good guess as to what pathogen killed a person after an autopsy, but this one had me stumped. The lungs suggested pertussis, the intestines and bowels looked almost like Campylobacter, and the skin still made me think group A strep. There was only one person I would trust with a case like this one.

“Microbiology,” she replied confidently. “Dr. Victoria Luttrell.”

Torrie Luttrell and I met years before we began working in similar fields, years before either of us was ever referred to as “doctor”, when we were Lisbet Dreiser and Torrie Holmes. It was the summer before our senior years in college, and a common love for the sciences brought both to Emory University for the Summer Undergraduate Research Experience. Our similar career goals and desire for juicy gossip brought us together as fast friends, a bond which has lasted over twenty years and great distances apart.

“Lisbet! You’re working late,” Torrie commented as she picked up the phone.

“No kidding,” I replied dryly. “So how are the kids?” We exchanged pleasantries for a few minutes, then it was all business.

“I’m sending you samples of my case today. I think you’ll find it very interesting,” I told my old friend.

“Level 4 stuff?”

“Of course.”

“What’s your gut reaction?”

I chuckled bitterly. “This one has me stumped. Respiratory system says pertussis, GI tract says Campylobacter, skin says necrotizing fasciitis, and then there was a great deal of hemorrhaging as well. I’m definitely thinking bacterial, though, which is why it’s going to you.”

“You know, a bad streptococcus could cause all of that.”

“Yeah, but it doesn’t seem right. It could be many different bugs all at once, but I really don’t know what the odds of that would be. I’m thinking it’s one, and one that we haven’t seen yet."

“Well, I must admit, I’m intrigued. I’ll take a look at it and see what I can find. I’ll let you know as soon as I know anything. You going to be working on this over the weekend?”

I sighed in frustration. I wished I could say no, but I knew that that would be a lie. “Yeah. I was supposed to take this weekend off and spend some time with Etierme and the kids, but I guess that’s not going to happen.”

“Probably not,” she replied thoughtfully. “Well, have a good time looking at this stuff. I know I will.”

“Yeah, it’ll be a blast. I’m going to be in Atlanta for an Epi conference in a few weeks. You going to be around?”

“I have no other plans. I’ll see you then.”

I was taping a double pair of gloves at the wrists after changing into BSL-4 scrubs the next morning when I was paged to report to my boss’s office. Frustrated at having wasted the time it took to change, I quickly changed back into street clothes and headed toward the office space, prepared to make sure Colonel George Jackson heard about this as soon as I arrived at his office.

“I have an assignment for you,” he said before I could speak.

“I already have one,” I said, too confused to yell at him as I had planned. “The autopsy from yesterday.”

“Same case,” he replied, never wasting words. “I’ve constructed a special Epidemiological Intelligence Service team for this. You leave in an hour.”

“First of all, I’m supposed to be at home with my family right now, not being sent to whoever-knows-where with an EIS team. Second, it’s one case. That’s hardly an epidemic,” I argued.

“One human case,” Jackson corrected. “Along with twenty capuchins. It’s actually on your old stomping grounds.”

Thinking he was referring to Emory, where I spent five years of my life earning my MD and MPH, I was about to ask why the CDC, literally across the street from Emory, wasn’t handling it. Then he continued: “Hiram College.”

Ah, those stomping grounds. The place where I spent four years earning my BA in Biology and Biomedical Humanities. Yes, those were my old stomping grounds, but that wasn’t all: they were also Nicolette Fontenot’s current stomping grounds.

My daughter was following in her mother’s footsteps, mostly against my protests. She was planning on going to med school, and decided to attend the small Hiram College in northeast Ohio instead of a bigger pre-med school like Harvard, Johns Hopkins, or Emory. She said she wanted the smaller, more personal environment. I must admit, it seemed to be working well for her. She was currently taking microbiology, actually with the same professor I had more than twenty years ago.

“An hour?” I asked with a heavy swallow, forcing myself back to reality. “I better get my stuff ready.” There was no way I was missing a chance to make sure that that my daughter didn’t end up like the young woman I saw the day before.

“So how many capuchins?” Dr. Andrew Renton, the chief veterinary pathologist, asked later as he taped his gloves to his wrist in the portable dressing room the team set up.

“Twenty,” I replied, also taping my gloves. “And you know the rules: you do all of them, and you’re not in the suit for longer than eight hours at a time. I want you out for four hours between shifts.”

“That’ll take me about five shifts to complete,” Renton pointed out as he checked his suit for tears.

“That sounds about right,” I replied calmly as I contemplated whether I would need a BSL-3 or –4 suit.

“But if everything goes well, we’ll have this thing figured out before you’re done.”

“Let’s hope so. What are you going to be working on?”

I thought about the rest of my team. There was Dr. Renton and his veterinary assistant. They would be doing capuchin autopsies most of our time here. Then there was Dr. Travis Robbins, an internist with a specialization in infectious diseases. He would be treating patients. Lt. Peter Lund, the youngest of the team and on his first EIS mission, was an epidemiologist, and would be interviewing people. As both a physician and epidemiologist, I was qualified to do either job. “I’m going to start working with Travis and check up on Pete every now and then. I’m also going to talk to some of the girl’s professors and see if they can shed any light on the situation.”

“What was she taking?” Renton asked, now through the microphone built into the portable space suits.

“Microbiology,” I replied as I stepped into my suit. I had settled for BSL-3. Despite the improvements that have been made to BSL-4 suits since my first time wearing one almost twenty years ago, they were still atrocious. BSL-3 suits were more comfortable, and I wouldn’t be dealing with anything that could make me sick. I hoped.

“Same as Nicki,” he said matter-of-factly.

“Yeah,” I replied. I hoped there was no correlation between her class work and cause of death.

“You have a phone call, Dr. Fontenot,” Lt. Lund called out. Our first eight hour shift was behind us, and I had been trying to get some sleep. I didn’t need an interruption right then, but as the team leader, I didn’t have much of a choice but to answer it. Besides, I could go without sleep; at least, I was able to last time I spent significant time at Hiram College.

“This is Fontenot,” I said when I picked up the phone, the displeasure obvious in my voice.

“Did I wake you?” the caller asked playfully.

“Actually, yeah. I worked for eight hours and tried to get four hours of sleep. That’s what happens on field missions, but I guess you lab rats wouldn’t know about that,” I told Torrie.

She laughed. “You’re right. We just work as many hours straight as necessary. I got your mystery disease sequenced.”

“That was fast. I remember when it used to take weeks.”

“So do I. I’m a fan of the new system. Anyway, you have Group A strep, but it’s highly mutated. It appears to have picked up some genes from pertussis, campylobactor, cepacia, and agrobacterium. I’ve never seen anything like it before.”

The pertussis and campylobactor didn’t really surprise me after the autopsy, but the agro didn’t belong. Well, it didn’t belong in Group A strep, but I did know one place nearby where I could find it.

“Thanks, Torrie. You’ve been a real help, as always.”

After hanging up the phone, I dressed in a Level-4 field suit as quickly as the bulky rubber and plastic would allow, and headed for the microbiology lab. It was early in the morning, but not so early that the lab was deserted, as I had hoped. One tall, athletic teenage girl was standing at a filter hood, her long dark curls hanging down her back.

“Nicki,” I said simply, a bit taken aback at the sight of my eighteen-year-old daughter in the lab at six in the morning.

She turned, surprised to hear anyone, especially anyone with a voice distorted by the small speakers built into the suit. When she saw my outfit and the expression on my face, she broke down and began sobbing.

“It was all a mistake,” she began. I listened carefully as she told me the story.

“Meredith Conners was a senior double majoring in biology and psychobiology,” I began a few hours later, sitting in the field decon room, surrounded by my team. “Microbiology was her final requirement for the biology major. Micro at Hiram is a minimum of eight hours a day of lecture and lab. About two weeks ago, shortly after the course started, Meredith went into the Health Center with a sore throat, and was diagnosed with strep, but didn’t—couldn’t, really—back down from the workload.

“A little over a week ago, she was working alone in the lab, trying to finish one last project before the weekend. In order to finish quickly, she kept a beaker near her workbench for liquid biohazard waste instead of walking to the main waste container for each sample. After finishing her work, she cleaned her workbench, and knocked the beaker over, splashing the biohazard waste containing B. cepacia, B. pertussis, A. tumefacins, and C. jejuni onto her face. These bacteria recombined with the streptococcus already in her system, and her weakened immune system could not combat the newly-mutated bacteria.

“The capuchin bite came a few days after that, during a routine afternoon feeding. Another student, who was with her at the time, says that a coughing fit caused Meredith to place her hand on the cage, and a monkey, either viewing this as aggressive behavior or confusing it with food, bit her finger.”

“So it was the route of transmission, just not in the direction that you thought,” Dr. Renton commented.

“Yeah. The monkeys got the bacteria from Meredith, not vise versa.” I paused, remembering Nicki’s sobs as she told about her friend’s fate and her own fears. “Fortunately, none of the students or staff have tested positive for the bacteria, so I believe our work here is done. Andrew, pack up the remaining capuchins, and autopsy them back at USAMRIID. The rest of you, take care of decon and pack up camp.”

“What’re you going to be doing?” Lund asked.

“I’m sticking around to make sure nothing else happens, and I have some more business to take care before heading back to Fort Detrick.”

Hiram in the spring always confused me. The weather would be warm one day, snowing the next, with no rhyme or reason. It was the warm nights like the current one I always loved.

“So what were you thinking, Bill? Why those bacteria?” I had been wondering that since Nicki told me what happened in the lab.

My old microbiology and genetics professor rubbed his tired eyes. “I don’t know. This is the last class I ever teach. I wanted to go out with something different, something big, something the students would remember.”

“And you thought pathogenic bacteria would do the trick?” I asked sadly. “A girl died, Bill. I worked with Agrobacterium for ten hours a day for three weeks when I took micro, and I loved it—I later decided to dedicate my life to bacteriology and chasing diseases. The bacteria aren’t what makes microbiology memorable. It’s more than that. The students are either going to love it or they’re not, and the microbes they get to play with aren’t going to change that.” We sat in silence on the bench in Martin Commons for a few more minutes before I got up to find my daughter. I turned once as I walked away and saw my old mentor still sitting where I left him. I once admired him for his desire to do research for the sake of learning, not out of a desire to be remembered or idolized. I couldn’t help but wonder when or why that had changed.