Friday was a bad day in the E.R. Even before the creepy, ominous news came from New York -- and later Nevada -- about more anthrax, our hospital, a 700-bed megacenter, was full beyond capacity. There were more than a dozen patients in the E.R. "boarding" as inpatients, waiting for intensive-care beds. As recently as two years ago, that was unheard of, particularly on a nice balmy day in October.
But the president had spoken to the nation about the FBI's broad terrorism warning the night before, and while the speech and the overcrowding may have been entirely unrelated events, the coincidence was depressing. And as one last terrible portent, the waiting-to-be-seen boxes were full. Patients who had registered three or more hours ago were still waiting to be seen.
My first patient, an Asian woman in her 40s, had a measles-like rash, a high fever and a bad headache. There was no earthly reason for me to suspect smallpox. The rash was wrong. The natural progression of the disease didn't fit. Below her left shoulder, there was even a smallpox vaccine scar. But still, my stomach flipped and never settled down.
I called for the infectious disease specialist. "Sure does look like measles," he agreed.
"Why the hell does a grown woman have measles?"
Yeah, it happens, and there was, of course, nothing suspicious about it. Unless an hour later, the number of anthrax cases happens to double.
A resident physician checked out CNN on the Web from a computer in the treatment area, and saw the first report of the NBC anthrax case. She had just spoken with a friend who "knows things" at the Pentagon (in Washington everyone has a friend who "knows things" at the Pentagon) who had told her that "stuff" was already happening on both coasts.
My infectious disease consultant and I traded glances. A suspicious infection or not? Simultaneously we said, as casually as humanly possible, "Let's get some labs." "And a chest X-ray," he added. Smallpox leaves no traces on a chest film, but plague and anthrax do, as do a smattering of other bioterror agents.
As word of the New York anthrax cases filtered through the E.R. and the waiting room, patients started making their way to me. It was clear they all had seen "Special Report: America Panics Again." Few patients were brave enough to actually ask if their symptoms were something uglier than first suspected, but the look was in every face.
Some days in the E.R. we see nothing but car wrecks and work accidents, but on other days, we are deluged with the new virus hitting town and this was one of those days. Every patient's complaint seemed to begin with "fever and "
The E.R. doc who heads the hospital's disaster committee, and has been on double or triple duty since Sept. 11, came in ashen-faced. "The Public Health Department's sending us a 'rule out anthrax.'"
As we spoke, the hospital was setting up a procedure with the state epidemiologist to swab noses and send appropriate cultures for the foreseeable future. Our nursing coordinator tacked on every desk daffodil-yellow signs, emblazoned with a big, bold 800 number for the Public Health Department. The number to call to report any "suspicious" infection.
At 3 or so in the afternoon, by which time every infection was suspicious, a lawyer in his 30s came in with the worst story of the day. A healthy, active guy, he had been fighting a cold for the past two weeks. His doc had put him on an antibiotic a few days back and he had actually begun to improve for the first day or two. But that day, Friday, he woke up weak.
A medical student presented the case to me, so at first I didn't believe a word of it. When he reported that the patient's forearms and calves were weaker than his upper arms and legs, he had my full, undivided attention.
Guillain-Barré syndrome? Or was it botulism?
I had already turned to the Johns Hopkins bioterrorism Web page once that morning to look up the pictures of cutaneous anthrax and smallpox rashes to make sure my first lady didn't have them. I turned back again to read up on botulism. I had visited the page several times already since Sept. 11, but clearly, I hadn't retained much. Maybe I hadn't wanted to.
Stomach lurching, and dark bands tunneling my vision -- at this point I was having a full-blown panic attack -- I read the page twice: My patient had absolutely no botulism symptoms. Botulism descends -- from paralysis of the mouth, eyes and upper respiratory tract to the rest of the body. Guillain-Barré syndrome ascends, from fingers and toes up to the arms, and then to the respiratory musculature. And typically, it does so following a two-week period of mildly viral symptoms.
I called a neurologist who confirmed my opinion and I called back the infectious disease specialist who had been called to answer similar questions at another E.R. No, this guy didn't have botulism, just like the first lady didn't have smallpox.
Meanwhile, media teams descended and pulled docs out of the E.R. to give "reaction" to the news from New York. Patients continued registering at the front desk with sniffles and aches. Spores in envelopes continued to turn up across the country. A guy stuffed powder into a vent onboard an airplane at Dulles, just a few miles away. Flu won't even begin to enter the picture for another six weeks or so.
The disaster chief looked a little less ashen by the end of the day, and beds had opened up a little. Then we heard about the spores in Nevada. A normally unshakable guy, even the chief was getting rattled.
I started chanting what has become my new mantra, a British-ism straight out of the Royal Air Force that came from a Pentagon friend who knows things. "Steady the buffs, old man," I told myself, "steady the buffs."