Disease Beyond My Practice: Stories

By Glenn Vanstrum

DISEASE BEYOND MY PRACTICE--Stories

No one can survive a bi-polar world without a healthy dose of madness.

An infectious disease doctor falls in love with a dope addict/real-estate agent patient. A paranoid schizophrenic decides he must render himself sterile. A meth freak tries to destroy a trauma surgeon with a stolen tank. In a crazed universe, sometimes the only way to acquit oneself is through the insanity defense.

In these stories, characters discover the hoofbeats they hear may come, not from horses, but from zebras. A war correspondent with a spleen the size of a football returns home to get his first physical exam in a decade--and his doctor blows the diagnosis. A cardiac surgeon on safari, treating a patient dying from AIDS, finds enlightenment. One of a pair of Siamese twins seduces a psychiatrist, while the other empties his bank account.

Medicine is an art, not just a science. A doctor misjudges his son’s fastball and must learn to live within the limits of his own blind ambition. A man, confronting his checkered family history, must weigh the risks of donating half his liver to his brother. A plastic surgeon alters the appearance of a spy in a witness protection program and loses his clinic in the process.

Sometimes, it is nature itself that heals. A teenager on a magical Minnesota lake confronts both his own mortality and a budding awareness of the opposite sex. A pre-med student finds solace in both music and orb-weaving spiders. A young doctor struggles to keep a child alive high in the Andes, where love can be as scarce as oxygen, or as common as a mystic stone ruin.

The multiple ways people take ill--and become healed--may yet surprise, jaded as streaming media and 24-hour cable news have made us. Fiction, even as it entertains, can still lend insight into the hard-to-fathom depths of human suffering and rejuvenation.

• Language: English
• Publisher: Glenn Vanstrum
• Release date: Oct 30, 2011
• ISBN: 9781465940520

Glenn Vanstrum

Glenn Vanstrum’s fiction has been published in LITnIMAGE, the Bellevue Literary Review, and THEMA. His book of nature writing, The Saltwater Wilderness (Oxford), won a San Diego Book Award. Essays of his have appeared in Sierra, California Wild, and the Los Angeles Times.Vanstrum has written five novels and two story collections. Setting plays a major role in his character-driven fiction, work that often uses nature, music, or medical themes. His novels range from drama (Let Fall Thy Blade; Certain Stars Shot Madly) to historical fiction (Northern Liberties) to satire (S.I.C. Memorial). His latest work, Humboldt, a story set among the Northern California redwoods, is part roman noir, part satire, and part thriller.A Minnesotan by birth, Vanstrum majored in music at Grinnell College in Iowa and attended U.C.S.D. medical school. He has spent most of his life in California, where he practices anesthesiology.A professional nature photographer, he publishes images in numerous venues worldwide. Magazine credits include Audubon, Sierra, Terre Sauvage, National Geographic Traveler, National Wildlife, and Discover. The photographic stock agencies Animals Animals/Earth Scenes and Custom Medical Stock Photography represent his photographs.Vanstrum, a pianist from age five, still practices daily and performs works from the classical, romantic, and modern repertoire on a regular basis. A student of Cecil Lytle and the late Nathan Schwartz, he plays both solo and chamber pieces.The author, a lifelong surfer, has ridden waves in Hawaii, Mexico, Costa Rica, and Bali. Still riding a shortboard, he wipes out with great regularity.Further information on Vanstrum’s writing, including book reviews; music, including concert schedules; and surfing, including a surf blog; appears at http://www.gvanstrum.com"Glenn Vanstrum is a force of nature. In addition to being a published author (The Saltwater Wilderness, Oxford University Press, 2003), he is a concert pianist (and regularly performs complex pieces by Beethoven and Mozart in public venues near his home in San Diego), a highly regarded medical doctor, an accomplished surfer, an underwater photographer who has worked around the world, and a dedicated husband and father. Somehow, in this incredibly busy life, he continually produces exemplary works of fiction and non-fiction."I've known Glenn for fifteen years. In that time, I have read every single one of his books, and they are uniformly excellent. His fiction is distinguished by fast-paced plots, fascinating characters, amazingly realistic dialogue, and passages of great strength and beauty. His innovative treatment (in Northern Liberties) of Thomas Eakins' painting 'The Gross Clinic' was absolutely brilliant, and his collection of animal stories is par excellence--certainly in the league with such notables as Roger Caras and Ernest Thompson Seton."His non-fiction, best exemplified in the essays of The Saltwater Wilderness, reflects his love for the sea and dedication to the conservation of oceanic resources. In summary, any book by Glenn Vanstrum is worth reading and owning, and I enthusiastically encourage all those who value contemporary literature to explore the corpus--now available as e-books or print-on-demand--of this gifted American author. "--John A. Murray, senior editor, The Bloomsbury Review (1987-present); founding editor, the Sierra Club American Nature Writing annual (1994-2005); former director, graduate program in professional writing, University of Alaska; author of 42 books; recipient of Southwest Book Award and Colorado Book Award.

Book preview

Superbug

On the day the outbreak appeared, as on all her workdays, Valerie Hsiao did not rush to the hospital before first light like the anesthesiologists and surgeons. Nor did she arrive at eight a.m. with the other internists for clinical meetings and rounds. She specialized in infectious diseases, and the bugs kept all hours. Culture reports came out at eleven a.m. and nothing could be done before then, so she took her sweet time to sleep in, exercise, shower, and eat a leisurely breakfast of oatmeal, frozen blackberries, and walnuts.

Friday seemed like every other June-gloom day that envelopes San Diego with gray mist in early summer. She timed her arrival at Summit Memorial to 10:55, found what must have been the last parking spot in the doctor’s lot, and locked her ten-year-old Honda with a Club. Every year or so thieves pilfered an auto from the lot and hustled it across the border to Mexico. She’d read somewhere the Accord was the most commonly stolen vehicle in the United States. Even though Porsches and Jaguars surrounded her car, she put the extra lock on the steering wheel out of habit. Infectious Disease was not one of those specialties where you made tons of money, and she didn’t need the headache of a stolen set of wheels right now.

Valerie climbed the stairs to the fourth floor, entered the micro lab, and inhaled the familiar aroma of agar and media broth. At fifty, her herbal-creamed skin resisted wrinkling, but her eyes held a doctor-weary cast, and her black hair revealed every last streak of gray. For some stubborn reason she resisted using hair dye and refused to color away the signs of age. She’d had her share of lovers over the years, but only one offer of marriage--a guy who thought wedding an M.D. would benefit his gambling habit. She didn’t want to marry another physician, and she intimidated most of the other candidates, or they were deadbeats who wanted a free ride. She was not sure at what point a bachelorette become a spinster, but she decided she might be nearing it.

She mumbled greetings to Myra and Buzz, the day-shift techs, and walked straight to the printout. She had a dozen patients with cultures pending. Most of the results were expected, the odd urinary tract infection here, the negative swab of a wound there. But one report stood out.

Johann Fechner--3/4 BC +, Gm + in clumps. Coag pos. MR. VR. CLR. FR.

The cryptic letters seemed to leap out at her, to take her breath away. She sat down before she said anything.

Myra, Buzz. Is this some sort of a joke? Fechner’s Staph blood cultures--vancomycin resistant?

Myra examined a gram stain through a stereo microscope as Buzz diluted cultures on a rack lined with flasks. Both wore blue lab scrubs and plastic gloves. The two looked up from their work to give her the same, ominous gaze. For a long moment no sound could be heard but the bubbling of fresh broth in the sterilizer.

We checked and double checked, said Myra at last. It’s resistant to everything.

Don’t pick your nose after going near it, said Buzz.

A lame joke, nobody laughed. Valerie walked over to the incubator and stared at the cultures. Healthy colonies of Staphylococcus aureus, innocuous golden yellow blobs, grew over every plate. Not one zone of inhibition appeared in any of the antibiotic wells. The strain was methicillin resistant, vancomycin resistant, clindamycin resistant, you-name-it resistant.

I need to talk to the chief of staff. The culture report was a catastrophe. There’d been a handful of reports of vanco-resistant Staph in the country so far, but all had sensitivity to other drugs. This one could put Summit Memorial into the national news--best case--or, worst case, close the hospital down. Not to mention kill the index patient.

She walked over to a lab sink, poured antiseptic soap on her hands, and scrubbed them. Valerie was the senior I.D. doc at the hospital, and her attendance at meetings (if they weren’t held too early) and concern for doing things right led to her becoming the chief of the department. She was the one who spearheaded proper use of prophylactic antibiotics in the operating room. She was the one who pushed for strict handwashing for hospital doctors and staff. And she was the one who had mounted the--now failed--campaign to prevent overuse of vancomycin.

Dr. Hsiao. It’s Dr. Hillburton. Myra handed her the phone.

Something bad’s brewing in micro. Remember that dialysis patient, Johann Fechner? You worked on his A-V graft once.

Hillburton, a cardio-thoracic and vascular surgeon, preferred fishing off his boat in the Pacific to working in the hospital. He did volunteer to be chief-of-staff, though, so she knew he wasn’t totally lacking in ambition or community spirit.

Fechner? I remember him. Unfortunately.

He’s got three of four blood cultures positive for a Staph aureus that’s resistant to everything. Vanco, Cleo, Septra, methicillin. We’ve got to call the CDC, shut down the dialysis center, culture everybody who had contact with him. This is a friggin’ nightmare.

The surgeon, however, didn’t get it. Close down the dialysis unit? Isn’t that a bit extreme?

You don’t understand, do you? She imagined him on the other end of the line, a nautical chart spread out on his desk as he mapped his planned Saturday morning course on the high seas to catch yellowtail. Before World War II, before sulfa and penicillin, do you know how many people used to die from garden-variety Staph infections?

Yes, Valerie.

Don’t patronize me, Tony. This bug, if it gets out, could shut down the hospital. Shut down the city, even the country, if it gets into the community.

Surely the CDC’ll have something.

We’ll see. But I need your support in culturing every soul that came near Fechner in the last 72 hours. And we need to put a wall around that kidney unit.

You sure?

Yes, goddammit, I’m sure. Shouting and cussing at the chief of staff was not a common practice for Valerie, but with Hillburton acting like such a blockhead, she had no choice.

Next she talked to a Dr. Bjork at the CDC, who confirmed her fears and instructed Myra and Buzz on how to freeze samples of the culture at -60˚ C in Brucella broth containing 15% glycerol. They would ship them overnight to Atlanta. She left the lab, put on a starched white coat, and hiked up four flights of stairs to the dialysis ward.

As she caught her breath from the climb, she glanced into the dialysis unit itself, where eight patients sat in vinyl easy-chairs hooked to machines lined with rotating pumps, tubes of blood entering and leaving them via vascular shunts. The patients, cachectic faces lined and skin color gray, looked stoic and bored. Neither they nor their caregivers showed any hint of impending catastrophe. Valerie approached the nursing desk.

May I speak to the unit supervisor, please?

The ward clerk, deep in a phone conversation, paid no attention.

I need to speak to the supe.

She was never sure if people ignored her because she was small, or because she was Asian, or because she was a girl. But her blood pressure started rising.

Dammit. It’s an emergency. Where the hell is the nursing supervisor?

Oh, sorry, Dr. Hsiao. I didn’t hear you. She’s at a meeting in 803.

Valerie stomped to the room on the ward that had been converted to an office and filled with rows of computers, telephones, and swivel chairs. A half-dozen senior nurses sat deep in conversation; all six wore fashionable dresses and shoes under doctor-like white coats. She listened for twenty seconds to get the gist of the conversation. It involved nursing staffing, the new designation of the ward as a step-down unit, and an unfunded state law mandating strict nurse/patient care ratios.

I have a solution to your staffing problem, she said, interrupting.

As one they turned and looked at her.

Yes, Dr. Hsiao? said Jackie Morton, the lead in charge. A short, rotund woman, she wore a string of pearls and a pair of gold hoop earrings.

Mr. Johann Fechner in 838. You know him?

Yes. She grimaced. What’s wrong now?

He’s growing a Staph in his blood resistant to vanco, methicillin, and just about every other antibiotic known to mankind.

The nurses rolled their eyes in unison. They all knew Fechner.

Figures, said Jackie. But how’ll that solve our staffing situation?

We’re shutting down your unit. As of noon today, in exactly five minutes. I’ve talked to Tony Hillburton, chief of staff, the infection control team, and the CDC. Everyone on this floor, everyone in the hospital who sets foot here, will have to get a nasal swab culture. The eight dialysis consoles—we need to culture ‘em, tear ‘em apart, and sterilize ‘em.

But what about our patients?

Once they’re culture results are known, we’ll bus them up the freeway to Hobart Memorial.

It’s going to cost a fortune and delay dialysis in dozens of patients. What about our nurses?

Culture their noses, get perineal skin swabs, and send them home.

There was shocked silence in the office. Valerie didn’t have time to nurse the nurses, though.

I’ll be in the lab if you have further questions. After I speak with Mr. Fechner.

§

Fechner, a juvenile-onset diabetic, contracted renal failure eight years earlier. Two years after that, reacting to a life dependent on a contraption that washed urea and potassium from his blood three times a week, he became an intravenous drug abuser. He had never-ending access problems at dialysis because of infections due to his poor circulation, and because of his habit of shooting up dope and falling asleep--without moving--for hours. This behavior would, without fail, clot off his arterio-venous fistulae. They started him with arm grafts: left, then right, forearm, then upper arm. Now the surgeons were digging into his legs, although his diabetes had already blessed him with a left below-the-knee amputation.

The result of this medical history: Mr. Fechner had morphed into a giant Petri dish for resistant bugs. He’d received more doses of vancomycin in his life than the administrative nurses sipped cups of coffee.

Barrier materials and a sink stood halfway down the hallway; Valerie stopped to put on gown, gloves, and mask. She filled out a Strict Isolation sign and pasted it to the doorway of room 838. Taking a deep breath, she entered.

Mr. Fechner?

Yo, mama.

Mr. Fechner, forty-four years old, looked thin enough to be called emaciated. He’d traded in his hospital gown for a blue velvet bathrobe and sported a salt-and-pepper beard, a diamond earring in his left ear, and a huge smile, although several key front teeth were missing. An amazing thing about Fechner: In spite of his diabetes, his end-stage renal disease, his dialysis, his amputation, and his drug addiction—he held down a job. Fechner, a freelance real estate agent, worked in National City, where $200,000 houses appreciated faster than anywhere in a city with a volatile market and an average home price of half a million. He was the sort of smooth talker that could sell a blind man a Corvette. Another thing about the guy: He had health insurance. Not MediCal, not Medicare, but real honest-to-goodness Blue Cross PPO health insurance. He kept paying the premiums on a policy bought before he got sick; in return, he received back a thousand-fold in care.

Today, though, a shadow filtered through the man’s smile. He did his best to maintain his bonhomie, but he looked thinner than usual. A dullness dimmed the sparkle in his eyes.

Mr. Fechner, remember me? Dr. Hsiao.

Of course I remember. But why would a lovely lady like you hide behind such a get-up?

Your blood cultures came back positive, Mr. Fechner.

I suspected that, Valerie. But why the mask and gown? They form an impediment to our getting to know each another. And please, dear heart, call me Johann.

The third thing: Fechner was a hopeless flirt and lady’s man. Along with his sales gift, he could make any woman feel twenty years younger and thirty years sexier.

Valerie ignored his charms.

Johann. Remember those fevers you’ve been having?

He nodded.

Your blood’s crawling with a nasty bacteria. It’s the source of the fevers. We don’t know what antibiotic to give you yet. We’re sending a sample to the CDC for their help.

The CDC?

Yes. In Atlanta.

Fechner fell silent. His mask of flirtation slipped away, and he looked sick and miserable. He folded and unfolded his good leg and his prosthesis. He wore matching corduroy slippers, a wardrobe touch that lessened the impact of the artificial foot.

I’m warning you, she said. Even though you don’t feel very energetic—he had spiked a fever at 6 a.m. to 104˚ F—you’re not to leave this hospital room until we figure out what medicines to give you.

But I can’t smoke here.

She felt her patience whither.

Mr. Fechner. You don’t get it. Nobody did. Not Halliburton, nor Morton, nor Fechner. This could be the worst organism we’ve isolated in the entire United States. Worse than Ebola or some other jungle virus. Everybody has Staph growing on them. If this bug gets out in the community, we could lose the ongoing jihad microbes wage against us. Your body, Mr. Fechner, is now the Baghdad of that war.

She left the room, dumped the gloves, mask, and gown in a bin, and washed her hands for thirty seconds. Then she called Eliza Dunwood on her cell phone. Eliza, the infection control team nurse, was one person who got it. A no-nonsense gal about thirty year old, she was blessed with the kind of figure and blonde hair a woman like Valerie could only dream about.

Yes, Val?

We need to put a 24-hour watch on Fechner. He’s not to leave his hospital room.

I’ll make sure.

He wants to scoot up to the roof to get his nicotine fix.

Darn that rascal. We’ll assign him one of those suicide guards from Psych.

Make sure they wear gowns, gloves, and masks.

We’re doing everything we can to shut down the dialysis unit. A couple of patients, though, have high potassium levels. They can’t wait three days for culture results and a transfer to Hobart.

Can the dialysis company send out a new, clean machine? The hospital contracted with an outside company to supply dialysis nurses and equipment. That, she knew, was part of the problem. The infection control practices of such companies were not as scrupulous as she would have liked.

I’ll ask.

Don’t ask. Tell.

What a nightmare of a day. Staph aureus. In Latin, ‘aureus’ meant ‘gold.’ Far from bearing riches, though, the bacterium, a brutal pathogen when unleashed and unchecked, could turn a human body to mush in twenty-four hours. Valerie had to get some kind of antibiotic going on Fechner, or he’d be dead soon. At the nursing station, she found his chart and wrote an order to begin linezolid and quinupristin/dalfopristin, newly synthesized drugs seldom used in the hospital. Linezolid caused nausea and the pristins muscle aches and pains, but they might save Fechner. She doubted the bug would be resistant to them. It had better not be.

She needed time to think everything through, and she was starving. It was already 1:30 p.m. She ignored the elevator and ran down the eight flights of stairs to the doctors’ lounge. It was deserted and silent, except for Fox News blaring an interview by some bloviating right-wing idiot. She shut off the television and found a stale bagel and a foil-wrapped pack of cream cheese. As she spread the cream cheese she noticed a small boil on her right index finger. Odd. It hadn’t been there last night. She pressed it with her left hand. About the size of a BB, it was raised and tender. She knew she would have to lance and culture it later in the lab.

After the bagel and a cup of coffee, she felt better. She reviewed her flurry of actions from the morning and decided she’d gotten things rolling, but much remained to be done. Since her mother and father died two years ago she’d become a workaholic--after her relaxed mornings, she routinely put in twelve hour days. Funny how she would drift and muse about her parents at the most stressful times: her mother, puttering with her orchids in the greenhouse behind their hillside Oakland home, her father, the retired Berkeley professor with his library and lectures. They had been such gentle and understanding people--although her failure to marry had been a sore spot marring her relationship with them. If only she could have met a younger equivalent of her father, someone as handsome, knowing, and empathetic...

Her beeper erupted and destroyed her reverie. The hospital operator held Dr. Bjork on the line from the CDC.

We’ve decided to send a team to Summit Memorial, Dr. Hsiao. They should be there this evening.

Can you bring extra linezolid and quinupristin/dalfopristin? We have only enough for seven days for one patient.

Can do. We’ve never encountered Staph resistant to those drugs, especially linezolid. If your bacteria has that plasmid, we’re talking about a superbug.

My bacteria?

The Hsiao strain. It’s official now, named after you.

Valerie refused to feel honored.

I’d rather have my name associated with the cure.

§

Back in the lab she prepped her index finger with Betadine, waited for the iodinated solution to dry, and speared the abscess with a sterile 20-gauge needle. She pressed a culture swab against it and milked creamy white pus into the cotton tip. She took a second swab and prepped a slide for a Gram’s stain; afterwards she washed her hands, put a Band-Aid on the wound, and slipped a glove over that.

Myra. Swab this out for aerobes, anaerobes, acid-fast, fungal.

What’s the source?

My index finger.

Uh-oh.

Five minutes later she had the stain done. She slipped it under the microscope, focused, and stared at blue clusters of bacteria. Gram-positive cocci bunched like wine grapes--Staph aureus. Wondering what the sensitivities were, she started herself on an oral antibiotic, cephalexin, and hoped she wouldn’t need linezolid and the pristins like Fechner. She’d never gotten near the man. Never touched him.

§

At ten p.m. she drove the Honda down to Lindbergh Field and met the CDC team, a doctor and two nurses. Her infected finger protected by the glove, she avoided shaking hands with any of them, including the leader, Dr. Zollnick, a young man with black-frame eyeglasses and a body so slender--Fechner-thin--she wondered if he ate more than once a day.

In baggage claim they collected three hundred unit doses of linezolid and quinupristin/dalfopristin packed in boxes of dry ice. They also picked up a large aluminum case, some sort of portable laboratory.

We know you have a state-of-the-art lab, said Zollnick, but we wanted to get a separate set of cultures growing and send them back to Atlanta. Just in case.

Zollnick told her he’d just gotten back from Central Africa, where he’d been investigating a hemorrhagic fever outbreak in the Congo.

That Marburg virus... He shook his head. People bled to death through their eyeballs. Valerie drove him to the Hilton on Mission Bay, the rest of the team following in a rental car. After briefing him on what she’d done, she left to go home and get some sleep. It was midnight. Fog still wafted in off the ocean.

§

A throbbing in her finger wakened her the next day, a Saturday. She ran to the bathroom and saw that the knuckle was swollen and erythematous--the skin had become inflamed, an ominous purple-red. She soaked it in a bowl of warm, soapy water as she read the morning paper and ate her oatmeal, trying to ignore it, doing her best not to panic. She swallowed another 500-milligram cephalexin pill. The digit hurt too much for her to continue with her usual exercise routine, so she showered and dressed and drove to the hospital through the fog grasping the steering wheel with her good fingers.

Her beeper buzzed as she pulled into the hospital--the nursing unit on the 8th floor. She rode the elevator, not feeling up for the stairs, and went straight to the barrier station, where she pulled a glove over her right hand.

Doctor Hsiao. It was Jackie Morton. She looked tired; dark bags hung under her eyes.

Yes, Jackie?

Fechner’s short of breath. He’s spiking fevers. Blood pressure’s dropping.

She slipped on latex gloves--double covering the right hand--as well as a gown and mask, and entered 838. Fechner sat up in bed, gasping. Sweat dampened his blue velvet robe. His eyes were glassy.

Johann?

He tried to answer but his labored breathing took all his energy. Valerie felt his pulse. It hummed faint and fast. His brown skin dripped sweat. Petechiae covered him, tiny purple spots she could just make out through his dark pigment. She took a look at his distended neck veins and slipped the stethoscope off from around her shoulders. The lung fields crackled. She placed the bell of the scope over his heaving chest. A loud murmur grated. The obvious diagnosis: acute mitral regurgitation from endocarditis. The infection had spread to his heart.

She raced back to the nursing station.

Get Hillburton right away. Reach him on his damn fishing boat if you have to. And page the intensivist on call, stat. Get the crash cart. We need to tube Fechner, transfer him to an isolation room in the CCU. Also, order a stat trans-thoracic echocardiogram.

Anything else, Doctor? said the ward clerk, her voice sarcastic.

She felt her finger throb and her head grow dizzy.

Yeah. Page Dr. Zollnick overhead. I need a doctor myself.

§

Valerie opened her eyes and stared with blurred vision at what appeared to be a hospital room. Narrow bed, a white electric cord at her pillow ending in a button, a tray table with a glass of water and a telephone, i.v. bag dripping into a tube attached to her left wrist. No doubt about it. She was a patient. She looked to the right, saw that somebody had wrapped her right hand in a large dressing and elevated her arm on pillows. A sharp pain ran down to her elbow. The sour smell of rotting flesh rankled her nostrils.

It all came back to her. The resistant Staphylococcus. Fechner. The CDC. Surgery on her finger. She had no business sitting in a hospital bed. There was too much to do.

She reached over with her left hand and found the phone on the tray table. Reflexively, she dialed the lab.

Myra. What’s going on?

"We