Sierra Peaks: A Novel of Bioterrorism

By Blair Beebe

Few experts in the world know more about Asian epidemics than Dr. Luke Lucas and his microbiologist wife, Lynn. But as a stream of new patients travel from the same city in Uzbekistan to the emergency room at University Hospital in San Francisco, each hopes for a miracle that the doctors are not sure they can deliver.

As the hospitals capacity is tested with patients battling tuberculosis caused by microbes resistant to all antibiotics, other victims wander the city, coughing amid crowds of people and creating a public health disaster. Now forced to battle against the complacency of the press, the police, and even some health officials who fail to appreciate the magnitude of an impending epidemic, Luke and Lynn must race against time as they attempt to determine whether or not they are facing an act of bioterrorism. And if so, is it too late to stop the attack?

In this medical suspense novel, two doctors struggle to uncover the cause of a highly contagious and lethal illness ravaging the streets of San Francisco.

• Language: English
• Publisher: Archway Publishing
• Release date: May 16, 2016
• ISBN: 9781480831292

Blair Beebe

Blair Beebe, MD served as physician-in-chief of the Kaiser Permanente Medical Center in San Jose, and later as associate executive director of the Permanente Medical Group in the Northern California region. He was also a member of the clinical faculty of the Stanford University School of Medicine. Sierra Peaks is the final installment of a trilogy.

Book preview

Copyright © 2016 Blair Beebe.

All rights reserved. No part of this book may be used or reproduced by any means, graphic, electronic, or mechanical, including photocopying, recording, taping or by any information storage retrieval system without the written permission of the author except in the case of brief quotations embodied in critical articles and reviews.

Archway Publishing

1663 Liberty Drive

Bloomington, IN 47403

www.archwaypublishing.com

1 [phone]

Because of the dynamic nature of the Internet, any web addresses or links contained in this book may have changed since publication and may no longer be valid. The views expressed in this work are solely those of the author and do not necessarily reflect the views of the publisher, and the publisher hereby disclaims any responsibility for them.

Any people depicted in stock imagery provided by Thinkstock are models, and such images are being used for illustrative purposes only.

Certain stock imagery © Thinkstock.

This is a work of fiction. All of the characters, names, incidents, organizations, and dialogue in this novel are either the products of the author's imagination or are used fictitiously.

ISBN: 978-1-4808-3128-5 (sc)

ISBN: 978-1-4808-3129-2 (e)

Library of Congress Control Number: 2016907178

Archway Publishing rev. date: 05/16/2016

TABLE OF CONTENTS

CHAPTER 1 SAN FRANCISCO

CHAPTER 2 LUKE AND LYNN

CHAPTER 3 INSPECTOR PASQUAL

CHAPTER 4 CHARLES

CHAPTER 5 JINGO

CHAPTER 6 ANATOLY

CHAPTER 7 THE ASSASSINS

CHAPTER 8 THE HAIGHT-ASHBURY

CHAPTER 9 ABDUL AND FAHAD

CHAPTER 10 THE EPIDEMIC

CHAPTER 11 STAKEOUTS

CHAPTER 12 THE OLD BALL GAME

CHAPTER 13 THE TENDERLOIN

CHAPTER 14 THE RAID

CHAPTER 15 VOLUNTARY QUARANTINE

CHAPTER 16 MAC

CHAPTER 17 THE ASIAN ART MUSEUM

CHAPTER 18 BURGLARY

CHAPTER 19 DISCOVERY

CHAPTER 20 SNOWSTORM

CHAPTER 21 ESCAPE

EPILOGUE

ABOUT THE AUTHOR

ALSO BY BLAIR BEEBE

NOVELS

Doc Lucas USN: A Novel of the Vietnam War (2010)

The Nagasaki Cluster: A Historical Novel of Medical Discovery (2013)

Secret Pestilence: A Mystery Novel of the AIDS Outbreak (2013)

NONFICTION

The Hundred-Year Diet: Guidelines and Recipes for a Long and Vigorous Life (2008)

ESSAYS

Doctor Tales: Sketches of the Transformation of American Medicine in the Twentieth Century (2008)

SHORT STORIES PUBLISHED IN TANGENTS:

The Journal of the Master of Liberal Arts Program at Stanford University

"The Hero" (2009)

Gathering Storm (2012)

Sister (2013)

For Sue

Of all the things that could kill more than ten million people around the world, the most likely is an epidemic stemming from either natural causes or bioterrorism.

Bill Gates

New England Journal of Medicine 372:15

April 9, 2015

CHAPTER 1

SAN FRANCISCO

The medical resident in the emergency department at University Hospital studied the abnormal chest x-ray and immediately called Dr. Lucas. I have a patient with a cough you can hear three rooms away, and his chest x-ray shows moderate-sized cavities in both lungs. In spite of the crowd of voices in the ER---including a screaming baby and an anguished nurse yelling about a patient having trouble breathing---the resident sounded calm and matter-of-fact. For him, chaos was routine.

Have you looked at his sputum yet? Luke asked.

No, but your wife has. She says it contains a whole zoo of pathogens, including swarms of red snappers. The medical resident meant red-stained tuberculosis bacteria, not the fish. He was using archaic slang that was back in use as a result of the recent surge of new cases. In this patient, it was apparent the tuberculosis was far advanced, since the large red bacteria appeared in great numbers and had eaten away part of his lungs.

Do you have him isolated? Luke had understood that the patient was not only critically ill but also highly contagious.

Yeah, but we'd like to move him out. We need the space. Where do you want us to send him?

He'll have to go up to an isolation room next to the ICU. I'll see him as soon as he arrives. What's his story?

He doesn't speak English, but he has a passport from Uzbekistan---wherever that is. He's got some old needle tracks on his arms, so he's been an IV drug user. An ambulance picked him up at San Francisco International.

My God! Luke swore under his breath. He ended the call and thought of the hundreds of people who may have been exposed.

Luke knew Uzbekistan was famous for three things: ancient archeological ruins, a stopover by Alexander the Great, and large numbers of AIDS patients with multidrug-resistant tuberculosis. It was in the middle of the AIDS Hot Zone that stretched across central Asia and bordered on Afghanistan immediately to the south, the world's largest source of heroin. Although some Afghans were heroin users, most were Muslims, so heroin addiction had not spread there to the degree that it had in the countries of the former Soviet Union to the north. Intravenous drug addicts in Uzbekistan had easy access to the heroin and risked acquiring HIV each time they used a contaminated needle, which was why so many of them had AIDS. Because of their immune deficiency, they were not only more vulnerable to tuberculosis but also spreading the treatment-resistant variant of the disease among themselves.

Luke's wife, Lynn, was a microbiologist, and both she and Luke were familiar with exotic emerging diseases in Asian countries. Few experts in the world knew more about Asian epidemics than they did. They had participated in on-site research in southern China in 2003 during the outbreak of SARS (severe acute respiratory syndrome), in which 744 people died, most of them in Hong Kong. The Chinese government had suppressed news of the epidemic for several months before finally taking preventive steps and enforcing quarantine of infected people.

Both Luke and Lynn had seen homeless tuberculosis patients in San Francisco with antibiotic resistance to one or two drugs, but neither of them had yet seen a single American patient with the more threatening multidrug-resistant microbes found in central Asia. For patients from Uzbekistan, most of the more than twenty existing antituberculosis antibiotics developed over the previous fifty years had limited or no benefit. Lynn would have already started the cultures needed for antibiotic sensitivity tests on this patient, but chances were that the results would show few---or occasionally even none---to be effective against the bacteria infecting him. Patients with severe multidrug resistance sometimes improved on antibiotic combinations, in spite of the lack of activity demonstrated in the laboratory tests, but that was rare. More often, the victims died.

While Luke was contemplating what to do, he received a call from the nurse on the ward notifying him that the patient had arrived and was in an isolation room. I'm on my way, he said. He had once commented to Lynn that with fear as a motivation, contagious patients got moved out of the emergency room and into isolation quickly. He caught an elevator to the critical-care area.

Outside the patient's room, Luke washed his hands, stripped off his full-length white coat, and hung it on a hook next to the door. In its place, he unfolded and put on a long yellow paper gown with matching paper booties and mask. Then he slipped on latex gloves and gazed at the closed door, feeling a cold shiver. He'd faced having to examine a patient with a highly contagious deadly disease many times, but each time he felt the same anxiety and experienced the same rapid pulse and cold sweat. He knew the odds were against him. It was only a matter of time before he became a victim, just like the patient inside the room. He stood for a full minute staring at the knob before opening the door and moving to the bedside.

The patient was a skeleton gasping for breath. With his high cheekbones and blond hair, he could have passed for Russian. His passport indicated he was twenty-eight years old, but he looked twice that age because of his sunken cheeks and hollow eyes. He'd curled up in the fetal position facing the wall and was still wearing a crumpled black suit with an equally wrinkled white shirt. The nurses hadn't attempted to undress him. Every few seconds he coughed weakly, and he clutched a rag soiled with blood-tinged sputum. On the bedside table was a paper bag he had brought with him containing his medicine bottles, all of which carried labels with Cyrillic letters. No intravenous fluids were running, for even in a hospital emergency department, this patient was an untouchable. The nurses were leaving the task of starting the IV to Luke.

Luke said, I'm Dr. Lucas. Do you speak English?

The patient turned over slowly and glanced briefly at Luke; then he rolled back toward the wall and restarted his weak coughing. Luke touched his shoulder and pulled him gently onto his back again, and then he helped him remove his jacket and shirt. The old needle-mark scars on his arms were apparent, but none of them looked fresh. At least he wouldn't complicate his tuberculosis treatment by undergoing heroin withdrawal at the same time. Luke looked at the whites of the patient's eyes, noting the yellow color typical of the jaundice from hepatitis C found in many drug addicts. He almost certainly acquired both hepatitis and AIDS from the same contaminated needle, or needles, or from the same infected prostitute. In developing countries, tuberculosis was rampant in AIDS victims, and they often died of it.

With his gloved hands, Luke found enlarged lymph nodes in the patient's neck. They felt like small olives. Next, he listened with a stethoscope to the wheezing and gurgling in the man's chest. Palpating the sunken abdomen revealed enlargement of the liver, probably from his hepatitis. The patient seemed dehydrated, with tenting of the skin on his arms typical of a loss of elasticity. Luke held up a cup of water and pantomimed drinking. The patient squinted briefly at the cup, took a quick look at Luke, and again rolled back to face the wall. Luke set the cup of water on the bedside table. He wrote orders and started some IV fluids to relieve the dehydration. Then he left the patient's room and removed his paper attire and latex gloves. After placing them in a large contaminated-materials disposal basket lined with a red plastic sack, he headed to the laboratory to see Lynn.

CHAPTER 2

LUKE AND LYNN

Lynn was petite, slender, dark-haired, and athletic. Sometimes she flashed a smile that attracted men, but her friendly demeanor changed abruptly whenever she entered the lab---or anywhere else if she were engaged in a conversation about infectious diseases. Then, she was all business.

Luke was handsome, but in contrast to Lynn, he was tall, blond, and always dead serious. He wore a frown as he entered the lab. She gave him a quick nod when she saw him.

What do you know about Uzbekistan? he asked.

I don't need to know much. From examining your patient's sputum and hearing about his chest x-ray, it's clear he isn't going to last long. I've never seen sheets of tuberculosis bacteria that dense. I did a PCR test too. The results show that he almost certainly has multidrug resistance to most antibiotics.

The PCR test (polymerase chain reaction) was a rapid method that could immediately identify when tuberculosis microbes were present and whether they were resistant to the drug rifampin, which had been universally effective for treating tuberculosis in North America in the past. If the test came out positive, it usually meant the microbes would be resistant not only to rifampin but also to other similar antibiotics in the same class. Confirmation with cultures for testing of antibiotic resistance would be more complete and more reliable, but those cultures required several weeks of growth in an incubator---time this patient didn't have.

I just saw him, Luke said. He's wasted way beyond calling him just frail, and the crackles in his chest sound like clothes sloshing around in a washing machine. I think he's terminal. A few days at most.

She leaned back in her chair and looked up at him. She knew that the whole of central Asia from the Caspian Sea to the area north of Afghanistan was a hot spot for both tuberculosis and AIDS. A large proportion of the population living in central Asia had positive tuberculin skin tests whether they had AIDS or not, indicating that they had been exposed to tuberculosis sometime in the past. Many of them survived their exposure without treatment and with very few symptoms, but those with AIDS almost always became sick and ultimately died of their tuberculosis.

Did he come in by ambulance? she asked.

Yeah, they picked him up at San Francisco International.

She gasped. Oh my! The public health people are going to have fun with this one. Do they know the airline?

I don't know, but I'll make some calls as soon as I have a free minute. Uzbekistan is on the other side of the world, so he probably had several plane changes involving different airlines.

She shook her head slowly. He could have infected hundreds of people all by himself on just one trip. Do the ER nurses and the ones upstairs on the ward know about the contagion risk?

He hadn't needed to tell them to be careful. They were plenty frightened. Luke and Lynn found it interesting that the professional staff had become almost complacent about the risk of acquiring AIDS from patients after all of the panic of the earlier years, but a coughing patient spewing a cloud of tuberculosis microbes still terrified them. Quarantine of tuberculosis victims had worked to prevent the spread of TB in the early twentieth century, but antibiotics had not completely eliminated the disease as anticipated. In North America, more people were now infected with tuberculosis than before the introduction of the first antibiotics against the disease around 1950. Antibiotics still worked for many TB victims in the United States, including for most homeless patients in San Francisco, but the importing of treatment-resistant microbes from central Asia was a major threat. Some of the newer antibiotics might work against the tuberculosis in their Uzbek patient, but in his case, the disease was so advanced that he had little chance of survival even if the tests on his sputum showed some newer drugs to be effective.

Are you going to treat him? she asked.

Yeah. He looked down at the floor. I wrote some orders for a triple antibiotic cocktail, but I know it's much too late.

She looked away and frowned. Sick people in developing countries often lacked access to the drugs available in the United States, and here they were about to use expensive drugs on this patient with almost no chance that he would survive. Of course, even when tuberculosis victims in central Asia did obtain the newer drugs, they often took them inconsistently and for too short a time, leading to the development of more antibiotic resistance. But in this case, whether the patient's microbes had antibiotic resistance or not, treatment of any kind would almost certainly fail.

The nurses looked for translators who spoke any of the many languages spoken in Uzbekistan, and they found an Iranian nurse who spoke Persian. Unfortunately, the patient seemed to understand nothing of what she was saying, but the translator noticed the Cyrillic writing on the labels of the medicine bottles on the patient's bedside. I know that many people in central Asia write using Latin letters nowadays, but the ones who speak Uzbek or Russian often still use Cyrillic lettering on official documents. Those include prescriptions, so it's not unusual to find them on a medicine bottle label. She commented that several styles of Cyrillic existed, but that she thought the writing on the bottles appeared to resemble Russian more than the Uzbek language. That might not help you much, though, because Russians make up a substantial minority of the population in Uzbekistan, especially among professionals such as doctors and pharmacists.

San Francisco had a number of Russian neighborhoods, and University Hospital had several Russian-speaking employees. One from the housekeeping department confirmed that the writing on the bottles was Russian, but when she tried speaking to the patient, he refused to answer. She said, The pharmacist who filled the prescription was probably Russian, and I think the patient can read the labels, but he won't answer simple questions about how he's feeling or even give me his name.

I wonder why he doesn't want to talk to us, Luke said. Is he frightened of someone?

He seems very anxious to me, the interpreter said. But I suspect that he understands me.

1.jpg

Over the next few days, the patient's HIV and hepatitis C tests returned positive. His low CD4 count (cluster of differentiation) showed that his immune system was severely compromised from the AIDS. The patient had almost no natural capability to resist ordinarily harmless microbes, let alone a virulent disease like tuberculosis. He ran a constant low-grade fever and refused to consume food or even liquids. Luke kept him hydrated and supplied some nutrients in his IV fluids, along with the intravenous drugs treating his tuberculosis and his AIDS.

Five days later, a nurse found the patient dead in bed. The complete antibiotic sensitivity tests on him returned later and showed resistance to all antibiotics tested. Treatment had been of no avail, just as Luke and Lynn had feared.

1.jpg

Luke followed up with the public health department. An employee there concurred that the patient could have been in contact with literally hundreds of people in airports and airplanes along the way from Uzbekistan. They would work with the World Health Organization and use the patient's passport to identify the specific flights. For foreign airlines and airports, the WHO could only recommend follow-up with a series of tuberculin skin tests or chest x-rays for the flight crews, airport workers, and other passengers on the flights. They cautioned that collaboration was never good regarding health issues on flights within the countries of the former Soviet Union.

1.jpg

Two weeks after the Uzbek patient had died, another one with advanced tuberculosis appeared at the emergency department of University Hospital. He arrived directly from San Francisco International, this one by taxi instead of in an ambulance. He too had come from Uzbekistan and appeared