The Inquisitor

Wednesday, April 2, 5:30 a.m.

Palliative Care Unit, St. Paul 's Hospital,

Buffalo, New York

The air on the ward hung thick with the smell of flatulence, body odor, and sweat-soaked sheets. What little light could be seen curdled in pools of shadow. The cries that rose and fell against the outside of her door might as well have been a wail of wind, because here no one would heed them. The nurses paid attention only when the moaning stopped.

Somewhere someone retched with a force that must have stripped the stomach bare. The sound echoed along the hallway.

That might bring them.

Soon the squeak of crepe soles on linoleum would announce their approach.

None came.

"Store up all the tiny details. Let me smell, taste, hear, see, and touch through your telling of them." The command, issued to me so long ago, resurfaced, resonating in memory with the freshness of an order spoken on the spot and not to be disobeyed. As always before a mission, it marshaled a frame of mind fine-tuned to observe, the ideal state to be in for keeping myself and the records sharp.

"Can you hear me?" I whispered, holding back on the plunger of my syringe.

"Yes." Her eyes remained shut.

I leaned over and brought my ear to her mouth. "Any more pain?"

"No. It's gone."

"Do you see anything?"

"Only blackness." Her whispers rasped against the back of her throat.

"Look harder! Now tell me what's there." I swallowed to keep from gagging. Her breath stank.

"You're not my doctor."

"No, I'm replacing him tonight."

She didn't respond.

I gave her a gentle shake. "Mrs. Algreave?"

"Just leave me be. It doesn't hurt anymore."

Leaning back, I studied her gray, skeletal face. The moonlight cast a silvery blue tinge over her pallid skin, making her appear already dead. As for the rest of her, so much had wasted away that the soft material of her lace nightgown clung to the hollows between her ribs and reminded me of white gloves on bony fingers.

I glanced toward the closed door- the nurses shouldn't start their rounds for another half hour yet- and reapplied my thumb to the plunger. A slow push, and her pulse grew weaker. "Do you see anything yet?"

No answer.

"Mrs. Algreave!"

"Yes?"

"Tell me what you see."

"It's too dark."

"Look carefully."

"But I can't see."

"Do you sense yourself rising?"

Again no answer.

I shifted my mouth closer to her ear. "Talk to me, Mrs. Algreave." The words must have sounded like a shout.

"Leave me alone."

"Not until you tell me what you see." I gradually increased the pressure on the plunger. Her pulse diminished to clusters of barely discernible bumps, readable only to experienced fingertips, like Braille. It shouldn't be long now. Her failing circulation would abandon the lesser organs- kidneys, ovaries, digestive tracts, large and small- and reroute itself entirely to spare the more essential meats, the lungs, heart, and brain. A perfectly orchestrated sequence, designed to save neurons so that they could record the final seconds. Anyone bold enough could tap the knowledge hidden in those moments. "Are you looking down on us yet?"

At first I thought she hadn't heard me. Then her lips moved but emitted no sound. Turning my head, I hovered an inch above her mouth. She exhaled against my cheek, sending another whiff of rot drifting through my nostrils to play at the back of my tongue. "What did you say?"

"I… see… me…"

Her words filled my ear one breath at a time, elongated and no louder than a puff of breeze. But I could just make them out, having become a practiced listener to messages from this plane. Excitement mounting, I turned on the tiny tape recorder in my breast pocket. "What else can you make out?"

"The… bed… nightstand… pictures… all my pictures…"

On the small bedside table a silver-framed black-and-white shot of a young man in uniform stood propped behind an array of more recent, color snaps, the kind processed in an hour: a dark-haired couple, three grinning boys in front of a Christmas tree, a woman holding a baby. Only the soldier interested me. "Is that your husband?"

"Yes…"

"What's his name?"

I barely made out the word that followed. It sounded like "Frank."

"Is he dead?"

Her breath diminished to a point it wouldn't have fogged a mirror. "Yes…"

"Do you want to find him?" Most did. The yearning to meet up again never died.

"Yes…"

"Are you still looking down on yourself in bed?"

"Yes…"

"Let go. Allow yourself to float, escape the hospital, go high above the building. You must do this before you can see Frank."

"Yes…"

"Look up."

"No…"

"Look up and you'll see Frank. He's waiting."

"I… won't… get… back…"

"Look up!"

No reply. Had I forced her too far? No, she still had a pulse. Nevertheless, I eased off the plunger. "Can you hear me?"

"Yes…"

"What do you see?"

"Too… vast…"

"What? Night? Space? Stars?"

"Gray…"

"Gray what?"

"Cold…"

"Tell me what's there."

"Nothing…"

My insides tightened. "You've got to see something."

"It's horrible…"

"What is?"

"Help me…"

Damn her, why didn't she tell me? "Describe where you are, or I'll leave you there. Frank won't ever find you."

This time I heard a sharp intake of breath. "No… please…"

"Then tell me."

"Nothing… to… tell…"

The pulse under my fingers raced stronger. Her breath blew against my ear with more force.

"It's… terrible… Get… me… out… Please… get me out…"

The faint sounds became a cry. Her eyes shot open, wide with terror.

No one had ever come to before now.

I clamped my palm over her mouth and watched the door again. Had one of the nurses heard?

No footsteps approached.

She looked straight at me.

"You recognize me now?" I asked, my thumb still on the plunger.

She nodded and tried to say something, but the sound vibrated against my palm. It tickled.

"Shh! Don't speak!" I advanced the plunger. Just give her a little more, enough to subdue her again. "You've been having a bad dream."

She shook her head and fixed her stare on where I'd stuck the syringe through a rubber portal in her IV. Her brows shot upward and her forehead furrowed with alarm, and the squeals she made against my hand pierced the quiet. I pressed down harder. "I said quiet!"

She started to buck, making the bed squeak.

Oh, God, where did she find the strength? The others hadn't. I leaned on her, pinning the emaciated form to the mattress. "I warn you, stop it!" I had meant to whisper, but my voice rasped out of me in a crow's squawk.

The bed rattled as she writhed under my weight.

I pushed more forcefully against her mouth.

Her movements continued. The iron frame began to creak in off-key squeals, the noises grating along the inside of my skull. Any minute a nurse would be sure to hear.

I increased the pressure on the syringe.

Flailing at me, she struck my arm, and the plunger lurched ahead, injecting the entire contents of the chamber into her IV.

I gaped at the emptied cylinder in horror.

She gradually stopped moving. Her pulse vanished. The respirations slowed to a standstill. Yet her brows remained raised, and she continued to glare at me, but with the flat dilated pupils of the dead.

Nausea swept through me, and my heart rate bounded into triple digits. I'd never killed one before. Just kept them in limbo as they died.

Swallowing until I had no more spit, I pulled out the syringe, replaced the safety cap, and pocketed it. A quick check of the covers and floor verified that nothing had been dropped or left behind. But as I bent over, the microcassette recorder slipped out of my breast pocket and clattered to the linoleum. Retrieving it, I clicked the off button. Close call. Had it hit a mat or her bedding without a sound, I might not have noticed.

I steadied my breathing and, surveying the scene, satisfied myself that everything would seem natural.

As I backed toward the door, the moonlight shone across her face at a low angle, filling the hollows and depressions with deep shadows. Her eyes, still open, glittered from the bottom of gaunt sockets. Despite my knowing better, I could have sworn they watched me every step of the way.

Three months later

Dr. Earl Garnet sensed it the instant he stepped inside the marbled front entrance.

St. Paul 's Hospital buzzed with a palpable nervousness and excitement unlike the feel of any other morning.

July 1.

Changeover day.

All over North America flocks of freshly minted medical graduates wearing crisp white coats streamed into their respective teaching hospitals, ready to begin the arduous residencies that would forge them into physicians.

And more staff doctors showed up at 7:00 a.m. than at any other time of the year. Ostensibly they'd come to welcome their charges, but he knew their early arrival had more to do with protecting patients from the newcomers and scrutinizing the latest batch of future healers for early signs of who would bear watching. Earl found himself exchanging pleasantries and brushing shoulders with colleagues he hadn't seen in months.

Except this July 1 would be like none St. Paul 's had ever experienced before.

He lined up to be screened for fever alongside the rest of the employees. With four tables working, the crowd moved through quickly today. Nurses already dressed in OR gowns, shoe covers, surgical hats, goggles, gloves, and tight-fitting thick masks greeted him. One applied a thermal strip to his forehead: normal. Another asked a few quick questions that he and everyone else now knew by heart, and he just as quickly rattled off the answers: no cold symptoms, no foreign travel, no unprotected contact with suspect or probable cases. That done, he received a dated stamp on his hand, the kind that discos and theme parks use- except instead of opening the doors to fun-filled entertainment, it granted him admission to his own ER for another day on the job. He moved on to the next stop, where similarly attired porters dispensed a complete set of protective gear to every single person entering the hospital.

Welcome to the "new normal" of SARS in America.

Severe acute respiratory syndrome, the scientists had named it the year it first appeared in China. At the time residents took to calling it SCARES.

An electron microscope mug shot of the suspected cause, a smudged-looking sphere surrounded by a ring of tiny balls, had made the front pages of newspapers all over the world. The crownlike appearance allowed it to be recognized as a member of the coronavirus family, a microbe with many different strains, some responsible for up to 30 percent of common colds in people, but most infected only the lungs and bowels of livestock, such as chickens, pigs, or cows. Yet somehow one of these latter strains had acquired a genetic makeover and jumped the species barrier to take on humans in a deadly new way. Similar events with other organisms had given rise to some of our most lethal diseases- the so-called swine flu of 1918 is thought to have come from pigs, AIDS from monkeys, avian influenza from chickens. Humans, having never had prior exposure, lack immunity to these invaders, so the prospect of a brand-new bug that's highly contagious always grabs the scientific world's attention.

The real kicker is that researchers couldn't isolate the coronavirus from over half the cases, which left the possibility that this disease might be a multiheaded monster that attacked its victims in ways not yet understood, or that some other completely different unknown, a deadly X, could be floating around out there killing people.

That first year the outbreaks were beaten back. But just when the world thought itself safe, the organism mutated, the new vaccines against it were suddenly obsolete, and pockets of infections began to crop up again. Even then, until a few months ago, it had been largely the problem of other countries, the few cases that occurred in the United States being relatively mild. Everything changed after a busload of tourists returning from a religious meeting in Toronto, Canada, center stage for the initial North American endemic and center stage for its reappearance, brought back more than a few Mountie souvenirs.

According to the latest count, there were 169 confirmed cases admitted to designated Buffalo hospitals, 31 of them under treatment at St. Paul 's, and most of them health care workers.

In the first wave of infections among hospital staff, two nurses and a doctor died. After that, there'd been no containing it. People broke quarantine, others lied about having symptoms or where they'd been, and while the number of new cases leveled off in the community, the virus continued to strike doctors, nurses, orderlies, and residents all over the city. Even now, every few days at St. Paul 's someone with a fever would be pulled out of line at the screening station to be put in isolation for observation. Most turned out to have nothing more than a cold, but with a 15 percent mortality rate, no cure, and some survivors left so short of breath they could barely walk across a room, fear had become the norm for those who treated the sick.

Fortunately, no one who'd gone through with Earl this morning got tagged. After suiting up, they broke into smaller groups and hurried off to their respective departments.

"Heads up, guys."

"Eyes sharp."

"And cast-iron stomachs all around."

Their parting banter reminded Earl of soldiers moving out on patrol.

Upstairs, the nurses would be adopting an edgy alertness as well, scanning their wards the way ship captains keep a lookout at sea, always ready for trouble. If a rookie went alone into a patient's room, they'd keep tabs on him or her. When a novice wrote a medication order, they'd double- and triple-check it for mistakes. And during any attempt by a first-timer to perform a procedure, they'd hover over the event with the anxious scrutiny of spinster chaperones. They also would set their radars to home in on any of last year's junior trainees who might stride through the corridors a little too cockily, lording it over those who'd replaced them on the bottom level of the teaching pyramid. Arrogance could kill as readily as inexperience, and the two together were even more lethal; no one could pop them both faster than veteran nurses. Their weapon of choice: sidle up to any offender who showed off to the newfound underlings and say, "So, you finally brought me someone on the floors who actually knows less than you do. Remember, honey, that ain't saying much."

The result of it all?

Already anxious patients clutched their blankets and hoped for the best every time a new masked face with youthful eyes came near them. And they soon learned the surest way to spot a beginner: even under the surgical gowns all the clinical manuals and packets of cue cards these kids invariably kept stuffed in their pockets made telltale bulges. Earl sometimes fantasized these junior doctors pulling no end of things out from under them- suture kits, crutches, their lunch- like Harpo Marx in OR gear.

He tried not to smile as another throng filed by. The bulges of this bunch stuck out like tumors, indicating pockets laden well past the bursting point. Through the backs of their badly tied outfits he spotted their short white clinical jackets, trademark for the lowest of the low.

Medical students.

Their rapid-fire chatter, typical of first-day jitters, bounced off the walls.

"… orientation's in the basement auditorium…"

"… but where do we meet our chief residents…"

"… me, I'm following my nose to the coffee…"

Surgical masks couldn't hide that they seemed younger than ever, he thought, indulging in a twinge of melancholy. He'd been through twenty-five changeovers and found the day marked the passing of yet another year with more impact than his own birthday.

He continued at a brisk pace toward the emergency department and pressed a large metal disc on the wall, setting off a loud hiss as the frosted glass barrier that separated his domain from the rest of the hospital slid open.

Just like Captain Kirk on the Enterprise, he thought, stepping through with a grin, only to have the volume of chatter coming from inside wipe it away.

That much sound meant a lot of patients. Too many.

"Morning, Dr. G.," the triage nurse greeted him. She was a cheery woman in her mid-twenties. He knew her mask hid three rings in her right nostril, and slightly spiked but short black hair stuck out from beneath her surgical cap. She glanced up from taking the blood pressure of an elderly lady who had frizzy white hair and lay gasping for breath on an ambulance stretcher, a red handbag clutched to her chest with both hands. She also was masked, and her frightened eyes stared at him over its tight-fitting rim. The material puffed in and out with each respiration.

To the left the walking wounded, equally well masked, kept their distance, prowling a waiting room meant to hold half their number. On the right another sliding door led to the inner sanctums of ER, where patients unable to sit or stand would be parked on stretchers.

"Morning, J.S.," he replied, raising his voice to make himself heard above the chatter of a hundred conversations.

The initials stood for Jane Simmons. They'd used call letters to address each other since shortly after she came on staff. It began, as did many traditions between people in ER, during the rush of a resuscitation. The intensity often cemented first impressions- for better or worse- and her impact on him had stuck for the better. Despite dressing the part of a punk rocker, she had good hands when it came to starting IVs in the worst of veins, and her calm never cracked- not then as a new kid, and not since, even during the toughest cases.

"Need any help?" he asked her. The elderly woman's rapid breathing had automatically put him on alert.

" Nan." J.S. reassuringly patted the lady's arm. "Meet Mary."

"Hi, Mary, I'm Dr. Garnet, the guy who runs the joint." He placed his gloved hand over hers and gave it a gentle squeeze.

"Only a touch of heart failure," J.S. continued, "but this little sweetie's going to be just fine as soon as we give her oxygen, relax her airways, and get her peeing."

Some of the fear drained from the old woman's gaze, and she appeared less forlorn despite the puffy circles drooping over the upper edge of her mask. An orderly whisked her through the inner door and down the hallway to a treatment room.

"Ready to whip another crop of greenhorns into shape?" Earl asked J.S. while glancing over the ambulance sheet to see what calamities the city of Buffalo had delivered up overnight. He mentally ticked off the cases that he could use as good teaching material for introducing first-year residents to ER.

The corners of her eyes crinkled, and he knew her infectious, crooked grin had appeared. She lifted an upper tie to loosen the corner of her mask and blew a strand of loose hair off her forehead. "Just let me at 'em."

Before he could remind her that she shouldn't breathe unfiltered air, even for a second, a single low growl from a siren announced the arrival of another ambulance. The signal meant they'd brought in a patient still breathing, but barely, who needed help fast.

J.S. pivoted and charged out the door leading to the garage.

Several nurses darted from the inner corridors to follow her. They passed where a teenage boy sat clutching a skateboard and doubled over in pain. J.S. must have deemed him stable enough to wait, but Earl didn't like the greenish tinge and sheen of sweat that no mask could completely hide. "Do you need to lie down?" he asked, walking over and kneeling at the young man's side.

"I need to vomit, sir."

"Just hang on." He rummaged through the equipment racks behind J.S.'s triage area, dug out a bedpan, and shoved it into the youngster's lap.

The sounds of more ambulances pulling into the unloading area reached his ears.

Busy day to break in a fresh crew, he thought, hurrying inside to marshal his staff for the onslaught. At the door he stopped to double-glove and double-gown, the added body armor required for anyone working ER. He also donned another prerequisite for anyone on the front lines of medicine these days: a cast-iron attitude of que sera sera.

An hour later they'd diuresed a liter of pee from the woman in heart failure, identified a ruptured spleen in the skateboard kid, and resuscitated the case that had so alarmed the ambulance technicians: a diabetic stockbroker in his fifties named Artie Baxter. He'd skipped breakfast after his morning insulin, then collapsed and seized. "I had a great tip before the market opened," he'd explained when a shot of IV glucose woke him up. "So I phoned all my clients instead of eating my usual toast and cheese…"

A few of the nurses scribbled down the company's name and ran for the wall phones.

"Can I see you outside a moment?" Earl said to Susanne Roberts, the head nurse, and led her by her elbow to a quiet spot in the hall.

"What's up?" Her pixie haircut peeking out from under her OR cap made her appear young, and only the lacework of tiny lines that fanned out at the corners of her eyes hinted at her age. She'd been on staff in ER for nearly as many years as he had, but she'd kept her passion for the job long past the point at which most lose it. Like all gifted leaders, she brought out the best in those around her.

"I'm going to try to make the end of the orientation session for the residents," he told her. "But I'm worried about this guy. Keep him on the monitor with the IV running."

"You expecting trouble?"

"His story doesn't add up. A man who's been on the needle for years and he pulls a stunt like that? I think he's not telling us something. And all that stock talk- a little too smooth for my liking. He got a wife?"

"She's on her way in."

"Ask her if he's been as well as he claims."

The speeches were almost over when he let himself in through a side door near the front of the auditorium stage. The audience occupied a steeply raked semicircle of seats, providing a wall of OR green before the speaker at the podium, Dr. Stewart Deloram, St. Paul 's resident genius in critical care. His mop of jet-black hair sprang out from the sides of his headgear like burst springs, flopping about as he animatedly extolled the virtues of a quiet, calm demeanor while dealing with life-and-death situations. "Especially when working on a patient who has suffered cardiac arrest," he emphasized in a grave, sonorous voice.