Inhalation Anthrax in NYC-Fall 2001 (Part 2)

Within hours of dropping the slant off at the lab we had positive preliminary results for anthrax.  Sadly the patient never regained consciousness and died on Halloween. We knew from her doctors and co-workers that Ms. Nguyen worked as a stockroom clerk, lived alone and kept mostly to herself, but we’d never be able to interview her. The mailroom was next to the stockroom, so we told ourselves her case was not unexpected and fit with the other cases where contaminated mail was the route of exposure. 

The hospital voluntarily closed and a team of epidemiologists from NYC and CDC plus detectives and agents of the JTTF (Joint Terrorism Task Force comprised of NYPD, State Police and the FBI) descended on the building before dawn. I got there just as the TV crews were setting up and they mistook me for a patient and let me pass unmolested.  We were operating on the premise that anthrax spores, once settled, didn’t re-aerosolize.  The FBI and NYPD didn’t share our view and while they debated the risks of entering the building without moon suits we brazenly, and perhaps foolishly, began the investigation.

One team swabbed the basement for spores while others interviewed her boss and co-workers.  We were looking for anyone who was ill or had information on Ms. Nguyen's activities. Her locker contents and her clothes were swabbed. Anyone who worked near the stock or mail rooms got their noses swabbed and a vial of antibiotics. Patients who had been in the building that week were contacted and their health evaluated. No suspect cases were identified. Two curious leads emerged from the interviews.  Ms. Nguyen had a past relationship with a person described as an “agent” and two days before her illness she got dust in her eyes that irritated them enough that she asked a nurse to irrigate them.   We didn't find a single spore anywhere in the hospital or her home.  We had to reevaluate our hypothesis.

Historic thread-October 29, 2001 (Part 1)

We were stationed at the lab to help with the deluge of specimens to be tested for the presence of anthrax spores. It was hectic. New Yorkers had white powder fever in the fall of 2001 and were seeing danger in ordinary items they had previously taken for granted. Mail was carefully inspected and thrown away unless it contained a check or bill. The sugary remains at the bottom of a package of Little Debbie snack cakes or flour spilled innocently on the floor became suspected conveyances of anthrax. All of these specimens were being brought to the city's lab by cops only too happy to drop their packages and run away.

Denis built a database and we spent our days logging in samples and reporting the results to the Health Commissioner, Mayor, NYPD, FBI and an assortment of politicians and dignitaries. We had not heard of a new case of skin anthrax in nearly a week and were looking forward to getting back to our regular jobs and lives outside of work.  Sixteen hour days were getting old. On Sunday a doctor from an uptown hospital called, he had a worrisome case. The 61-year-woman didn't work with the mail, but appeared to be in the throes of a serious infectious pneumonia. By late Monday afternoon the hospital lab had isolated a large bacillus in the woman's blood. It was growing in long filamentous threads. Our hopes of returning to normalcy dashed, Denis and I hopped the uptown subway and met the lab director in the empty lab. Excitedly he ushered us over to a microscope. I peered down the barrel, adjusted the focus remembering my days in the emergency department looking at gram stains of cerebral spinal fluid searching for bacteria and white blood cells. Oil immersion, 100x. The lab director had taking a drop of the blood culture media and prepared a gram stain. Unlike my sparse csf gram stains, this one was a chaotic mix of red and blue. It took me several moments to orient myself, but I began to see the white blood cells in a matrix of what looked like blue thread. As I looked closer I could see that the threads were composed of long, brick-like cells. I had seen this before, not under a microscope but in a book. It was anthrax. He handed us a slant: a screw-top test tube filled with media and inoculated with a sample of the growing bacteria. I slid it into the steel canister we brought with us and placed it into my jacket pocket. Only specialized labs could make the definitive diagnosis of anthrax and we had to get it back to the city lab to know for sure.

Before we left we met the head of infection control who took us to the patient's bedside. Beneath the wires, tubes and tape lay an unconscious woman. Sedated, on special drugs to maintain her blood pressure and high powered antibiotics to beat back the infection, she was waging a war we couldn't see, except on the X-ray, which showed her chest and lungs filled with blood and fluid. On the subway ride downtown Denis and I tried not to speak and act non-chalant, but there were too many questions. 

"Do you think it is?" he asked. 

"I don't know," I replied. "It fits clinically, and the gram stain is suspicious." I didn't want to say what I felt. Denis wasn't a physician and although he had been an EIS officer I couldn't be sure how he'd react and after all we were straphanging in a rush hour subway car. He smiled, the nervous smile that sometimes creeps across the faces of people facing really bad news. 

"Where would she have gotten it?"he asked.

I looked around, maybe it was my baseline paranoia but some riders seemed to be listening to our conversation with interest. Others were lost in the complications of their lives. 

"I don't want to think about it," I replied. I knew the only persons to contract the inhalation form of anthrax during the outbreak had either been postal workers or at the AMI building in Florida. None in NYC. Terrorists had long eyed the NYC subway as a target. I re-examined our fellow riders. This changed everything. Our lives wouldn't be returning to normal, in fact, craziness was about to be cubed...

Down under

Two weeks ago a Queens construction crew broke more than ground. The story appeared as a short blurb in the NYT and was less than inaccurate:

http://cityroom.blogs.nytimes.com/2011/10/06/for-female-found-by-police-being-unresponsive-is-least-of-it/?scp=5&sq=body%20found%20in%20Queens&st=cse

The land was formerly a cemetery and the crew accidentally broke an iron coffin.  The coffin dated from around 1850 and iron was used instead of wood to prevent the transmission of communicable diseases.  Although the corpse was well preserved, no one mistook her for the recently alive and she was taken to the OCME for an "academic" evaluation. Tests did not find any evidence of infectious organisms. After 160 years the proteins of life had all disintegrated.

The Prisoner of Malta

It was a hot August night in the ED. The air conditioning pumped out tepid air and one could build a sweat just washing your hands. The asthma room was quiet, a welcomed relief from the usual standing room only crowd. I was near the end of my shift and looking forward to a shower and some homemade grub when Jenny, a third-year resident poked her head from behind a cubicle curtain.

“Dr. D, can I show you something?” I hopped off the stool that barely had time to make a dent in my derriere. Sitting anxiously on the stretcher was Maria, an 8-year-old girl. She held a bottle of soda in her mouth. Her mother stood by her side, also anxious.

“She can’t get it off,” Jenny said.

I looked closer. It was a bottle of Malta, a malt-flavored soda popular in the Spanish community. The bottle was short and stocky, with a wide mouth. Stuffed into that wide mouth was Maria’s tongue.            “She sucked the air out of the bottle and now it’s stuck,” explained her mother.

The girl watched me like a cornered squirrel. Her tongue was beefy red and swollen, but it was hard to tell much else through the brown glass. The weight of the bottle pulling down on her tongue was painful, so she was raising it up into her mouth. She was a mouth breather so positioning the bottle was tricky; not too far into her mouth so she couldn’t breathe but enough to take the weight off her tongue.  When one arm got tired she switched to holding the bottle with the other.

I delicately took a hold of the bottle and applied minimal downward traction. It didn’t budge but Maria’s eyes did, they bugged out. She looked weary and what concerned me was that her breathing was somewhat labored.

Several residents stopped by to see what was going on, sharing suggestions such as breaking the bottle with a reflex hammer or heating until it expanded and dropped off. The tongue is perhaps the most sensitive and vascular organ in the body.  We rejected both those ideas.  Instead we retrieved from the supply cabinet an infant feeding tube. About the size of a cocktail straw and made out of soft plastic, we used feeding tubes in the ED as urine catheters. The intended use was to supply nutrition for premature infants who had not the strength to suck. Jenny applied sterile lubricant to the tube, and gently attempted to insert the tube between the glass rim of the bottle and Maria’s tongue. It was a little like trying to push a lace that has lost its plastic tip through a sneaker eyelet.  It took several attempts and we had to steady Maria so she wouldn’t jump off the stretcher or pull the tube out once we had it in. Eventually Jenny got the tube in place. Nothing happened. The tube should’ve released the vacuum but it was pinched closed by Maria’s tongue against the glass. We went to plan B. Jenny reached for a 3cc syringe.

“You are going to need a bigger one,” I advised her.

“She started to unwrap a 10cc syringe.

“Bigger still,” I said.

 Jenny settled on a 20 cc syringe and attached it to the end of the feeding tube. Maria watched with trepidation. Jenny slowly pumped air into the bottle like a flat tire. After the second 20 cc the bottle slid a little and Maria jumped.  After 20cc more of air the bottle shot off into Maria’s lap with a pop and a puff of malty smoke. We examined her tongue, soaked it some cool water and after an hour or so Maria and her mom were sent on their way, with a promise to lay off the Malta or use a glass.