FALLS CHURCH, VIRGINIA — Cecele Murphy is a good ER doc. She picks up on real symptoms from the only imagined, doesn’t overdo testing to appease her patients’ expectations, and talks to them in plain English. On Friday, October 19, a patient who sorted mail for the Senate at the Brentwood Postal Facility, told her he knew his body and it didn’t feel right. A few hours later, she gave him a diagnosis of anthrax. News of the two deaths in D.C. had not yet been made public, and the only cases of inhalation anthrax were dead or recovering in Florida. The diagnosis was, to say the least, a tremendous leap. The man’s complaints were pedestrian: achy, a little chest congestion, tired. Not right. He had come to get a nasal swab test, but had his blood drawn and a chest x-ray taken.

“The thing is,” Dr. Murphy said, “it didn’t look terrible. But there was an effusion [fluid surrounding the lung] and a patchy infiltrate. I actually thought he might have cancer.” She showed the film to a colleague, John Howell, who agreed the patient certainly had something going on. Dr. Howell had been chairman of Emergency Medicine at Georgetown University Hospital for several years and so, like Dr. Murphy, no slouch. But his experience with anthrax was, like everyone else’s, limited to what he’d just taught himself in the last weeks. He agreed the potential occupational exposure and unsettling film was suggestive. He recommended Dr. Murphy get a CT scan of the chest, just as she thought he would.

“The guy himself was pretty stoic,” Dr. Murphy said. “His wife or girlfriend was more worried than he was. He kept saying he was going to be fine, but she kept on asking him how did he know?” Murphy tried to reassure them that he’d do well, but the girl turned the same question around on her: “Well, how do you know?”

Which was the first time it hit home for Dr. Murphy: this could be anthrax, and she had no idea how he would do.

It took another hour to get the patient to the CT scanner and then a while longer for the radiologist to phone in a report: the mediastinum, the central portion of the chest, appeared widened. It was consistent with inhalation anthrax.

Dr. Murphy said three months ago she would have never ordered a CT scan for effusion. “I got lucky,” she said. “I mean, he got lucky because he was so emphatic about not feeling right and his exposure to the Senate’s mail.”

Eleven hours later, by the end of her shift, the patient was coughing up a blood-tinged sputum and his urine was the color of tea. His vital signs were stable, however, and he was feeling more or less the same: alert and comfortable but deeply fatigued.

The microbiology lab called to report his blood culture was growing gram-positive bacilli. Anthrax. He had long before received Cipro intravenously as well as a couple of other antibiotics, just to be on the safe side.

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The next day a patient came in with a ferocious headache. The worst of his life, he said. He had been in contact with his doctor earlier in the day, who recommended a trip to the ER to have his head CT scanned, to rule out a stroke. His high fever had prompted his doctor, Dennis Pauze, to perform a spinal tap, to rule out meningitis, encephalitis, and brain abscess. Doctors and nurses throughout the hospital were still discussing the details of the first patient’s clinical picture, but nothing about the second patient’s symptoms tripped their suspicions for anthrax. In fact, when Dr. Pauze left for home on Sunday morning, he still didn’t know what was wrong with his patient.

“His tap was negative,” Dr. Pauze said. “But he still had a headache and the fever, so his admitting doc ordered a routine chest film.” Dr. Pauze, who received a Teacher of the Year Award from the Emergency Medicine Residents at George Washington University, chuckled at the power of routine overkill. “There was no reason in the world to get a chest film on him, except for the fact that we always order chest films on admissions. And it was horrible.” It looked like anthrax. A few hours later, the second patient’s blood cultures turned positive, establishing what a CT scan of his chest had already shown. Then the doctors learned that he, too, was a postal worker at Brentwood.

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On Monday, my first shift in the ER after a weekend off, we admitted another four patients who had ugly chest X-rays and some association with the Senate, House or its mail. One even showed mediastinitis on a CT scan. By the next day, however, none had blood cultures growing the germ. After that, we saw nothing more than the waves of the worried and the pseudo-exposed. A virus had blown into town and was making people achy and sick. I repeated the same speech over and over again: they didn’t have influenza or flu — it was too early in the season for that — and in all likelihood their cold symptoms were just a matter of unfortunate timing. But just in case, here’s your Cipro.

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On October 27, a little over a week after Dr. Murphy’s anthrax patient, a woman arrived with an unsettling story. She worked for the post office, in the same room and on the same line as one of the men who had died of anthrax. After being notified the previous Sunday she would need antibiotics, she stood in line for the meds and began taking them, as directed, right away. At the time, she too had been achy and weak, a little headachy with chest congestion. Six days of Cipro later, she felt much better.

She asked me, “Did I have anthrax? Do I continue taking Cipro?” She showed me a cut on her finger. A paper cut, nothing unusual about it, except it had been there for two weeks without healing. There was no ulcer or blackened eschar in the middle, the features of cutaneous anthrax I’d recently learned. It didn’t match the pictures on the CDC Web page or the linked Journal of the American Medical Association article that all ER docs have recently studied.

I went looking for Dr. Murphy or Dr. Pauze to see if they could help me out. They’re the experts now. I told the patient to stick with the Cipro, or Doxycycline if her doctor so recommended, for a good long time.