[Editor’s note: The names in this piece have been changed to protect physician and patient confidentiality.]
SYRACUSE, NEW YORK — Late Tuesday night, at a couple of minutes to midnight, Dr. Lisa McClusky arrived at the Emergency Department of Upstate Medical University. In the parking lot, three ambulances unloaded new patients. In the waiting room, patients sat in plastic chairs, sleeping or watching television. Pushing through two sets of heavy double doors, past the security and triage stations, Dr. McClusky entered the ED. Twelve more patients were boarding there. They had already received treatment but there was no room for them elsewhere in the hospital. There was only one medical resident on, but he had been there for six hours already and was complaining instead of working.
3:37 a.m. Dr. McClusky had things under control. The waiting room was almost empty. Then she heard a commotion. The hospital security guards and the triage nurse spoke excitedly with two Syracuse Police officers assigned to the hospital. She intervened and learned that the security guards had overheard the triage nurse talking to a new patient. They heard the word ‘anthrax’ and ordered the patient to stand outside in the cold. They called 911, which brought the police. The patient was now sitting in Triage 2, a secure negative-pressure chamber outside the ED where potentially contagious patients are evaluated.
Everyone is jumpy these days. New memos from the state health department arrive daily, outlining procedures for the surveillance, treatment and control of potential bioterrorism agents. Emergency physicians are required to keep tallies of suspicious exposure, to identify and report clusters of certain symptoms or non-endemic diseases at the end of every shift. Disaster drills are updated to reflect threats of bio-terrorist attacks. The red binder that sits on the counter in the ED has grown fat with these memos. The latest memos, at least one hundred and fifty pages and counting, concern anthrax.
Dr. McClusky entered the code on the keypad outside Triage 2 and opened the door. Air whooshed into the vacuum designed to keep pathogens from being sucked out of the room into the ED. A man with a brush cut and thinning hair sat hunched over with his forehead on a metal tray table, sleeping. He was wearing jeans and a T-shirt and black square-toed motorcycle boots. A white hospital blanket was wrapped around his shoulders. The triage nurse’s notation said his name was Thomas, but Dr. McClusky preferred to use ‘Sir’ and ’Ma’am’ when addressing patients.
“Hello, sir, I’m Dr. McClusky, the supervising physician, what brings you here tonight?” She sat down in an empty chair. “How can I help you?”
The patient raised his head from the tray table. He sat up straight and yawned, pulled the blanket off his shoulders, rubbed his eyes with his fists. Then he crossed his arms and swung one leg over the other and leaned back in his chair. He looked at the wall. “They didn’t tell you why I was here?”
Dr. McClusky noted the crude tattoos of crosses and hearts on his arms and the backs of his knuckles, the cracked cuticles rimmed with black grease, his thick veiny arms. He had a military bearing about him, or the bearing of someone who wanted to appear like someone in the military. “No, sir, I need to hear the story from you.”
“So, they really didn’t tell you why I’m here?” He looked at Dr. McClusky out of the corner of his eye. “You didn’t see all those cops and everything?”
“I’m aware that police officers were here and that you’ve spoken with them, but I really need to hear from you why you’re here.”
“I got up Monday morning. It was a pretty good day, or so I thought it was going to be a good day.” The patient talked at the wall, glancing at Dr. McClusky only to emphasize a point. His hands were tucked under his arms. The tattoos on them looked like jailhouse tattoos. She had seen them on the prisoners who come to the ED handcuffed to gurneys, attended by Sheriff’s deputies with guns. She wondered if he had ever been arrested for assault. "I was on my way to work. Normally I take 481 but since they closed the Teall Ave. exit I’ve been going — "
“Sir, why don’t you start at the beginning when things became relevant to why you’re here tonight.”
“The beginning? Can you give me an example?”
“I don’t need to know the route you took to work unless you got into a car accident and you have pain now. Did you get into an accident? Are you in pain now?”
“That’s a start. Now can you tell me why you’re here?”
“Like I was trying to say,” he says. “I was on my way to work and I stopped at a gas station. I was pumping gas and all of a sudden I notice this Arab guy.” The patient stands up and pushes the tray table against the wall. He walks over to Dr. McClusky and stands in front of her chair. She is looking at his belt and holding the clipboard against her chest.
“This Arab guy is pumping gas this close to me,” he said, indicating the distance by waving his hands in the space between himself and Dr. McClusky.
“He was two feet away from you,” Dr. McClusky confirmed. She made careful note of this fact on her clipboard. “Two feet. Okay. Got it.”
“Yeah, he was real close. I’m standing there pumping gas and I notice that this Arab guy is looking me right in the eye. He’s wearing a suit. Then he starts doing this.” The patient stuffed his hands into his pockets and moved them around.
“Looking for keys, for example?”
“No, he was fiddling with something, just fiddling there,” the patient said. He sat down again. He folded his arms over his chest and crossed his legs. “He looked me right in the eye. He had no reason to do that. Why would he do that? I wouldn’t go looking at someone in the eye. Would you? So, I was looking back at him, pumping gas, and he gave me this little smile. Then he got in his car and sped off. I thought it was kind of suspicious. I said, ‘Tom, you know, there’s been a lot of stuff on the news. Think about it.’ I paid for the gas and as I was driving down the road I started thinking that maybe I overreacted. Just then my nostrils started burning.”
“Are they burning now?”
“No, but I’m congested. You know, all stuffed up.”
“Okay, when did the burning stop?”
“I got home that night after being at work and it was on my mind. I called the FBI and told them that I think this Arab guy exposed me to something. That they better investigate this guy because of everything that’s happened. He could be a terrorist. They’re living among us. You know what he told me? He said, ‘If you were exposed to something on Monday you wouldn’t be talking to me right now.’”
“Sir,” Dr. McClusky said, “can you be specific about what’s bothering you, physically speaking?”
“The guys at work told me that people in Florida were getting swabs in their nose for anthrax. They said I should come here because you could test me for it.”
“We could do that, sir, but I’d need to know more about how you’re feeling.”
“My nostrils started burning. It made me suspicious,” the patient said. “I’m just trying to do my part. It’s the least I can do. The FBI sure didn’t help. So I did some investigating because, you know, I have the capabilities. I took down his license number and had a friend of mine trace it. He’s a cop. You know what I found out?”
Dr. McClusky shook her head.
“He’s an Arab.” He looked at Dr. McClusky out of the corner of his eye. Dr. McClusky didn’t say anything. The patient looked out the wire and glass mesh window in the door. “I don’t understand why all these police are out there.”
“They’re just doing their job, let’s not get sidetracked,” Dr. McClusky said. “Let’s focus on you and why you’re here and then we can deal with everything else. We have a lot of sick people here tonight that need my attention. You said after this suspicious activity that your nostrils started to burn. Do they still burn?”
“And are they still congested? Have they been congested since the burning stopped?”
“Do you have any other complaints?”
“Well, I’ve been waiting here for a long time.”
“Do you have any other concerns about your health?”
“Is it fair to say that you believe you were exposed to anthrax?”
“Yeah, I came up here to get tested for it. I’m worried that I got it.” Dr. McClusky made a note on her clipboard. “I’ve been on Cipro.”
“Who gave you Cipro?” Dr. McClusky asked.
“Why did your surgeon put you on Cipro?”
“Do you really want to know?”
“Yes, I really would.”
“Because I have a boil on my ass.”
“I see,” Dr. McClusky said, making a note on her clipboard. “And how long have you been taking the Cipro?”
“Almost two weeks, but I ran out because after this thing with the Arab guy I took the whole bottle. I probably should get more of that, too.”
“I understand your concern, sir,” Dr. McClusky said. “But were you aware that taking Cipro as a prophylactic doesn’t guard against getting anthrax unless you’re on it every day?” The patient shook his head, no. “Let’s try to determine if there’s any reason to suspect that what happened to you on Monday gives us reason to believe you’ve been exposed to anthrax. Let’s get back to how you’ve been feeling. In addition to the nostril burning, have you had headaches, sore throat, fever, cough, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, skin rashes or lesions, besides the boil on your butt?”
Dr. McClusky told the patient that after one to six days of exposure, he should have developed one or more of these symptoms. Presently, he had no reason to be concerned. But if any symptoms she mentioned did develop, he should return to the ED for re-evaluation. “Don’t you think I should get more Cipro, anyway?” he said.
“If you finished your prescribed course, I’d contact your surgeon and ask him if you need more Cipro since you took them all. And keep your appointment with him.”
“But I heard on the news that what they treat anthrax with is Cipro.”
Dr. McClusky explained the dangers of using such a powerful drug, how super strains of bacteria resistant to antibiotics could develop. “Cipro is not indicated right now, sir.”
The patient listened carefully and nodded. He thanked her for her time, then said, “I don’t understand why all those cops need to talk to me. I’m just trying to do the right thing by my country. I just want to help.”
“And we thank you for that, Thomas,” Dr. McClusky said, getting up from her chair. She left the room and spoke to the police officers waiting in the triage area. They asked for her assessment, and she told them that she didn’t believe the patient was ever exposed to anthrax, that the patient himself didn’t believe he was ever exposed, and that this was merely his moment in the spotlight. Treat him accordingly.
4:02 a.m. Dr. McClusky looked at the new triage notes. A pregnant woman had come into the ED in the meantime with vaginal bleeding. An ultrasound confirmed fetal demise. Dr. McClusky pushed through the double doors and hurried into the ED, passing by the wire and glass mesh window in the door of Triage 2. The cops were standing in front of the patient, hands on their hips. The patient leaned back in his chair. He folded his arms, crossed his legs. He yawned. He began his story.