Death Benefit

“Dr. Rothman, can you hear me?”

“What are you doing?” George’s nerve was failing him on many counts. Neither of them was on an internal medicine rotation, so they had no business or excuse to be there, and why was Pia trying to talk to Dr. Rothman? The man was delirious. Apart from the trouble they could get into, George was nervous about the salmonella that was making Dr. Rothman sick. The man looked gravely ill, with an ashen coloring and loose strands of hair matted to his pale forehead.

“He doesn’t look good at all,” Pia commented.

“Tell me about it,” George said nervously.

“My gosh, look! He’s losing some hair.” Pia pointed to tufts of hair on Rothman’s pillow, but George wasn’t interested. Rothman had become agitated now, twisting against his restraints while mouthing some words. Pia grabbed his chart and was flipping through the pages.

“His temperature’s up-not a lot, but up nonetheless.”

“Pia . . . let’s go!” George stage-whispered.

“You go, George, I’m not leaving. Not yet.” From working with Rothman, Pia had learned a great deal about typhoid fever and its cause, salmonella typhi. She knew the danger signs of the illness and the fact that the disease attacked the small bowel, concentrating in lymphoid tissue in the small intestine called Peyer’s patches. Rothman’s gown was pulled over to one side, and Pia exposed Rothman’s abdomen a little more. She slowly pushed in on his upper abdomen, and Rothman squirmed and moved his head from side to side.

“He’s definitely showing signs of discomfort, maybe pain in his abdomen,” Pia said. “This is not a good sign.”

George was beside himself. He could see a few people passing by in the outer hall through the wire- embedded windows in the two doors of the isolation room. He walked over and closed the blinds, hoping to buy Pia some time. When Pia suddenly let up on the pressure she was exerting, Rothman reacted slightly, to Pia’s surprise, as if that caused more discomfort.

“Did you see that? He recoiled. Would you say he recoiled?”

Pia repeated the maneuver and got the same result.

“He definitely recoiled.”

“Whatever it is you’re doing, it’s going to get both of us kicked out of school if we don’t leave right now. We’re pushing the limits on a couple of celebrity patients.”

“It’s rebound tenderness,” she said. “It’s a sign of peritonitis, inflammation of the lining of the abdominal cavity. It means the bacteria have penetrated the lining of the small intestine.”

Pia reached over and punched the intercom button. The nurse at the station picked up.

“Is Dr. De Silva available? If she is, get her in here stat. The patient has developed rebound tenderness.”

George was hopping from one foot to the other. Now she’s really done it, he thought.

At once, Dr. De Silva came in the room, palpated Dr. Rothman’s abdomen and confirmed Pia’s finding.

“And look, he’s losing some hair,” Pia said.

“That could be the chloramphenicol. But regardless, the rebound tenderness suggests the chloramphenicol is not controlling the infection. We’ll have to change the antibiotic. I’ll call Springer and get his suggestion. Thanks for your help.”

Dr. De Silva ducked out of the room.

“He’s getting worse,” Pia said, looking at Rothman forlornly.

“Rebound tenderness isn’t a good sign, I know that,” George said. “But you’ve done all you can do. Let’s go. You heard her, she’s calling Springer.”

By the time George and Pia took off their gear and got back to the nurses’ station, Dr. De Silva was on the phone with Springer. Pia stood where she could hear Dr. De Silva’s half of the conversation. It sounded like Springer was doing most of the talking.

“Okay, ceftriaxone . . .” she said. “. . . And the hair loss . . . Right, of course we’ll stop the chloramphenicol…. Okay. I’ll see you soon, and I’ll call Dr. Miller.”

Dr. De Silva turned and saw Pia. She hung up the phone and redialed immediately. She covered the receiver with her left hand and talked to Pia as the phone rang.

“Dr. Springer’s on his way in. He wants to check the rebound tenderness for himself-Oh, hello. I need Dr. Miller. . . . Dr. Miller, this is Dr. De Silva in Infectious Diseases. I’m treating Dr. Rothman and Dr. Yamamoto. Dr. Springer would like a consult. We’re seeing rebound tenderness in Dr. Rothman and may have to remove the infected bowel…. No, just Dr. Rothman at the moment . . . His temperature is up slightly. Other levels-blood pressure, pulse, oxygenation-are the same. Okay, thanks.”

Dr. De Silva hung up the phone and exhaled. She was a small woman of Sri Lankan descent who prided herself on running a tight ship. She was embarrassed that a medical student had picked up an important sign that she’d missed. “I just checked him a few minutes before you two showed up. Temperature was holding steady,” she said, half to Pia, half to herself. She turned to Pia.

“It can come on very quickly. Dr. Miller, the chief surgical resident, is coming in. And Dr. Springer’s on his way over. So, who’s your preceptor? I should at least give you credit for what you found. And how did you know what to look for? I’m impressed.”

“Actually I’m not on internal medicine at the moment.”

“Are you on an infectious disease elective? If you are, I haven’t heard your name.”

“I’m not on an infectious disease elective either.”

George was desperately trying to get Pia to shut up. Out of Dr. De Silva’s line of sight he was frantically making a time-out gesture like a football official.

“Well, what brought you here?” Dr. De Silva asked.

“I just happen to know a lot about salmonella.”

“Really? From whom?”

“Dr. Rothman,” Pia said, as George grabbed her arm and literally pulled her away, angling her toward the elevators.

George felt a sense of relief as they left the hospital. With as busy as Dr. De Silva was, he hoped she wouldn’t say too much about the two mysterious med students, one of whom had been very helpful. Actually he doubted she would. He knew that there hadn’t been any negligence on Dr. De Silva’s part, but he knew that in the competitive atmosphere of the academic center, she was probably chagrined that she’d been, in a fashion, upstaged by a medical student. Pia had detected the change in Dr. Rothman’s condition before she did. But George’s relief was short-lived.

“I want to go back to the lab,” Pia said, stopping suddenly. They had just reached the corner where 168th Street turns into Haven Avenue. “I want to see if there are any clues as to why or how he got infected. He’s so careful, I don’t understand it. He’s so detailed and compulsive about his work, his organization, his technique, it’s all flawless. It doesn’t make sense.”

Still lurking in the back of Pia’s mind was the thought that Rothman had infected himself intentionally. But why would he involve Dr. Yamamoto? It couldn’t be the case, or could it? What she wanted to do was completely eliminate the idea as even a remote possibility. If Rothman died, it was going to be a betrayal of sorts, but she didn’t want it to be his betrayal. Betrayal by fate she thought she could ultimately handle. Personal betrayal by Rothman would be something entirely different.

George groaned inwardly. Visiting Rothman had been bad enough. Visiting a lab that was off-limits by order of the CDC was something else entirely. “The lab is closed,” George said in a fashion that wouldn’t brook discussion. “Order of the CDC. Let’s head up to your room. I saved the sandwich you didn’t eat.” To prove his point, George pulled the food from his pocket.

“I’m going,” Pia said.

“What on earth do you think you’re going to turn up that the CDC hasn’t?”

“I don’t know, but I can’t do nothing. You can come with me or not, I’m going anyway. Of course two sets of eyes may be better than one.”

George realized Pia was asking for his help, however indirectly, which was a first. Still, it wasn’t an easy