FALLS CHURCH, VIRGINIA — A sensible-looking, fifty-five-year-old man was my first patient in the ER on October 17. Solid and affable, he had received a letter at work, the Naval Federal Credit Union, the day before. The letter had a funny smell, made his eyes turn red, and he woke up this morning with a dry cough. The words "That sounds more like..." were out of my mouth before I stopped myself from saying that what he was describing sounded more like a chemical agent than a bio agent. He didn't look like the victim of a chemical weapon. "How you feeling now?" I said. He looked perfectly healthy. "Oh, I'm fine, now." My patient related how he put the envelope in his desk after sensing the odor. "Dull" is how he described it, and soon after went home for the day. He hadn't wanted to alarm anyone unnecessarily, so I was getting the whole story for the first time. The exposure had been around eighteen hours before, and the possibly chemical-laden envelope had to be at least twenty-four hours older than that. I briefly considered excusing myself to check out the Jane's Chem-Bio Handbook ten yards away in my backpack, but decided against it. The guy was only concerned about exposure to anthrax spores so, following the patient's same motivation the day before and not wanting to cause undue alarm, I didn't mention my concerns. I looked him over: pupil size OK, no redness that had bothered him at first, no signs of respiratory distress, no vomiting or intestinal distress. Vital signs steady. With culture swabs in hand, I realized that I didn't know the recommended way to swab a nose for anthrax. One way would be to take the oversized Q-tip and follow up under the bridge of the nose, aiming for the forehead, the other way would be to shoot straight back, parallel to the palate, until I reached adenoids. No one had bothered to tell us which way gets a better yield. Guessing — and it was just a guess — I chose the deeper, more irritating path straight back. A swift dart in and out. My patient gasped and reflexively grabbed at me. "Damn, doc!" Then I did it again, he grabbed at me again, and our session was over. He re-confirmed his home and work phone number from the ER log, and I told him to expect a call in one to two days with results, positive or negative. The secretary didn't know what to do with the swabs. It was her first shift since Friday October 12, the day that anthrax and white powder started turning up in New York and elsewhere. The charge nurse, Joanie, didn't know if the policies and procedures were any different for potential chemical exposures and potential biological exposures. Though the morning lull was ending and patients were starting to pile up, we decided it was well worth our while to look it up, and we discovered an interesting fact. If a patient came in to the ER with a suspected chemical contamination, we were to call 911 right away. When we read that, Joanie's eyes popped. She let out a bark of a laugh, muttering about the idiots who write policies. Two more patients were waiting for anthrax swabs, one an executive type who had received a powder-containing letter a few weeks ago, the other a woman who found a sticky substance on her cell phone. "Ask her if she's been to Krispy Kreme," Joanie suggested. Word had come from Capitol Hill the day before that Senator Tom Daschle's office had tested positive for "professional grade" anthrax. Having read Ken Alibek's book BioHazard several months ago, I immediately considered the ugly prospect of a strain of anthrax resistant to multiple drugs. For the first several hours that day, CNN wasn't illuminating on what professional grade meant, and enhancing the sense of everything sliding toward chaos, they reported that the finely milled, inhalable spores got into the air ducts in the halls of Congress. The pasty, uneasy look that begs for a clear, simple, reassuring answer started showing up on people's faces again. Docs, nurses, patients, everyone. At about three in the afternoon, I saw the hospital's Infectious Disease specialist. He was our liaison with the Center for Disease Control and all the people in Response Planning, and I saw him as my opportunity to get some answers. He was in between meetings, so I ran to keep up with him. "So what's the story?" I asked. "There's no suspicion yet of this being a resistant strain." The longer they refused to say, I thought, the worse it had to be. "Bullshit," I said. "Is it or isn't it?" "We don't have to scrounge around for new drugs just yet," he said. "Okay?" Then he was off. "DC. Meeting. CDC. Feds." A few minutes later, CNN broke the same news. Antibiotic sensitive. But a few minutes after that, I ran into one of our hospital's clinicians who consults for FEMA and the Justice Department on bio-preparedness issues. He used to travel across the country organizing citywide and regional drills back in what seems to be a very long time ago, when they were just hypothetical scenarios. "The kind of anthrax sent to the Senate can only be produced in four places," he told me. "U.S., Russia, Iran and Iraq." He, too, was rushing to get downtown to the meeting between health officials, law enforcement, intelligence personnel, regional hospital directors and everyone else who wasn't getting much sleep anymore. "I leave it to you to draw your conclusions," he said. (This particular gnawing gut-speculation later seesawed away from foreign sources only to be replaced by the new worry over chemical lacing of spores to improve aerosol-ization.) "You heard it wasn't a resistant bug," I said. I wanted at least to offer something positive. "Yeah, I heard," he said. He stopped and smiled, something he rarely does. "Do me a favor?" he asked. "Sure," I said. "Anything." "Can you sign four scripts? If I have to be away, I want my family to have some Cipro." Over the next few hours, enough patients came in sick and injured to keep me from dwelling on the implications of a normally stalwart man asking for a prescription, a hedge, an insurance policy. The next time I had a chance to indulge my CNN fix, welcome news came from the Capitol. The anthrax had not, it turned out, been floating in the air or circulating through vents. Just more bad mail. No new cases had turned up. The confusion and disinformation at the Capitol, however, generated a new crush of patients needing nasal swabs. We got a call to prepare for a lot more folks coming our way. We were told not to issue any antibiotics unless the patients were from the offices of Senators Daschle or Feingold, Daschle's neighbor on the hill. The first woman came through at seven, just as the shift was changing. The secretary from the morning told the new secretary how to enter "Rule Out Anthrax" into the computer system. The doc coming on to relieve me nodded as I signed over the belly pain waiting for a CAT scan, the motor vehicle wreck waiting for a head CAT scan, and the vag-bleeding pregnant woman waiting for a pelvic sonogram. A dozen people checked in at triage for nasal swabs. I forgot to ask her how she would swab: up or straight back.
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