Medical Center in Atlantis was only a mile away, and they arrived there at 2 a.m. On admission to the emergency department, Bob seemed delirious. In the words of his medical case description, “he was not oriented to person, place, or time.” Clearly his brain was under some sort of stress. Maureen reviewed his behavior and symptoms for the past few days with the emergency room doctor. After an initial examination the presumptive diagnosis was meningitis, an inflammation of the membrane covering the brain. Although the causes of meningitis are various, one common source is bacterial infection. Accordingly, Bob was started on multiple antibiotics—cefotaxime and vancomycin—in addition to medication for nausea that made him sleepy. Maureen herself displayed none of Bob’s symptoms. Her earlier fever proved to be transient and unrelated to Bob’s.
Around 5:30 a.m. the emergency room staff prevailed upon Maureen to go home and rest for a few hours. When she returned to the hospital at 8 a.m., she learned that Bob had suffered a seizure and been intubated—a tube was threaded through his nose into his respiratory passage. The tube was attached to a ventilator, a device to help him breathe. A spinal tap had also been performed to examine his cerebrospinal fluid for signs of infection or other abnormalities.
Dr. Larry Bush, an infectious disease specialist, is an amiable skeptic with a fondness for conspiracy theories. Medical lore holds that when you hear hoofbeats, think horses, not zebras; that is, when trying to come up with a diagnosis, don’t start with remote possibilities. Larry Bush is something of a zebra man. He is inclined toward less conventional thinking. He doubts, for example, the official line that President Kennedy was assassinated by a lone gunman shooting from the Dallas Book Depository building. “I stood at the site and some bullet trajectories line up with the grassy knoll.” He smiles and shrugs as if to say, “That’s what I think, so shouldn’t I say it?”
Whatever one thinks of his Kennedy assessment, the mind-set of this slightly built physician with a gray-brown beard and mustache helped him point to the diagnosis of a lifetime. Bush began practicing out of the JFK Medical Center in 1989, a year after completing specialty training at the Medical College of Pennsylvania in Philadelphia. At 8:30 a.m. on Tuesday, October 2, 2001, he was in his office a few blocks from the hospital. He was about to leave for a meeting at the hospital when the phone rang. “We’ve got a 63-year-old man here with fever and apparent meningitis,” a laboratory technician said. “His cerebrospinal fluid is cloudy and we did a Gram stain. We’d like you to look at it.” Bush shot back, “I’m on my way. See you in a few minutes.”
Cerebrospinal fluid, which runs through the brain and spinal column, is normally clear, like water. A cloudy sample, obtained through a spinal tap, suggests the presence of white blood cells, an indication of infection. The process of identifying the bacteria causing an infection commonly begins with a Gram stain. Introduced in 1844 by the Danish bacteriologist Hans Christian Gram, the test involves staining bacteria with crystal violet, a coloring agent that he developed, and then washing them with alcohol. Bacteria tend to fit into one of two categories according to whether they retain the violet color or not. Those that do—for example, bacteria in the genus bacillus , clostridium , s treptococcus , or s taphylococcus —are deemed Gram positive; those that do not are Gram negative.
When Bush arrived at JFK Medical Center he went directly to the laboratory. He looked into the microscope and then at the patient’s record. His undergraduate degree was in microbiology, “so I tend to think like a microbiologist as well as a physician,” he says. The Gram stain was positive, and the shape of the bugs amid the white cells suggested they were bacilli of some sort.
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