DEMANDING A DIAGNOSIS, AND OUTWITTING ANTHRAX
31 Dec 2002
Source: New York Times, December 3, 2001.
Demanding a Diagnosis, and Outwitting Anthrax
By KIRK JOHNSON
STAFFORD, Va. -- Leroy Richmond, gifted with a mellifluous voice and precise elocution, was often asked to read safety announcements at the Brentwood Road complex of the Postal Service in Washington. But the three October mornings that he stood to read the latest news about anthrax now seem strange, he said, a fractured memory that plays over and over in his head.
Though he did not know it on those days, Oct. 11, 12 and 13, Mr. Richmond was already sick. He had inhaled anthrax spores, postal officials later told him, most likely on the morning of the 11th, while cleaning near a contaminated mail-sorting machine. A medical odyssey that would shake him and his family to the core and help rewrite the book on anthrax -- its complications, its treatment, its survivability -- had begun. And no one knew.
"Here I am reading about anthrax, not aware, not conscious, that here it is already in this building," Mr. Richmond said. "Here it is. It's already been opened. Here it is up in the air. Here it is inside of me."
Since the first anthrax attacks in September, through the sprawling medical and criminal investigation that followed, the nation's experience with bioterrorism has been like that -- always off balance and behind the curve, knowledge out of reach, risks unknown. Mr. Richmond's account -- the first detailed account of inhalation anthrax from a survivor of the attacks -- shows how that process of epidemiological catch-up played out in the ordeal of one man who, at least by the common medical wisdom, probably should have died.
Mr. Richmond, who turned 57 in the hospital on Oct. 22, does not easily wear the mantle of heroic survivor or medical pioneer. Sitting in his living room in this middle-class suburb an hour's drive from Washington, he tends to talk about weaker moments, the times he cried or lost hope, the nights in his hospital bed, sleepless, trying to find one concrete thing in the midst of so much that had become unfathomable.
"I'd put my hand on my navel and I'd say, 'I know this is reality,' " he said.
But doctors and relatives say that, in his own quiet way, Mr. Richmond was heroic, and that that made his survival possible. Put another way, he insisted on kicking up a fuss.
Anthrax succeeded in killing two of his Brentwood colleagues, men he prayed with and played cards with. In those early days when they all began to feel bad, doctors did not know that postal workers were at risk, and flu symptoms were considered exactly that. But Mr. Richmond was the one who demanded medical attention, because somewhere deep inside he knew he was ill and would not take no for an answer.
"When the doctor said, `I hear a little wheezing, but it's nothing to be concerned about,' I'm thinking, `Well, he's the doctor, but I just don't believe him,' " he said.
Once doctors decided he most likely had anthrax -- then believed to be fatal about 85 percent of the time -- they were confronted not only with an unfamiliar disease but by a whole suite of uncharted complications that emerged when their patient did not, in fact, die. The hesitant tone in their voices, Mr. Richmond recalls, was a message in itself. The doctors, he realized, were pretty much making up his treatment as they went along. Mr. Richmond is one of 11 people who have come down with inhalation anthrax since late September, and one of six who survived.
"It was striking how little information about anthrax was out there," said Dr. Susan Matcha, an infectious disease specialist who treated Mr. Richmond at Inova Fairfax Hospital in Virginia, just outside Washington. "And there was nothing at all about what to do in the hospital after they start surviving."
Through four weeks in the hospital -- three in intensive care -- humor and dread became Mr. Richmond's daily currency. He was constantly surrounded by packs of highly trained doctors, but despite all the attention, he remembers one night complaining after not getting his dinner. Perhaps it was a mixup, but in any case, he recalled, the head hospital chef brought out a special meal for Mr. Richmond, who is a vegetarian, and offered a profuse apology.
But Mr. Richmond remembers another day, too, when his minister came by and said what many had thought but none had uttered: "You're supposed to be dead."
Crooked Path to Discovery
By the time Mr. Richmond reported for work at 4 a.m. on Friday, Oct. 19, he had felt slightly, if vaguely, ill for nearly four days, and for a man who never doctored himself with anything stronger than aspirin, enough was enough. He approached a supervisor, asking for a medical form to visit the plant nurse, but was told to come back later because the supervisor was too busy reading a bulletin from headquarters about, of all things, anthrax.
Since the previous Monday, when an anthrax-laced letter was opened in Senator Tom Daschle's office at the Hart Senate Office Building, the nation had erupted with a wave of anxiety and speculation about bioterrorism. Although no one knew it, the impact was already starting to hit at Brentwood. Three other postal workers were already ill.
Mr. Richmond said he has since come to conclude that the difference between living and dying on those pivotal few days was whether or not you believed what you were told. The two men who died, Joseph P. Curseen Jr. and Thomas L. Morris Jr., both saw doctors and were sent home. Mr. Richmond simply would not leave.
"I knew there was something physically wrong with me -- I knew I had pneumonia, I believed it more than anything," he said. Anthrax, at that point, had not crossed his mind. "But I knew something was wrong with my breathing because it was getting shallow, and that coughing yellow phlegm meant something," he said.
Treating in the Dark
There was a medical gantlet to be run first.
The nurse at Brentwood told him he had a low-grade fever, and that it was probably nothing to worry about. Then the doctor at his HMO center told him he did not seem very sick.
The emergency room doctor who was working at Inova Fairfax that day, Cecele Murphy, similarly did not find much that concerned her. Mr. Richmond's chest X-ray looked only mildly abnormal. The fact that he was a postal worker, however, pushed her to act, she said. She admitted him and started him on an intravenous treatment of ciprofloxacin antibiotics immediately, before she had any confirmation that he indeed needed the drug.
Dr. Murphy said that a combination of raw information and unexplainable intuition went into the decision. There was at that time no medical protocol that said doctors should be on the alert for anthrax exposure in postal workers. But the intense media focus on a lethal letter on Capitol Hill, she said, and the fact that she had just spent two weeks watching almost nothing but CNN on her vacation -- much of it all anthrax all the time -- hovered in the back of her mind. Still, she was not sure.
"I told him we're going to treat you as if you have anthrax, but I don't think you do," Dr. Murphy said. Laboratory results confirmed the next morning that Mr. Richmond indeed had anthrax.
Mr. Richmond said that much of his care was like that.
"There was never a diagnosis -- to say this is a diagnosis and this is what we're going to do," he said. "No. They'd say, 'This is a process that we're going to try.' It was always a process and never a diagnosis."
After about a week in the hospital, Mr. Richmond developed a life- threatening blood disorder. It, too, was treated by inference and intuition, as doctors struggled to understand what was happening to his body, and whether it was a consequence of the original anthrax infection or an unfortunate coincidence.
Mr. Richmond said he vividly recalled the moment when the specialists were clustered in his room, pondering the new development, and one doctor started talking about an article he had read several months earlier in a medical journal about a procedure called plasmapheresis.
"Here's a doctor who's read something months before, and he's bringing this knowledge forth," Mr. Richmond said. "All the other doctors in intensive care gathered and said, 'Well, maybe we should try.' I think the doctors, as they looked at me, each in their own little field of expertise, could see me as their individual patients -- the gastroenterologist, the doctor who did the blood work, all these guys sort of separated me out, 'This is what I think should be done.' "
One of Mr. Richmond's doctors, Jonathan Rosenthal, an infectious disease specialist at the Mid-Atlantic Permanente Medical Group, said that the blood complication -- a low platelet count with many destroyed red blood cells -- could have been caused either by an inflammation of the blood vessels, called vasculitis, or another condition, called TTP. And while he said the doctors believed that the condition was linked to anthrax, they could not be sure.
So Dr. Rosenthal said they decided simply to treat the measurable symptoms they could find and forget about causes. They gave Mr. Richmond a regimen of steroids and processed his blood with plasmapheresis, a procedure similar to dialysis but in which the plasma is removed and replaced by donated plasma.
"We were flying by the seat of our pants," Dr. Rosenthal said.
Daughter's Tenacious Vigil
Meanwhile, Mr. Richmond's daughter, Alicia Richmond Scott, often appeared to be the one in the pilot's seat. Ms. Scott, a program analyst at the Department of Health and Human Services, frequently spoke by phone from the hospital to a physician friend in California who told her to keep an eye on her father's blood tests and the measurements of his breathing volume, and what to watch for if those numbers reached certain critical levels.
"If his numbers get this low, then you need to worry about this; if his numbers in terms of his breathing get this low, then they could consider a respirator -- things like that," Ms. Scott said.
She also pumped the nurses and interns assigned to intensive care for information about Mr. Richmond's case, then used that information to go back and challenge the attending doctors. And while the process ruffled a few egos, she also gradually won respect in the intensive care unit, Mr. Richmond's doctors said, if only for her devotion and tenacity.
"When my sons are her age, if they look after my interests the way she did, I'll be in good shape," Dr. Rosenthal said.
The Long Road Back
Mr. Richmond likened many of those days to a kind of middle passage, where hope was to be found in unlooked-for places. One morning, for example, he said he got out of bed, dragging his intravenous tubes, trying to make it to the bathroom, but got so tangled and frustrated that by the time a nurse named Karen walked in, he was in tears.
"Karen came in and said -- she called me Bud -- she said, 'Oh, Bud, it's going to be all right,' " Mr. Richmond said. "And I felt she was crying too. I guess she could feel my pain; she reassured me that it was going to be all right. That was one of my very low moments."
Later, his father, William Richmond Sr., 84, a church deacon in Newport News, Va., arrived at the hospital and prayed.
"He said, 'Let the doctors know with all their medicine, that this is my son; let them know that this is a good son,' " Leroy Richmond said. "I sort of fed off that, and that prayer."
The plant manager from Brentwood also came by the hospital, Mr. Richmond said, and together they talked through the events of his probable exposure -- all of which pointed to a case of simple bad luck. Mr. Richmond, who worked in the Express Mail section, had volunteered for a cleanup detail on Oct. 11, and was working near one of the big sorting machines -- the very one through which the anthrax-infected Daschle letter is believed to have passed -- when the powerful air-jet cleaners were turned on to blow out the machine's dust and dirt.
"It all made sense, it all made sense that that was the same machine Joe worked on," he said, referring to Mr. Curseen, who died on Oct. 22. "I'm cleaning up an area right behind the machine, dust and soot and everything else coming up, and I was right about there, where that lamp is," he said, gesturing five feet across his living room.
Since he was discharged from the hospital on Nov. 13, Mr. Richmond has had his blood tested every other day. In a month or two, his doctors have told him, they want to take a pint or more for research into an anthrax vaccine. His weight has dropped to a rail-thin 128 pounds on a 5-foot-10 frame. He tries to walk a mile or more each day, but his lungs, which at the nadir of his illness had shrunk to the size of two large grapefruits, have not fully come back.
Time, he said, has become a matter of individual days -- some good, some much less so.
"I don't know what the future holds," he said. "I talked to a guy from work. He said, 'You coming back to work? It's not the same without you,' " Mr. Richmond said. "I said work is the farthest thing from my mind. I love my neighbors. I like my yard, I like this place."
As he spoke, Mr. Richmond's son, Quentin, 6, brought over a picture and a story he had written. It was about a man who played basketball and then went to the store, and as Mr. Richmond praised Quentin's work and read the story aloud, his hand strayed up to touch his chest. The ribs are still sore, he said, and what is worse, he still cannot sleep, and the doctors cannot really tell him why.