LIKE MOST PEOPLE, David Jeffries had never truly appreciated the molecular marvel that bacteria represented, nor the fact that whether an infection, once started, would be contained or spread depended on the outcome of an epic molecular battle waged between the bacteria's virulence factors and the human body's defense mechanisms. He also had never truly appreciated the threat that bacteria continued to pose, despite the extensive pharmacopoeia of antibiotics available to the modern physician. He had been aware that bacteria were responsible for terrible scourges in the past, including the black plague, but that had been in the past. He certainly hadn't worried about bacteria the way he worried about viruses such as H5N1 (bird flu), Ebola, or the virus that causes AIDS, whose threat was continually hyped by the media. Besides, David had been vaguely aware there were so-called good bacteria that helped to make things like cheese and yogurt. So when he had entered Angels Orthopedic Hospital early one Monday morning in 2007 to have his anterior cruciate ligament repaired with a cadaver graft, bacteria weren't one of his concerns. What he had worried about was the anesthesia and not waking up after the operation was over. He had also worried about the possibility he'd go through the whole ordeal, which a buddy had confided was painful, and it wouldn't work, meaning he wouldn't be able to get back to the tennis he loved.

As a computer programmer for a high-flying Manhattan-based software company, David had spent, as he put it, a lot of hours on his butt, shackled to his monitor. Being an athletically inclined individual from as early as he could remember, he needed competitive exercise, and tennis was his thing. Up until his injury a month prior to his surgery, he'd played at least four times a week. He'd even vainly tried to interest his two preteen sons in the game.

As for his injury he had no idea how it had happened. He'd always kept himself in good shape. All he had remembered about the event was charging the net after making what he thought had been a good lead shot. Unfortunately his shot had not been as good as he had hoped, and his opponent had followed up with a well-placed return to David's left. On the run, David had planted his leading foot and twisted left to try to get to the ball. But he never got near it. Instead, he had found himself on the ground, clutching a painful knee that had immediately begun to swell dramatically.

Considering David's fulminant postoperative course, one certainly could say that he should have been more respectful of bacteria. Within hours of his surgery, relatively small numbers of staphylococci, which had found their way into David's knee and the distal bronchioles of his lungs, began their molecular magic.

Staphylococcus is a common type of bacterium. At any given time, two billion people, a third of the world's population, have them commensally residing inside their nares and/or in moist locations on their skin. Indeed, David was so colonized. But the species that had gotten inside David's body was not from his flora, but was rather a particular strain of staphylococcus aureus that had taken advantage of the ease with which staphylococci exchange genetic information to enhance their virulence and hence competitive advantage. Not only did this particular subspecies resist penicillin-like antibiotics, it also carried the genes for a host of nasty molecules, some of which helped the invading bacteria adhere to the cells that lined David's smallest capillaries while others actually destroyed the defensive cells that David's body sent to deal with the developing infection. With David's cellular defenses crippled, the invading bacteria's growth rapidly became exponential, reaching in hours a secretory stage. At this point, a group of other genes in this particular staphylococcus genome switched on, allowing the microorganisms to spew out a library of even more vicious molecules called toxins. These toxins began to wreak havoc inside David's body, including causing what is commonly referred to as the "flesh-eating effect," as well as the symptoms and signs referred to as toxic shock syndrome.

David was first made aware of the gathering storm by a slight fever, which developed six hours after his surgery, well before the invading bacteria reached the secretory stage. David didn't give the rise in temperature much thought, nor did the nurse's aide, who duly recorded it in his digital record. Next, he noticed what he described as tightness in his chest. With his narcotic pain medicine onboard, the administration of which he was able to adjust himself, he didn't complain. He thought these early symptoms were par for the course until his breathing became labored and he coughed up blood-tinged mucus. Suddenly, it was as if he couldn't quite catch his breath. At that point, he became truly concerned. His anxieties ratcheted up when he called attention to his worsening condition and the nurses responded by erupting in a flurry of anxious activity. As blood cultures were drawn, antibiotics were added to his IV, and frantic calls were made about a possible emergency transfer to the University Hospital, David hesitantly questioned if he was going to be all right.

"You'll be fine," one of the nurses said reflexively But that reassurance notwithstanding, David died several hours later of overwhelming sepsis and multiorgan failure while en route to a full-service general hospital.

LIKE MOST PEOPLE, Paul Yang never truly worried about his ultimate fate, yet he should have, particularly around the time that David Jeffries was losing his molecular battle with bacteria. Similar to other fellow human beings cursed by the knowledge of their mortality, Paul didn't dwell on the harsh reality of death, even with the nagging reminder of progressively aging at a gradually quickening pace. At age fifty-one, he had too many more immediate concerns, such as his family, which included a spendthrift wife who was never materially satisfied, two children in college and another soon to follow, and a large suburban house with a commensurate mortgage and the constant need of major repair. As if all that wasn't enough, over the last three months his job had been driving him to distraction.

Five years previously, Paul had given up a comfortable yet predictable and somewhat boring job at an established Fortune 500 firm to be the chief and only accountant for a promising new startup company proposing to build and run private, for-profit specialty hospitals. He had been aggressively recruited by his former boss, who had earlier been recruited to be the start-up's CFO by a brilliant woman doctor named Angela Dawson, who was just finishing her MBA at Columbia University. The decision to switch jobs had been agonizing for Paul, since he was not a gambler by nature, but his growing need for disposable income and the chance to make it big in the rapidly growing, trillion-dollar healthcare industry trumped the uncertainties and the associated risks.

Remarkably, everything had gone according to plan for Angels Healthcare LCC, thanks to Dr. Angela Dawson's innate business acumen. With the stock, warrants, and options Paul controlled, he was within weeks of becoming rich along with the other founders, the angel investors, and to a lesser extent the more than five hundred physician equity owners. The closing of an IPO was just around the corner, and due to a terrifically successful recent road show that had institutional investors drooling, the stock price was just about set at the upper limits of everyone's expectations.

With an anticipated five hundred million dollars to be raised on the first go-round, Paul should have been on cloud nine. But he wasn't. He was more anxious than he'd been in his entire life, because he was ensnared in an epic ethical dilemma exacerbated by the series of recent corporate accounting scandals, including that at Enron, which had rocked the financial world during the previous six or seven years. The fact that he had not cooked the books was not a consolation. He religiously adhered to GAAP – Generally Accepted Accounting Procedures – and was confident that his books were accurate to the penny. The problem was that he didn't want anyone outside of the founders to see the books, specifically because they were accurate and therefore clearly reflected a major negative-cash-flow situation. The problem had started three and a half months previously, just after the independent audit had been completed for the IPO prospectus. It began as a mere trickle but rapidly mushroomed into a torrent. Paul's dilemma was that he was supposed to report the shortfall, not just to his CFO, which he certainly did, but also to the Securities and Exchange Commission. The trouble was, as the CFO quickly pointed out, such reporting would undoubtedly kill the IPO, which would mean that all their strenuous effort over almost a year would go down the drain, perhaps along with the future of the company. The CFO and even Dr. Dawson herself had reminded Paul that the unexpected burn rate was a mere quirk and obviously temporary since the cause was being adequately redressed.