He sat in the stillness of his office and felt the place weigh on him. Eight hundred beds, eight hundred souls, and if he weren't careful, every one of them would land a problem in his lap. And to think that just two days ago Jimmy had accused him of being too little involved with the rest of St. Paul's. Earl wondered if the real danger wasn't that he might get too entangled and be sucked dry. Because when he sensed something wrong, he couldn't let it slide.

But it was one thing to let the workings of an ER consume him. The tenacity that drove him not to quit on a patient took hold when trouble hit. His reflex as an ER physician was to leap on a problem the way he would a bleeder, well before it got out of hand. Yet he took the challenges in stride and inevitably, one way or another, found solutions. It all happened on a scale that never threatened to overpower him.

He leaned back in his chair and regarded the spartan furnishings- a steel-gray standard hospital-issue desk, two simple chrome chairs covered in black Naugahyde for visitors, a solitary potted plant that somehow survived the closed space and poor light from a grime-coated window the size of a cafeteria tray- and chuckled. The hospital CEO had offered him surroundings "much more suitable" to his new position, but he'd declined the upgrade, having always found it an advantage to demand sacrifice and best efforts from people if he himself worked out of an austere setting. The trick now would be to keep his perception of what needed fixing just as free of clutter.

He'd have to compartmentalize like never before, carefully choose his causes, and forget about charging off on wild hunches.

Keep everything at scale.

As for Yablonsky, well, he'd deal with her at death rounds.

Except something about her bothered him. She had definitely been edgy as he looked through those five files. Of course, just being around him could make her nervous, especially if his double-dose theory regarding Matthews was true. Yet..

Another event niggled at him- her reaction to the word cluster the evening before Matthews's death.

In a medical context doctors used it frequently, referring to a grouping of any unusual incidents or diseases, even symptoms and signs. So it had an unpleasant connotation to begin with, but not one that should have upset an experienced nurse. Unless…

He knew one context in which the term cluster carried a resonance that gave him a chill.

He dialed the nursing station and asked for Dr. Biggs. "Hello, Thomas. I wonder if you could go to our teaching files and dig out an article for me. It's one of the epidemiologic chestnuts on CPR in the New England Journal that I present to the residents every year, so you'll probably remember it." A lot of nurses would too, including Monica Yablonsky. The nursing director had asked him to give sessions about it with her staff on several occasions.

"Sure. What's the title?"

" 'Mysterious Clusters of Deaths in Hospitals.'"

Earl hung up and returned to checking discharge statistics for palliative care, going a lot farther back than three months.

Jane Simmons bought the kit at a pharmacy far from her apartment where no one knew her. She needn't have gone to the trouble. The salesgirl didn't so much as look up during the purchase.

In the privacy of her bathroom, she applied the drop of urine and waited.

In one minute she'd know.

Reruns of the last six weeks tumbled through her mind.

She'd missed before. Rather, it had come late a few times, by as much as two weeks. She'd assumed that this time she'd skipped a cycle altogether but that her period would arrive any day now. She'd been so careful to use the foam with her diaphragm and insist he wear a condom. It never occurred to her that they could have messed up. "The problem arrives when you forget," Dr. Graceton had reassured her in recommending the switch after the damn pill kept causing nausea, even after many tries on different types and dosages.

But there had been times in the middle of the night when she woke with him entering her again. God help her, she loved yielding to him in that half-asleep state. Even then she remained aware enough to feel he'd put on protection, and the diaphragm would still be in place from when they'd made love hours earlier, then fallen asleep in each other's arms.

The trouble was she hadn't added more foam.

Thirty seconds.

She looked out the open door at the rest of her apartment. It didn't seem so bright anymore. The paintings she'd chosen for color rather than any specific artist looked drab and cheap, every bit the pathetic imitations they were. Strange how baubles meant to comfort lost their luster when real trouble hit.

Ten seconds.

She felt so stupid sitting there on the tile floor, her future in the hands of a reagent to detect the chemistry of an embryo implanted in her womb. It would be six weeks old now, little more than a ball of cells, but the tissue already beginning to differentiate into what would become brain, heart, and skin. She hugged her knees and began to rock slightly, the way she had as a little girl whenever something worried her.

Such little problems then: homework, what boy would or wouldn't talk to her, exams. Even her worries an hour ago now seemed insignificant: paying bills, what groceries to get. All little stuff. Her only big concern had been what would happen to Dr. G. That still mattered.

Shit, what would he think of her now? And Dr. Graceton. She'd been so kind, taking her on as a new patient- doubtless because Dr. G. had spoken to her.

Or her mother. She'd been ecstatically proud to have a daughter who would be the first woman in the family to have a profession, as opposed to her own lifetime of waiting on tables at the local Denny's, double shifts galore after Dad died.

Now this.

And how would Arliss, her little brother, take it? They'd planned to escape Grand Forks together. First she'd get out through nursing, then he'd follow, and she'd help with the money for his college tuition. He'd been crazy about animals since they got their first puppy, and he dreamed of becoming a vet. If she stopped work, his future crashed as well.

And most of all, what would Thomas think?

Or would she tell anyone? She could just get rid of it privately, with no one she cared about the wiser.

She stared at the indicator dot.

It turned blue as a newborn's eyes.

Later that same evening, 5:45 p.m. CEO's office, St. Paul's Hospital

Dr. Paul Hurst threw down the article Earl had shown him. "But they're supposed to die. It's a terminal ward."

"I still thought you should know."

"On the basis of… what did you say? A fall in average length of stay from twenty-seven days to twenty-four about three months ago, and a point-five increase in the number of deaths reported each morning? That's infinitesimal."

"Not exactly. It's a rise of fourteen deaths a month, all of them occurring at night. And three months before that there had been a similar change, an increase of about eleven deaths a month, again mainly at night. In the previous years, the rate appeared to hold steady, about three-point-three deaths a day, and only half of them on that shift."

Hurst rolled his eyes at the ceiling. "Will you listen to yourself? You sound like my stockbroker pitching nonexistent returns. Besides, it could be that patients are admitted at a later stage of the disease these days and therefore die sooner once they're here. Hell, it sounds like something you should applaud, a reduced length of stay and more efficient use of beds. You spearheaded that trend everywhere else in the hospital to keep ER from getting overcrowded. Why not in palliative care?"