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🔬
Jack hears the pneumatic tube thud into its cradle.
“Don’t let that sit,” He says without turning around. “If it’s from the ED, it’s coming in hot.”
Time is the biggest pain in his lily-white ass. A blood culture bottle left at room temperature too long means an overgrowth of skin flora, no matter how sterile they think their technique is down there. A cerebrospinal fluid sample delayed even thirty minutes turns delicate neutrophils into lysed ghosts, segmented nuclei dissolving into pale debris that tells him absolutely nothing. A urine sample unrefrigerated becomes a breeding ground for urease-positive opportunists and yup, pointless. When no one reaches for it, Jack sighs, rolling backwards to snatch it up. The canister hisses open: inside are two aerobic and two anaerobic blood culture bottles, green and purple caps, barcoded. A folded requisition slip secured with tape.
Jack logs the specimens himself, scanning them into the Laboratory Information System: time of collection, site (peripheral draw, left antecubital), clinical indication (fever, hypotension, new murmur, concern for endocarditis). Microbiology without context is taxonomy without ecology. “Incubate immediately,” He grumbles around the pen in his mouth, Ellis already reaching for the BACTEC instrument. The bottles disappear into the automated continuous-monitoring system — an incubator held at 35–37°C, agitated gently to encourage microbial growth, fluorescence sensors monitoring carbon dioxide production as a proxy for metabolism. If bacteria respire, CO₂ accumulates; if CO₂ accumulates, the machine will flag positive.
Jack thinks about what must be happening downstairs and he thinks of that teasing voice over the line. “Two sets of blood cultures before antibiotics. Different sites. Full sterile prep. Chlorhexidine, thirty seconds dry time.” Contamination rates in emergency departments are notoriously higher than in controlled inpatient settings. Skin flora — coagulase-negative staphylococci, Corynebacterium species, Cutibacterium acnes — wait patiently in hair follicles and sebaceous glands. A rushed prep, an ungloved finger that brushes a disinfected site, and the blood culture will bloom falsely positive in twenty-four hours, setting off cascades of unnecessary vancomycin.
Jack hates unnecessary vancomycin.
He flips over the requisition form to see M. Robinavitch. Concern for infective endocarditis. Please call with a preliminary Gram stain. New systolic murmur. History of IV drug use.
As if Jack doesn’t always call.
🔬
Robby calls the microbiology lab about a cerebrospinal fluid sample from a febrile toddler with nuchal rigidity for the first time in ‘06.
The toddler in Bed 12 had arrived from Chairs glassy-eyed and inconsolable in his mother’s arms, his temperature 103.6°F, and his neck stiff when the pediatric resident tried to flex it. Trying to get a lumbar puncture had not been easy. Poor little guy’s opening pressure was way higher than anyone liked to see and when the CSF finally dripped into the tubes, it was cloudy, turbid, and faintly opalescent under the fluorescent lights. No matter how much he’d hoped, it wasn’t the crystal-clear fluid of benign viral illness. This was so much worse.
Now Robby stands at the desk with the corded phone tucked between his shoulder and ear, white coat pockets sagging with folded notes as he dials up to Microbiology for the first time.
“Micro,” A voice answers, sounding more Boston than Robby expects.
“This is Robby in the ED, MS4,” He stumbles over his words like a homegrown idiot. “We just sent up a Peds CSF. Opening pressure elevated. Turbid fluid. I’m concerned about bacterial meningitis. Could you rush the Gram stain?”
“We rush always CSF,” The voice replies, the dumbass being subtext. “Cell count, differential, protein, glucose, Gram stain. Chocolate and blood agar plates incubated in 5% CO₂. Thioglycollate broth backup.”
Robby smiles into the receiver. “Good. I’m starting ceftriaxone and vancomycin and I’d rather not do it blind.”
“You’re always doing it blind,” The voice corrects him, coolly, again the dumbass is in subtext. “Empiric therapy precedes identification, MS4. I’ll call you with the results.”
They hang up.
Robby stares at the phone, oddly exhilarated.
Upstairs, Jack sets up the CSF Gram stain himself. He hates delegating pediatric CSF.
He loads the specimen into the centrifuge, balancing it with a tube of saline opposite. The machine whirs to life, climbing to 1,500 g. It takes about fifteen minutes to concentrate whatever organisms might be suspended in that cloudy fluid — fifteen minutes in which a toddler upstairs lies febrile and obtunded while antibiotics drip into a tiny vein, he reminds himself. He decants the supernatant, leaving just enough to resuspend the sediment. Then with a pipette, he mixes gently and transfers a small drop onto a clean glass slide. He spreads it thin with the edge of another slide. It’s taken years upon years of practice to get the slide perfect: too thick and the stain will be unreadable, but too thin and you miss the pathogen entirely. He lets it air-dry and then heat-fixes it, just enough to adhere the cells to glass without warping them into artifacts.
Crystal violet floods the smear for sixty seconds, the primary stain soaking into cell walls indiscriminately; then rinse. Next, iodine mordant for another minute. The complex forms, trapping dye in thick peptidoglycan layers; rinse again. Then comes the most critical step: decolorization with acetone-alcohol. Jack counts under his breath. One. Two. Three. Four. Five. Rinse; rinse now. If he waits too long even Gram-positives will bleach, but too short and everything stays purple.
Finally, safranin counterstain, a final wash of pink for whatever has surrendered the violet. He rinses and blots it dry. Perfect.
Jack places a drop of immersion oil on the dried smear and lowers the 100x oil objective on his scope into place. He adjusts the fine focus slowly, neutrophils crowding the field — lobulated nuclei, granular cytoplasm, evidence of the body’s frantic response. But between them, there. Gram-positive diplococci, paired and slightly elongated, the ends tapered and touching tip to tip. They’re lancet-shaped and purple against a pale background. He shifts the slide to check another field. He only finds more of them. Which means they aren’t contaminants or debris.
Streptococcus pneumoniae.
It’s bacterial meningitis.
He reaches for the phone immediately.
Downstairs, Robby is in the middle of stumbling his way through a conversation with Dr. Adamson when he gets a phone receiver thrust into his face, “Micro on line two.”
He grabs it. “ED.”
“Gram-positive diplococci in pairs, MS4.” The microbiologist’s voice is the same cool tone as before, but there is more worry now. “Consistent with Streptococcus pneumoniae. Cultures pending, of course.”
“You’ve got a strep pneumo,” The voice adds when Robby doesn’t respond fast enough.
“Thank you,” He finally blurts out.
Micro just hangs up.
🔬
Years pass measured in colonies between them.
Plates streaked in careful quadrants that bloom inside warm incubators like the flowers they never exchange. Quadrant one replete with growth, a thick bacterial lawn where the loop first touched down. Quadrant two is thinner. By quadrant four, the reward: isolated colonies, perfect and discrete, each a clonal universe descended from a single cell. On blood agar, patterns become personality. Beta-hemolysis: clear, glassy zones around colonies where red blood cells are lysed completely, and the agar is transparent due to the absence. Alpha-hemolysis: greenish halos of partial destruction, hemoglobin oxidized to methemoglobin, bruised but not obliterated. Gamma: no hemolysis at all, the quiet ones, growing without spectacle.
Jack teaches his new techs to read these subtleties the way other people read faces. “Start with the Gram stain,” He lectures, leaning over a bench. “Clusters or chains matter.”
He sets two plates side by side. “This, I need you to see what I see: golden colonies, beta-hemolytic, Gram-positive cocci in clusters.” He taps the lid. “Think Staphylococcus aureus. Catalase positive.” He demonstrates, touching a colony with his wand and smearing it onto a slide with a drop of hydrogen peroxide. There’s immediate fizzing, with numerous oxygen bubbles racing upward. “Bubbles mean catalase. Staph splits hydrogen peroxide into water and oxygen.”
Then the next plate. “Look here: small, translucent colonies. Beta-hemolytic, but in chains on Gram stain. Catalase negative.” He glances at the student. “That’s Streptococcus pyogenes.” He tests it the same way. There are no bubbles this time. The peroxide sits inert.
“And to confirm S. aureus?” He prompts.
“Coagulase?”
Jack nods: rabbit plasma in a small tube, inoculated and incubated. Later, the tilt test: liquid becomes a clot, and fibrin forms a scaffold around the organism. The bacterium cloaks itself, hides inside the host’s own machinery. “Positive coagulase,” Jack nods.
He checks his own workstation and reaches for the phone.
“Robby.”
“Gram-negative rods, MS4,” Jack says, even though Robby is a PGY-3. “Lactose fermenting on MacConkey with pink colonies, likely E. coli.”
Robby swivels toward the computer. “Source?”
“Urine culture matches at greater than one hundred thousand CFU per milliliter. According to you, a clean catch, good specimen. Sensitivity panel is pending.”
“Thanks, Micro,” Robby says.
Jack hangs up first. His Kirby-Bauer plates incubate in neat stacks around him: Mueller-Hinton agar poured to uniform depth, its surface inoculated with a standardized 0.5 McFarland suspension — turbidity matched to a card held against black lines, ensuring reproducibility, ensuring that millimeters mean something. Paper disks impregnated with antibiotics rest like small white moons on the lawn of bacteria. Ceftriaxone. Ciprofloxacin. Piperacillin-tazobactam. Trimethoprim-sulfamethoxazole. By morning, zones of inhibition will form where the organism cannot grow: clear halos that he will measure with calipers, which translates into susceptible, intermediate, and resistant. Thereby antibiotic therapy is reduced from a broad guess to a precise strike.
When he reaches for the phone to report preliminary results the next day, he can’t help twisting the coiled cord around his fingers, looping it once, twice, like a teenager talking to his boyfriend. It’s humiliating.
“Robby.”
“Susceptible to ceftriaxone,” Jack grunts. “Resistant to ampicillin. You can narrow.”
“Good,” Robby replies. “I will. Thanks, Micro.”
Jack hangs up before he can say something stupid.
🔬
Once Jack finally opts to lose his leg — after going on ten years of replacing more and more of it with titanium scaffolding, antibiotic spacers, revision plates that never quite held: he just lets go. It was chronic osteomyelitis in his ankle and tibia, hardware infections that smoldered and flared. He had read his own operative notes. He probably should have had the BKA five years ago, maybe six. But three weeks later, he rolls back into the lab in the same custom chair he’s been reliant on these last few years. His techs go quiet when he wheels past the benches. No one says welcome back. They just slide stacks of requisitions closer to his reach.
He transfers himself, gloves on, bench cleared, and a stack of blood culture bottles waiting for subculture.
That night, Robby calls about a sample that doesn’t need follow-up — two sets of blood cultures on a febrile patient who defervesced after fluids and acetaminophen. Forty-eight hours negative. He knows what the answer will be. He dials anyway.
“Micro?” His voice catches slightly before he can stop it. “Jack?”
“I’m busy, MS4. Your blood cultures are negative at forty-eight hours. Both sets. It was likely a contaminant from the initial draw. No growth on subculture plates.” In the lab, automated blood culture instruments blink green. Bottles flagged negative are unloaded, and a few drops are plated to confirm sterility before final sign-out. Chocolate agar. Blood agar. Nothing blooms.
“Thanks.” He wants to say more. I heard. I’m sorry. I’m glad you’re back. Instead, he hears himself ask, “How’s—”
“Label your specimens correctly,” Jack cuts in. “Full name. MRN. Source. Time collected. I’m sick of trying to decipher your chicken scratch only to be missing half of what I need.”
Downstairs, Robby looks at the chart in front of him. He easily finds his requisition from earlier — his handwriting slanted and hurried between traumas. He wrote all the right information, he always makes sure he writes all the information. “Yes, Micro,” He says softly. “Will do.”
Jack hangs up. He pulls a plate forward and examines a faint colony someone else might have dismissed. He measures a zone of inhibition with steady hands. He feels safe here. Mueller-Hinton agar doesn’t ask about his phantom pain. Catalase still bubbles or doesn’t. Coagulase still clots or stays liquid.
Downstairs, Robby rewrites his next label in big block letters, overly legible. He presses it firmly onto the tube.
Specimens move up. Results move down.
🔬
Now the blood cultures from Robby’s septic patient flag positive at twelve hours.
The automated system beeps and Jack glances at the screen. Bottle ID. Patient MRN. Time to positivity: 12:07. Early. Shit, early positivity suggests high bacterial load, organisms replicating fast enough in the enriched broth to trigger the CO₂ sensor well before the twenty-four-hour mark. In sepsis, hours compress. Twelve is not a comfortable number. He wheels to the incubator, unlocks the flagged bottle, and swabs the rubber septum with alcohol. A sterile needle draws up a small aliquot of cloudy broth. He prepares a slide. Air-dry. Heat-fix. Crystal violet. Iodine. Decolorize. Safranin. Under oil immersion, he finds them. Gram-positive cocci in clusters. Round, purple spheres gathered like grapes, irregular and dense between neutrophils and debris.
Staphylococcus aureus until proven otherwise.
He plates the broth onto blood agar and chocolate agar, streaking for isolation. He labels each plate in careful block letters — full name, MRN, source, time. His handwriting is unambiguous. Methicillin resistance matters, a lot. He orders a rapid molecular panel for mecA gene detection; the presence of mecA would confirm MRSA, altering, if not the empiric choice — vancomycin already covers — but the future narrowing. He inoculates a tube with a coagulase test, plasma awaiting the possibility of clotting.
The phone sits to his right. He reaches.
Dana holds out the phone. “Micro.”
Robby grabs it.
“Robby.”
“Gram-positive cocci in clusters, MS4.”
Robby doesn’t hesitate. “Already on vanco.”
“Good,” Jack replies evenly. “We’ll confirm MRSA status. Rapid mecA pending. Subcultures set. Coagulase in process.”
“Thanks,” Robby says. “Couldn’t do it without you, brother.”
Jack keeps the receiver to his ear even after the dial tone returns. He stares at the blood agar plate he just streaked. By morning, if it is what it looks like, colonies will rise: golden, beta-hemolytic, assertive. If mecA is present, they will represent a different fight: MRSA, resistant to beta-lactams, forcing reliance on glycopeptides and careful trough levels and battering kidneys already strained by shock.
He sets the phone back in its cradle slowly.
“Couldn’t do it without you either, Robinavitch,” He says to his empty lab.
🔬
The next month, the whole of Pittsburgh is coated in black ice. Bridges glaze up first, then side streets, then the hospital loading dock where delivery trucks sit stalled at crooked angles. Half of Jack’s staff calls out before dusk. “Roads are sheets.” “Car won’t start.” “State police advising no travel.” Jack doesn’t bother calling back. He’s already in. He never really leaves.
He's fine where he is: the incubators hold at temperature, the CO₂ tanks read full. Plates from the afternoon streaking bloom quietly, indifferent to the weather outside. He moves between benches in his chair, irritation riding just under his skin. Ice storms are an insult to systems. They jam doors, freeze locks, and interrupt the flow of everything.
Downstairs, the ED must be overflowing. He knows it without being told. Weather means falls, MVCs, hypothermia, delayed dialysis patients who couldn’t make their appointments, and infections that waited too long.
Then the pneumatic tube system jams.
The alarm blinks red above the receiving station — carrier stuck in transit. A hollow mechanical thunk echoes in the wall, followed by silence. Jack rolls over and tries a reset. Nothing. He tries again. The screen flashes an error. Pressure fault. “Fuck,” He growls. He knows there’s at least one code sepsis downstairs — he saw the stat order timestamped eleven minutes ago. Blood cultures marked urgent. Lactate pending. The protocol is tight: cultures in the incubator within thirty minutes to preserve yield, especially when bacterial load might be low or antibiotics have already started.
The elevator during ice storms is unreliable at best — slow, shuddering, occasionally stalled between floors when the power flickers.
So, he reaches for his cane. His prosthetic fits well, but long distances still aren’t easy on him, much less stairs. Still, he grips the cane and heads for the stairwell.
Downstairs, Robby is moving fast. Stretchers line the hallways. Everyone is tripping over each other and the slush from outside. But Robby cradles two sets of blood culture bottles against his chest, requisitions tucked between them. “These cultures need to incubate within thirty minutes,” He says to no one in particular. The tube station blinks red. He swears under his breath and pivots toward the stairwell. He’ll have to take them up himself.
The door swings open before he reaches it.
“MS4?” The short, stocky man says, smiling faintly. He’s got cheeks covered in freckles and gray curls that poke out at every angle.
Robby goes pink despite the chaos. “Hi, Micro.” Fuck, he’s hot. Jack’s cane tip slips slightly on the wet tile and Robby reaches out without thinking, his hand closing around Jack’s elbow, steadying him. “You came down,” Robby whispers, hushed, blushing all the way up to his ears.
“Yeah, the tubes are being shit,” Jack grunts, adjusting his footing.
“Going down the tubes?” Robby grins, lifting the bottles slightly in offering. “Two sets. Properly prepped. Chlorhexidine dry time observed. Separate venipuncture sites.” He wants Jack to be proud of him. He wants Jack to do a lot of things to him if he isn’t. Jack arches an eyebrow, taking the bottles, inspecting labels automatically. Full name. MRN. Time. Source. Legible block letters.
“Temperature control,” Jack frowns. “You shouldn’t hold them against your body.”
Robby huffs a laugh. “You could come downstairs more often. Teach me.” The words are out before he can swallow them.
“You could come upstairs for that, Chief,” Jack counters, licking his dry lips. He turns toward the stairwell again, cultures cradled carefully in one arm, cane tapping the concrete step ahead of his prosthetic leg. “Thanks, see ya around.”
Robby will think about that touch for months to come.
“See ya.”
🔬
Things begin to follow a new sort of pattern for them.
Robby finishes a shift and Jack is still in the lab, because Jack is always in the lab. Clinical microbiology is not a nine-to-five discipline. Bacteria replicate on their own schedule. Blood cultures flag positive at three in the morning. Susceptibility panels must be read at precise incubation times — sixteen to eighteen hours for disc diffusion, no sooner, no later, lest zone diameters mislead future treatment methods.
Robby starts going upstairs after his shift instead of going home. At first, he lingers by the doorway, watching Jack move between incubators and biosafety cabinets. The lab at night is different. Plates sit stacked in neat little towers: blood agar, chocolate agar, MacConkey, CNA. Anaerobic jars rest sealed with gas-generating sachets that scavenge oxygen, creating an environment for organisms that consider oxygen toxic. Jack is at the fume hood more often than not as he manipulates a loop with surgeon-like steadiness, streaking a plate in quadrants to isolate colonies. “You’re off,” Jack states without looking up. “Go home, old man.”
“So are you,” Robby replies. “And I’m only two years older than you, brat. Let’s go.”
“Nope.”
“You’ve been here sixteen hours.”
“Yup.”
Apparently, Jack intends to be at work for twenty-four.
One night, Robby wanders in eating a donut. Jack looks at him like he’s liable to take him over one knee for a nasty case of red ass. “Get that out of my lab,” Jack balks. Robby stops, stunned. “Dumbass, you can’t eat in here.”
“I’m in the hallway!”
Jack sighs, pulls off his gloves, and rolls toward Robby. He takes the donut from his hand and deposits it firmly in the trash. “You’re an ED doc,” Jack rolls his eyes. “You have seen nec fasc. You have seen pseudomonal bacteremia. That sugary shit is now covered with whatever the fuck is floating around in my lab, probably some HeLa I used months ago to test some agar. You can go stand in Shen’s hallway box for food and that’s it.” He used a roll of duct tape to make a little box on the floor in the hallway, a safe distance away.
Robby glares, “I’ve seen you lick a doorknob to prove a point.”
“Uh, yeah, most environmental surfaces contain primarily non-pathogenic skin flora and environmental organisms,” He shrugs. “Infectious dose matters; host immunity matters. I’m immunocompetent.”
Robby stares. “You culture multidrug-resistant Acinetobacter for a living.”
“So?”
🔬
Robby is a workaholic. He works double shifts, he works on days he should most certainly be off. He reviews charts at home. He reads UpToDate articles in the wee hours of the morning about obscure tropical infections, just in case. But Jack is something else. Jack arrives before dawn to review overnight culture results. He leaves after midnight because apparently, every susceptibility panel needs to be interpreted by him personally. He updates the hospital’s cumulative antibiogram annually: analyzing resistance patterns, tracking MRSA prevalence, ESBL-producing Enterobacterales, and carbapenem-resistant Pseudomonas aeruginosa. He attends infectious disease rounds voluntarily. He treats contamination rates like a moral failing. “Do you ever stop?” Robby asks one night as he slings his jacket around Jack’s shoulders.
Jack looks at him, nonplussed, “Why would I?”
Robby channels his restless energy into cooking. He makes elaborate meals: braised brisket, roasted vegetables, shakshuka simmered slowly until the tomatoes collapse. He keeps a kosher kitchen; Jack observes the separation of meat and dairy with immediate respect.
“You autoclave instruments at 121°C under fifteen pounds per square inch of pressure for fifteen minutes,” Robby parrots, handing him a plate. “But you have to ask three hundred questions about my double sink system.”
“Sorry for not wanting to fuck it up, MS4.”
After dinner, they sit close on Robby’s couch, cuddling though neither of them will admit that’s what is happening. Robby reads journal articles aloud about emerging fungal pathogens — Candida auris outbreaks in long-term care facilities, or increasing azole resistance in Aspergillus fumigatus. Jack sleepily mumbles commentary about horizontal gene transfer, plasmid-mediated resistance, and the elegant horror of bacteria sharing survival strategies like gossip, mostly into the wobbly chub of Robby’s belly, his new favorite pillow. "You’re,” Jack yawns, sleepily, “Streptobacillus moniliformis.”
Robby pets Jack’s curls. “What?”
“Streptobacillus moniliformis,” He pouts. “Gram-negative bacillus. Pleomorphic. When cultured in enriched media, like serum-supplemented broth — it forms these irregular swellings along filamentous chains. Bulbous enlargements, in older literature they call them ‘puffballs.’” He nuzzles deeper into Robby’s belly, “Puffball. Zoonotic. Rat-bite fever. My puffball.”
“Jack.”
“Well-nourished puffball,” Jack adds with that shit-eating grin.
“I’m not a puffball.”
“You are,” Jack disagrees. “A puffball in enriched media.” He nibbles a little. “Very enriched.”
Robby tips Jack’s chin up with two fingers. “Shut up.”
“Make me.”
🔬
Jack’s at the bench reviewing a set of susceptibility plates — Mueller-Hinton agar, standardized inoculum, antibiotic disks arranged just-so. The zones of inhibition are clean and measurable. Ciprofloxacin: 28 mm. Ceftriaxone: 32 mm. Vancomycin: not applicable — Gram-negative rod. He measures with calipers and writes the numbers down. Behind him, the incubators hum, the anaerobic chamber gurgles faintly, its internal atmosphere balanced at optimal oxygen deprivation. Somewhere, a MALDI-TOF mass spectrometer whirs, ionizing bacterial proteins and translating them into spectral fingerprints more reliable than anything else. Jack doesn’t look up when the lab doors swing open. He assumes it’s a courier. It’s not.
“Hey, Micro.”
Jack’s shoulders go tight and his biceps flex. “I’m busy, MS4,” He grunts without turning around.
“You’ve been here fourteen hours.”
“Twelve and a half.”
“I checked your badge log, liar. C’mon, I’m taking you home.” Robby crosses his arms with a scowl, Jack doesn’t need to see it to know it’s there.
“I have plates to read.”
Robby steps closer. “You’re done. The cultures will still be here tomorrow. The bacteria are not going anywhere. You have staff to do this. Staff that you trained to do this.”
“The bacteria are proliferating as we speak, MS4.”
“Let them.”
Jack hesitates. He really does have so much work to do: a stack of pending results, a blood culture that flagged positive at six, a carbapenem-resistant Enterobacterales isolate that requires confirmatory testing, and a fungal culture on day three of incubation that could declare itself overnight. But Robby leans down slightly and his breath tickles the seashell of Jack’s ear, “Your Streptobacillus puffball misses you.” His teeth graze the lobe. “I’d love to show you how much.”
Jack groans — fuck it, all is lost — his eyes flick to Shen and Ellis as he rubs at the bridge of his nose. “Monitor the anaerobic cultures at 0700,” He snaps. “If the BACTEC flags positive, call me immediately. Do not speculate on speciation without confirmatory testing.”
“Yes, Dr. Abbot.” They share a grin that he absolutely despises. Sure, they’re microbiologists in their own right — but still.
Jack lets Robby hoist him upright, grabbing at his crutches. “Alright let’s go, MS4.”
“After you, Micro.”
🔬