Sara hurried down the hall, already late for the internal medicine department’s not-to-be-missed meeting, Grand Rounds. “Got a minute?”
Rip fell in beside her. “Not really,” she said. “I want to hear this lecture. The guy won a Nobel Prize in medicine for his work.” He matched her stride for stride. “I think when you hear what I have to say, you’ll agree it’s more important than hearing a lecture by a Nobel Prize winner.” Sara made a sharp right into a side hall where they’d have a bit of privacy. “Okay, what is it?” “Does the name Ed Drummond mean anything to you?” “Not offthe top of my head. Why don’t you tell me what you’ve got, instead of playing twenty questions?” “Ed Drummond was one of our earliest Jandramycin patients,” Rip said.
“Septic shock from Staph luciferus pneumonia. Ring a bell?” “Vaguely.
What about him?” “He developed kidney failure.” “So he’s the one,”
Sara said. “Right. And it was hard to treat him because of his age and all his other medical conditions.” Rip paused like a quiz-show host about to announce a winner. “He died yesterday.” Sara took a step back, stopping when she felt the wall’s cold tile against her. “So now ���” “Now Jandramycin is killing patients.” “Are you sure his death was due to the kidney failure?” “His doctor signed the death certificate that way. There were other factors, of course, but that was the primary cause of death.” Sara pointed back the way they’d come. “We need to speed up our efforts. Let’s go back to my office and work on this.” “What about Grand Rounds?” Rip asked. “If we solve the Jandramycin puzzle, we might win a Nobel Prize ourselves.” She shrugged. “And if we don’t, more people are going to die.”
Jack Ingersoll checked his appearance one more time in the bathroom mirror. He frowned when he heard the phone ring. Was that Bob Wolfe, calling again to remind him that his presentation today was important��� to both of them? As if he needed a reminder. He looked around at the room he’d been given, thought about first-class travel and nice honoraria paid discreetly through the program committees of international meetings. He knew what was on the line, knew it better than the man who was bullying him. “Doctor��� er, Professor Ingersoll.” “Herr Professor, this is Wilhelm Lambert, the Generaldirektor of the hotel. I hope I’m not inconveniencing you by calling.” Despite the words, there was no apology in the tone. “Matter of fact, I was just leaving for my meeting,” Ingersoll said. “Then I will be brief. We’ve had a bit of confusion about your room. It seems that Jandra Pharmaceuticals may not, after all, be paying your expenses. I will attempt to contact Herr Doktor Wolfe later today to clarify this. Perhaps it will even be necessary for me to call the company’s office in America, but that will take several hours because of the time difference.” “I-” “In the meantime, please stop by the front desk on your way out and leave your credit card information, so that your bill can be covered.” A click signaled the end of the conversation. Message delivered. Ingersoll hung up the phone and turned to stare out the window of his room. The sun was up now, and he had a great view of the city, but his mind failed to register those images. Instead, he focused on the conversation he’d just had. He’d spoken with Wolfe only yesterday about Jandra covering his expenses.
There was no mix-up. This was a means of applying pressure, plain and simple. He grabbed his computer case and started for the door, where he paused and looked at the room rates posted there. Of course, no one paid these rates, there were always discounts, and he had no doubt that the meeting organizers had arranged one. But the Hessischer Hof was a five-star establishment that housed only the VIP’s, their tab picked up by companies with deep pockets, and the rooms, especially this one on the Executive Floor, weren’t cheap. If Ingersoll had to pay for this himself, he could count on dropping a couple of thousand dollars for a few days’ stay. He pulled the door closed behind him.
Okay, Bob, you’ve shown me the stick. It’s time to go after the carrot.
Ingersoll peered into the semidarkness of the lecture hall and tried to read the faces of his audience. He was on the next to last slide of his PowerPoint presentation, emphasizing probably his most important and most controversial point: that Jandramycin was 100 percent effective against the untilthen lethal scourge, Staphylococcus luciferus, with absolutely no adverse effects noted. Unfortunately, the combination of a dark lecture hall and the spotlights aimed at the podium made it impossible for him to see beyond the first row. In his limited field of view, Ingersoll didn’t see any frowns. No one was shaking his head. But he knew the reactions of the attendees in his field of view didn’t constitute a representative sample. At any meeting, the population of the first row consisted of those waiting to present, plus a smattering of speakers who’d already been on the podium but hadn’t been able to escape in a timely fashion. The acid test would come when the lights went up and the questions began. Most speakers were given ten minutes to present their work. Ingersoll was allotted twenty, with an additional ten for questions and discussion.
Not only that, his paper was the last one before a midmorning break, during which he would undoubtedly be held captive in the front of the lecture hall by individuals wanting a private word with him. Ingersoll pushed the button to project his last slide, one with a picture of an aerial view of the campus of the medical center with the seal of the university superimposed in the lower right corner. “I would like to thank my colleagues at the Southwestern Medical Center for their cooperation and assistance in obtaining patients for this study.” He pushed the button again, and the screen went dark. He paused a moment to emphasize the separation of professional from commercial, then acknowledged the research grant from Jandra Pharmaceuticals that made the work possible. “My thanks also to the organizing committee for this invitation. Now I’d be pleased to answer any questions from the audience.” The applause began immediately. In a few seconds, the volume rose as the translators in a glassed-in booth at the rear of the auditorium rendered his final words in German, French, and Spanish. Ingersoll looked to his left, where the session moderator sat at a table at the side of the stage, and asked with a lifted eyebrow and a gesture toward the podium whether he wished to take the microphone and direct the discussion session. The moderator, a French physician, gave a Gallic shrug and waved away the invitation.
Ingersoll wasn’t sure whether this represented confidence in the speaker’s ability to handle whatever came up or a desire on the part of the moderator to distance himself from the presentation. The questions followed a predictable pattern, and Ingersoll had the answers readily available, either offthe top of his head or in one of the slides he’d presented, a set still displayed as a series of thumbnails on the monitor in front of him. A young doctor in an ill-fitting blue suit stepped to the microphone that had been set up in the aisle. “In your doseranging study, what did you find to be the optimum dose?” Ingersoll moved his mouse over the appropriate slide and double-clicked. A graph filled the screens on either side of him as he discussed the dose-response curve, concluding his answer with,
“Even though there were no ill effects from the drug, we elected to use the lowest dose tested because the response was a 100 percent cure with it.” There you go, Bob Wolfe. That’s twice I’ve said it. An older doctor took his turn at the microphone. “Perhaps Dr. Clement can answer this. Will the recordings of this session include the discussion? ” The moderator leaned into the table, pulled his microphone toward him, and said, ” Oui.” Ingersoll’s amusement at the taciturn response died as he realized the implication of the question, something he’d totally forgotten. He ran his mind back over all the forms he’d completed and signed to confirm his invitation. He clenched his teeth when he realized that buried among them had been permission for his talk to be recorded. A few more questions followed, and Ingersoll answered them with no difficulty. He glanced at the clock on the podium. Time to wrap it up. He made a show of pushing back his sleeve to look at his watch. “We have time for one more question.” Two men stood at
the microphone in the aisle. The first in line was a young man with neatly styled black hair and a small Vandyke beard. The man behind him, who looked vaguely familiar to Ingersoll, wore a poorly cut blue suit that badly needed a pressing. The second man in line leaned forward and whispered urgently in the ear of the younger man. Whatever was said must have worked, because the man shrugged and gave up his position without a word. Blue suit moved forward to the microphone. Ingersoll recognized him and felt his heart rat-a-tat in his chest. ” Ich bin��� sorry. I’ll speak English. I am Dr. Herman Rohde from Ulm, Germany. Like you, Professor Ingersoll, I have had the privilege of participating in the study of Jandramycin. My colleague and I have treated a number of patients, and like you, we have been pleased that there are no instances where the Staphylococcus luciferus failed to yield to the drug. But we are concerned that you are reporting no adverse effects to the drug.” A low murmur swept through the auditorium. Ingersoll opened his mouth, but Rohde apparently wasn’t finished. “I would like to ask you this specific question. Are you aware of any adverse consequences, either during the treatment or afterward, that can be attributed to Jandramycin?” Ingersoll wasn’t sure whether this man was a plant or a fellow clinician asking an honest question. In either case, he had the answer ready almost before the words were out of Rohde’s mouth. “I am unaware of any such adverse effects.” Without waiting for a reply or a follow-up, he said, “That concludes our session. Again, thank you all for coming.” Ingersoll reached down to retrieve his briefcase from its position beside the podium, and flinched as he anticipated running the gauntlet of people already forming up in the aisles to ask him questions. He was about to head down the steps when he felt a hand on his shoulder. “Great presentation, Jack,” Bob Wolfe said. He pointed to a small door offstage to their right. “If we duck out that door, we can avoid the crowd.” Wolfe led the way into a small hallway. “Oh, by the way. Sorry about that mix-up about your hotel bill. I’ve got it straightened out now. Jandra is covering all your expenses, just as we promised. So enjoy your time here.” Ingersoll didn’t feel very grateful, but he managed to choke out a “Thanks.” Well, they’ve got me on tape twice. I guess they really do own me.
John Ramsey scanned the crowded lecture hall and saw Lillian Goodman with an empty seat beside her. Judging from the PowerPoint slide on the screen, John figured he’d missed at most five minutes of the talk. He eased down the aisle, but hesitated when he saw something in the seat next to Lillian. She glanced toward him, smiled, and lifted her purse from the seat, gesturing him to sit. “Thanks for saving me a place,” he whispered. She settled her purse onto the floor at her feet. “I thought you’d want to hear this.” At first, John was interested in the presentation. But as the speaker went deeper and deeper into the molecular and genetic basis of his theories, he appeared to lose the attention of most of his audience, John included.
“I thought this was going to be practical,” Lillian whispered. “It was, for about fifteen minutes. Then he tried to show how smart he is.” John glanced at the clock on the back wall. “If we can survive another twenty minutes of this, want to have lunch with me?” “Sure, but it’ll have to be fast. I have clinic this afternoon,” Lillian said. Half an hour later, they eased through the doors outside the food court into the patio beyond. “There’s a table,” John said. “Let’s grab it.” As they settled in with drinks and sandwiches, Lillian said,
“This is nice. It’s rare for me to get outside while the sun’s still up.” “Me, too,” John said. He went to work on the twist-top of his soft drink, trying to ignore the pain in his hand. “Can I help with that?” Lillian asked. Without waiting for a reply, she took the bottle and twisted the top free. As she set it back down, she looked at John’s hand and said, “That doesn’t look good. Did you see Rip about it?” John took a sip of his Coke, obviously embarrassed at having someone else open it. “He needled it and cultured the pus. The smear looked like Staph.” “So are you on an antibiotic?” John shook his head. “He put me on cephalexin, but I don’t think it’s helped much.”
“Won’t the lab have a preliminary culture report by now?” “Probably, but the antibiotic sensitivities will take another day or so.” He took a bite of his sandwich and washed it down with more Coke. “Let’s forget my hand for now.” “Fine. But don’t ignore it. Do what Rip suggests.” John nodded, anxious to leave the subject. “I really enjoyed talking with you the other night. And if you wouldn’t mind, I’d like to do it again.” He held up a hand. “Not a date, mind you. I just need someone to talk with.” Lillian smiled. “John, we both know these aren’t dates. I also know you feel guilty spending time with another woman. That’s natural. But the more you can talk out your feelings, the better your healing will go. Believe me, I know. I’ve been there.” “So maybe dinner tomorrow night?” “Sounds fine. We’ll discuss it tomorrow. Maybe I’ll cook for you,” Lillian said. “How long since you’ve had a home-cooked meal?” John’s throat tightened. He tried to blink away the moisture from the corners of his eyes. “Not since��� since Beth-” “But surely one of your children-” John had to swallow hard before he could get the words out. “Beth and I couldn’t have children. We thought about adoption, but somehow things kept getting in the way.” He decided he’d better get all of it out.
“And before you ask, I’m an only child. My parents have been gone for several years. When Beth died, it left me-” “That’s okay. We don’t need to talk about it.” They were leaving the table when John’s pager went off. “I guess I’d better answer this.” “I’ll see you back in clinic, then,” Lillian said. John pulled out his cell phone and dialed the number on his pager. “Dr. Pearson.” “Rip, this is John Ramsey. You paged me?” “Um, right. Can you come to Sara Miles’s office? I was with her when the lab paged me with a preliminary report on your culture.”
John screwed up his courage to ask the question he dreaded. “What’s the verdict? Is it MRSA? Do I need IV antibiotics?” “That’s what we need to discuss,” Rip said. “Yes, the treatment for this is giving IV.
But you don’t have MRSA. The culture grew Staph luciferus.”
16
John Ramsey wasted no time getting to Sara’s office, where he found her and Rip talking in low tones. He pulled up a chair and winced at the pain that shot through his hand. He took a deep breath and said, “Whoever dumped that syringe in the trash gave me a really nice gift, didn’t they? Staph luciferus. Where do we go from here?”
“Until recently, I think the decision would be clear,” Rip said.
“Jandramycin is the only antibiotic that works against it. No other drug can touch it.” John nodded in agreement. “But a certain percentage of patients receiving Jandramycin develop late complications-autoimmune disorders that are potentially fatal.” “I know about the late problems,” John said. “We’ve discussed them a bit already. But fatal?” “One of the Jandramycin patients, one who’d developed nephropathy, died with renal failure. There are other autoimmune disorders that can be lethal as well. We don’t know how many treated patients have developed them already. The risk is real, and it’s significant,” Rip said. “So we have a big decision to make.”
Four decades of practicing medicine had made John a realist regarding treatment decisions. “We have three options: do nothing, try another antibiotic, or use Jandramycin. Option number one would undoubtedly allow a spread of the infection, necrotizing fasciitis or gangrene, and amputation of the hand if I didn’t die first of sepsis. That’s out.” Rip started to speak, but John held up his hand. “We’ll have the sensitivity reports tomorrow, but barring a miracle, none of the antibiotics tested will be effective against this organism. So trying another antibiotic would be an expensive way to get the same result as doing nothing.” He waited to see if Rip or Sara had anything to say, but they simply nodded in silent agreement. He took a deep breath.
“Jandramycin will work. I’m not sure any of us truly believe that it’s been 100 percent successful, but that’s
what the studies show so far.
And not every patient who received it has developed an autoimmune disorder��� yet.” “And suppose you’re one of the unlucky few who do?” Sara asked. “There’s always the option of treatment with high-dose steroids. That may not be a lifetime solution, maybe they won’t work at all, but at least there’s a chance. And in the meantime, someone may come up with the key that can reverse the process.” John sat back in the chair, not particularly happy with the course of action to which he’d committed himself, but relieved that he’d been able to divorce his decision making from emotion and agree to what appeared to be the only viable solution. “Ordinarily, patients with this infection would be hospitalized,” Rip said, “but unlike our other patients, you weren’t treated unsuccessfully with one or two other antibiotics. There was no delay in administering proper treatment.
You’re not toxic with the infection. I think we can do this as an outpatient.” He lifted a sheaf of papers from his lap. “We might as well get you enrolled in the study, get some baseline blood work, and give you the first dose of Jandramycin. Let’s go to the clinic and get started.” As they filed from the room, John realized that Rip had held the papers for the Jandramycin study all along. It was truly the only option, but John was the one who had to decide to take that step. With his full knowledge of all that was involved, what he’d given was the very definition of informed consent. Very informed.
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