Lethal Remedy pft-4

by Richard L Mabry

  She’d already noted the lab tests she wanted, but now she added “anti-TPO,” a measure of antibodies formed against the patient’s own thyroid. She had no doubt this was another autoimmune complication after Jandramycin. How many more would there be? How many patients would have their lives turned upside down, even die, as a result of Jack’s wonder drug? Almost an hour later, Sara slumped in a chair in the dictation room, catching her breath before she moved on to her next patient. Lillian Goodman eased in behind her and took the next seat. “Tough afternoon?” “I just picked up another patient with a late complication after Jandramycin,” Sara said. “Autoimmune, of course.

  This was thyroiditis.” She gave Lillian a quick summary of the story.

  “And I’ve done about everything I can to get Jack to admit there’s even a chance that Jandramycin is at fault here. We could go to the FDA with our suspicions, but while all that plays out, more people are going to be affected. Some of them may die, just like that man with autoimmune kidney failure. I don’t know what to do.” “Personally, I’ve had visions of breaking into Ingersoll’s lab and holding him and Resnick at gunpoint until they give us the true story,” Lillian said.

  “So have I,” Sara said. She stifled a giggle. “Can you imagine us doing that? Just like Thelma and Louise, two gun molls.” She shook her head. “Sorry. I’m punch-drunk. Not enough sleep. Too much frustration about this Jandramycin thing.” “Was your last patient allergic?” Sara frowned at her colleague. “You mean was she allergic to any meds?”

  “No, did she have hay fever or asthma? Anything like that?” Sara thumbed through the chart until she came to the history sheet Mrs.

  Truman had filled out. “She has seasonal hay fever, on shots once, offthem now. Both parents had hay fever and asthma. Why?” “John told me about 15 percent of patients get a late complication after Jandramycin. For some reason, it popped into my head that about 15 to 20 percent of people in the U.S. have clinical allergy. I just wondered if there was a correlation.” Sara took a second to think about it. “Autoimmune disorders are basically situations where some of the patient’s tissues become allergic to themselves. It makes sense that underlying allergy might let Jandramycin trigger that kind of response.” She looked at Lillian with new respect. “You may be onto something.” “What was the original name of the compound before it became Jandramycin?” “I had to call Rip last night to ask him about that. It was��� Give me a second��� It was EpAm848. Why?” “Two reasons.” Lillian ticked offher points on her fingers. “First of all, experimental compounds are sometimes named for the components in them, so we should see what Ep and Am and 848 might stand for. It could give us a clue to the mechanism of action of the drug. And if we know that, we might know how to prevent these late complications.” “And second?”

  “Second, we don’t have anywhere else to go, John is getting Jandramycin right now, and the clock is ticking toward the time when he might have a potentially lethal late effect.”

  20

  John’s cell phone buzzed, but he ignored it and continued to talk with the patient who sat in his exam room. Twenty minutes later, he finished his dictation, laid the chart aside, pulled his phone from his pocket, and checked the number of the missed call. There was none.

  Instead, the caller ID showed “private number.” There was no message.

  He decided to ignore it, thinking they’d call back if it’s important.

  He was putting his phone back in his pocket when it rang. Once more, the caller ID showed “private number.” Might as well find out what this is about. He pushed the button to answer. “Dr. Ramsey.” “John, this is Mark Wilcox. I have some news about your malpractice suit. Do you want to get together tonight to talk about it?” John felt his stomach clench. “If we wait until tonight, I’ll develop an ulcer while I worry about it. Just spill it.” “Okay, I’ll have to make it quick.

  I’m between patients, and I suspect you are as well.” John didn’t feel the need to respond to that. He sent up a silent prayer that this would be good news, but his gut told him otherwise. “I told you the lawyer that filed the suit initially was a society lawyer, probably doing it as a favor for Randall Moore.” “Who’s Moore?” “Read the paperwork, John. That’s the name of the man suing you. Anyway, that lawyer has now turned the action over to Lewis Robinette. Recognize the name?” “I think I’ve read it somewhere. Isn’t he some sort of hotshot lawyer?” “You might say so. He specializes in malpractice cases, with an occasional class action personal injury suit thrown in for variety.” “Is he good?” “Sort of like Ted Williams was a good baseball player. Yeah, he’s very good.” John massaged his temples. “So now what?” “I’ll give him a day or two to contact me. If he doesn’t, I’ll call him. He might still be reasonable and agree to drop you from the suit.” “Think that’s likely?” A long pause gave John the answer, even before Mark spoke. “No.”

  Sara was about to enter an exam room when she heard Lillian Goodman call softly, “Sara, hang on a second.” She turned and watched Lillian walk swiftly down the hall of the clinic, a chart held at arm’s length in front of her like a stick of dynamite about to explode. “I don’t think I’d better see this patient. Would you take him?” “Sure. But why-” “Recognize the name on the chart?” Sara looked.

  “No. Should I?” “Let’s just say it’s someone I don’t want to establish a professional relationship with.” Lillian shook her head. “You know, maybe I should call Don Schaeffer. It would probably be best for the chairman to see him anyway.” “Don’t be silly.” She looked at the history form. Chief complaint: cough and fever. “Probably bronchitis.

  I can handle that. And maybe later you can tell me why you didn’t want to see him.” Without waiting for Lillian to respond, Sara tapped on the door and entered the exam room. A middleaged man in a Wwell-cut gray pinstripe suit sat in the patient chair in the corner of the small room. His white French cuffshirt was spotless, and she recognized his tie as a Gucci. He rose when she entered the room. “I want to tell you that I’m here despite grave misgivings.” His tone was mild, but there was no mistaking the emotion behind the words. “I have severe doubts about this institution in general, but my family doctor is unavailable and both my wife and sister insisted that I would receive good care here.” He bowed slightly. “Please don’t take that as an indictment of you or your capabilities. I don’t know you. But-”

  Sara waved offhis comments. “Never mind. You’re here, so we’ll just move on,” she said. “Have a seat and let’s talk a bit. What kind of problems are you experiencing?” The story was one she’d heard a lot in recent weeks. An upper respiratory infection that worsened and morphed into a persistent cough productive of green to yellow sputum. Fever and chills. Fatigue and loss of appetite. If the history didn’t suggest it, the man’s persistent cough and the perspiration on his brow gave her clues to his problem. He shed his coat and shirt when requested to do so, and perched uneasily on the edge of the exam table. When Sara placed her stethoscope on his chest and listened, her clinical suspicion was verified. Crackling rales and diminished breath sounds in both lungs, maybe a little worse on the left. Classic signs of pneumonia. “Just a chest cold, right?” the man asked. “So you can give me something and let me go.” “Afraid not,” Sara said. “I need to get some lab work and a chest X-ray, but I think you have pneumonia.”

  “But I don’t have time for that. I’m a busy man. Can’t you just give me a shot of penicillin or something like that?” She’d heard it all before, heard it so much that her response was almost a set speech.

  “This could be something quite simple or very serious. I won’t know how to treat you until I see the results of these tests. They won’t take long, and there’s a very good possibility we’ll be able to treat this on an outpatient basis.” She looked pointedly at her watch. “And the less we argue about it, the sooner we get the information I need to treat you.” He acquiesced, but it was obvious he was used to simply telling doctors wh
at he wanted instead of letting them determine what he needed. Sara hated that attitude, but she’d learned that trying to educate these patients was often an exercise in futility. While the patient donned his shirt, Sara stepped outside and handed the chart to Gloria. “PA and lateral chest. CBC. Sputum culture. And, oh, have them do a smear and Gram stain of the sputum right now. That will help me pick an antibiotic while the culture’s working.” Almost an hour later, Sara was leaving an exam room when Gloria motioned to her. “Got the lab on your patient.” She handed a chart to Sara, then fanned out three Post-It notes like a card player considering what she’d been dealt. “CBC showed a high white count with left shift.” Sara nodded.

  She’d expected this, evidence of a bacterial infection. Gloria shifted to the second note. “You may want to look at the films yourself, but the radiologist read them as bilateral bronchopneumonia, almost total consolidation of both lower lobes, with a small pleural effusion on the left.” Sara breathed a silent thanks to John Ramsey, who’d taught her and hundreds of other medical students the art of physical diagnosis. I made that diagnosis with my stethoscope. Gloria moved to the third note. “Saved the worst for last. The chief microbiology technician did a sputum smear. Grampositive cocci, clusters, and chains. She says it looks a lot like Staph luciferus.” Sara took a moment to collect her thoughts. There was no way this patient was going home. She needed to admit him to University Hospital for pulmonary treatments, supportive care, and antibiotics. That raised the big question. Consider Jandramycin therapy immediately, or wait until the culture and sensitivity studies were back? That would take at least two days, maybe three, and if this was really Staph luciferus, the man could be almost dead by then. But if this turned out to be another type of Staph, even MRSA, Jandramycin would be the wrong antibiotic. And the final kicker-Jandramycin would put the patient at risk for a late autoimmune complication, possibly a lethal one. Ask Jack to consult? Not with what she knew about him now. There was one person whose opinion she trusted. She’d consult him. “Please page Dr. Pearson and ask him to call me back as soon as possible,”

  Sara said to Gloria. “Then get the papers ready to admit Mr.-” She found the name on the chart Gloria had handed her: Randall Moore.

  “Admit Mr. Moore to University Hospital with a diagnosis of bilateral bronchopneumonia.”

  “Mr. Moore, I’m Dr. Pearson. Dr. Miles asked me to consult on your case.” Moore glared at Rip. “I don’t need a bunch of doctors poking around on me and running up a big bill. I told-” He doubled over with a paroxysm of coughing and took a moment to recover his breath. “I told that woman I just had a bad chest cold. I think I’ll leave and go to an emergency clinic somewhere. They’ll give me a shot of penicillin, and I’ll be fine.” Rip took a deep breath and tried to get his emotions in check. Maybe the best thing would be to let this guy sign himself out against medical advice. No, Rip remembered the oath he’d taken. Some members of his medical school graduating class had laughed at the process of repeating the Physician’s Oath, an updated version of the old Hippocratic oath. But he had sworn to abide by these words: “The health of my patient will be my first consideration.” “Mr. Moore, look at this X-ray.” Rip pointed with his pen. “Your lungs are operating at about half-capacity because of the infection. Fluid is already building up in them. If we don’t do something about it, you’ll die. And it won’t be pleasant. You’ll suffocate.” Maybe a little drastic, but judging by the expression on Moore’s face, effective. “So what do you need to do?” “Admit you to the hospital. Give you breathing treatments. Control your fever. And pump you full of strong antibiotics.” “How long do I have to stay?”

  Good question, and one to which Rip had no answer. “As long as it takes to get the infection under control and make sure your lungs are clearing.” He forced a smile. “Believe me, we’ll get you out of here as quickly as we can.” “Well��� ” Rip fired his last possible shot.

  “I’ll have the chairman of our department look in on you later today.

  And I can ask the head of our infectious disease division to take over your case if you’d like.” Rip was surprised when Moore shook his head.

  “Not necessary. I want you and that woman doctor to take care of me.”

  “Why?” Rip blurted. “Because you didn’t let me bully you. Usually my money and position in the community get me whatever I demand. You didn’t give in.” “I’m sorry, Mr. Moore, but I was unaware of both of those. I treat everyone the same, whether they live in Highland Park or under a bridge.” “I’ll bet you do,” Moore said. “But there’s another thing. Both of you seem genuinely interested in treating me, even though��� I don’t know if I should even mention it.” “Mention what?” “That I’m currently suing the medical center and a number of its doctors for several million dollars.”

  Lillian Goodman settled into the chair in front of a computer terminal in the medical center library. She could have used her office for this, but this way she was away from any distractions. Her cell phone was silenced, her pager set to vibrate, and no one but her secretary knew where to find her. She was determined not to give up until she’d broken through some of the mystery that surrounded Jandramycin, the compound that began life as EpAm848. She decided that her first order of business would be to figure out what Jack Ingersoll’s original area of research was when he stumbled onto his wonder drug. For instance, if the components were substances that might cause lysis of a cell wall, it was reasonable that they could be combined in such a way as to cause bacteria to swell and pop like balloons blown up too much. If they were involved in cell reproduction, the combination might act to keep bacteria from proliferating so their population would eventually decrease to zero.

  The only clue she had was the original name given the experimental preparation: EpAm848. She decided to start with the number. That was fairly clear-cut, and surely Google would help her run down its meaning. She had second thoughts when she saw that entering “848” yielded almost eighty million results. Then she tried “compound 848.”

  Better-only three million. As she trolled through the answers, she discovered that Google put the most likely at the top of its list.

  Good. After half an hour, Lillian was fairly certain that the number referred to R848, a compound associated with the immune response to harmful bacteria. Okay, immune response. That was a starting place.

  She jotted a note on the pad beside the computer monitor. “Am” was more challenging. She dug deep, pounding the computer keys until her wrists were sore and her fingers stiff, but nothing seemed to click.

  Then she decided that maybe it wasn’t “Am” at all. Maybe the designation had been “AM”- two words, each beginning with one of those letters. That led to a different search. After an hour’s digging into references, Lillian felt crosseyed. She stretched, moved around in her chair, and wondered if it was worth it. She dug into her purse, found a couple of Tylenols, and journeyed to the water fountain to combat the headache she was developing. Finally, she found an obscure reference in the Journal of Ethnopharmacology. It dealt with Chinese herbs, and stated that Astragalus membranaceus was thought to have “immunomodulating and immunorestorative effects.” In other words, it affected the immune system of the person receiving it, helping throw offinfections. That had to be it. Two-thirds of the compound name, and both referred to the immune response to bacterial infection. She felt the flush of victory, but determined to make sure. Instead of searching for words that began with “Ep,” Lillian tried the same tack that yielded her last positive result. She looked for two words that started with the letters E and P. This wasn’t easy, and she was about to give up when she encountered Echinacea purpurea. She was aware that a number of homeopathic and herbal remedies contained Echinacea for its alleged ability to help cold sufferers throw offtheir infection.

  Lillian plowed through reference after reference until, in one paper, she encountered the phrase: ” Echinacea purpurea is known for its ability to kick-start the immune
system.” She also found that many people were highly allergic to this natural remedy, experiencing reactions ranging from rash and swollen tongue to anaphylaxis and death. Could this be the “unpleasant result” Ingersoll sloughed offduring their discussion? Lillian sat back and massaged her temples.

  This might be the clue she and her colleagues had sought. Jandramycin, in its final form, acted to kick-start the patient’s immune system to make antibodies specific for the invader, Staph luciferus. Such a targeted response would undoubtedly assure that everyone capable of mounting a normal immune response would be rid of the bacteria within a few days. And the autoimmune responses? If these only occurred in patients with an allergic background, maybe the drug had an additional action on their immune system, generating antibodies to the patient’s own tissue. Nervous system, bone marrow, thyroid, kidney, blood vessels-any of these could be the target of the process. That could explain the autoimmune complications seen in allergic patients who’d received Jandramycin. It’s all conjecture. And if it’s true, what do we do to help those patients? She scooped her notebook into her backpack, stuffed her purse in after it, and hurried from the library.

  She had to call John.

  John opened the refrigerator and peered in, not really seeing the contents. He wasn’t particularly hungry, but knew that he needed to eat. “Keep up your strength.” He was startled when he realized the voice in his head that delivered the words wasn’t Beth’s. Instead, he heard Lillian Goodman. Did that mean Lillian was taking Beth’s place?