Rip spread salsa liberally over his scrambled eggs, then forked a generous portion into his mouth. He chewed, swallowed, and washed it down with coffee before answering. "Sorry. But you know the drill. Eat when you can—"
"Sleep when you can. Yes, I know. Now, what about Chelsea?"
"I think she's improving. As for Dr. Ingersoll, I can't say. He got some kind of urgent phone call when we were seeing Ms. Ferguson, and he's been gone since." Rip added more salsa and took another bite of eggs.
"What could make Jack take offlike that?" Sara had known Jack Ingersoll as intimately as was possible, and she couldn't think of anything more important to him than his patients and his practice. If he'd only been willing to pay the same attention to his family . . . but that was water under the bridge. "Anyway, how long do you anticipate keeping Chelsea on therapy?"
Rip chewed the last bit of egg, finished his last triangle of toast, and dabbed his lips with a napkin. "For Staph luciferus cases, treatment is given daily via intravenous infusion for a total of ten days." He said it as though by rote, and Sara realized he was parroting back the protocol Ingersoll and the drug company had written.
Rip shoved his tray aside and took a satisfied sip of coffee. "Now, how have you been? We don't see much of each other anymore."
Sara remembered when she'd first met Rip. She was sitting with a hundred other freshmen undergoing orientation at Southwestern Medical School. The Dean, resplendent in three-piece suit with a chain draped across the vest to display his Phi Beta Kappa key, had just said, "We didn't ask you to come here. But we may be asking some of you to leave."
She heard a muffled chuckle to her right and looked at the man sitting there. His wavy blond hair was fashionably long. In contrast with the casual dress of others in the class, he wore a button-down collared blue oxford cloth shirt open at the neck. His khakis sported ironed creases that could cut cheese. Top-Siders worn without socks completed the Ivy League look. He leaned toward Sara and whispered, "Sorry. Actually, they did ask me to come here. They recruited me, so I doubt they'll be asking me to leave."
After the lecture, he'd invited her for coffee, where she learned he was indeed the product of an Ivy League background. Roswell Irving Pearson III graduated magna cum laude from Yale. He broke the family tradition of working in investment banking, choosing instead to come to Southwestern to study medicine. "And please call me Rip. I'm trying to adapt to my new surroundings, and Roswell doesn't fit that image." Thinking back on that encounter, Sara decided that was probably when he began to put salsa on his eggs. It was more Texan.
"Sara? You went quiet on me. How have you been doing?" "I've been staying busy. Isn't that the recommended method for getting over a loss in your life? I think I recall that from the lecture on depression."
Rip reached across the table and touched her hand. "It's been two years since the baby died and Jack left you. Don't you think you should be over it by now?" Rip's words were soft, his touch even softer.
"Please, let's not talk about it. There's just so much—" The buzz of a pager cut through the din of the cafeteria.
Both of them consulted the tiny boxes they carried. "It's me," Sara said. "The ICU."
"Funny, I've got the same call," Rip said.
They looked at each other for a moment before Sara said, "Chelsea."
They left their dishes on the table and headed for the stairs at a brisk pace.
Rip pushed through the swinging doors of the ICU a half step ahead of Sara. The crowd of people in Chelsea's room confirmed their fears.
The head nurse, holding a chart, stepped out of the room. She addressed both doctors, swiveling her head from one to the other. "We were helping Chelsea out of bed and into a chair so we could change her linens, and she fainted. Now her blood pressure's down to eighty over sixty, pulse a hundred. I paged you both and drew blood for some stat blood work. They're getting her back into bed now."
Rip hesitated. Technically, Sara was still the doctor in charge of the case. But since Chelsea was in the study, Jack Ingersoll would undoubtedly insist he be involved in all treatment decisions. And in Ingersoll's absence, Rip had that responsibility.
Sara made it easy. She turned to Rip and said, "She's your study patient, and she's going into shock. Want to take the lead here?"
"I can't see EpAm848 causing her blood pressure to drop. Never been a problem before, and we've given it to some pretty sick people. Let's have a look at her."
Ten minutes later, Sara and Rip huddled in the hall outside Chelsea's room. "I think it's septic shock," he said. "She's had an indwelling catheter for a while, and my money's on sepsis from a urinary infection." Catheters in the bladder could eventually cause infection, and sometimes those bacteria spread to the bloodstream with disastrous results.
Sara opened the chart she held. "I'll order blood cultures, a urinalysis and culture, along with the lab work Janice already requested, but those will take a while. Why don't we get some urine, spin it down, do a Gram stain, and see what we've got?"
"That's scut work, Sara. You're faculty. I'm a fellow. I'll do it."
Sara shook her head. "If you hadn't decided to get postgraduate training, you could be on the faculty as well. We're equals, Rip. We've been together through four years of med school and three years of residency. I don't want to hear any more of that."
"Okay. You get the sample. I'll speed up the IV's and tweak the medications. Want to start a vasopressor drip?"
"What do you think?"
"Let's piggyback some Dopamine into her IV and run it as needed to get her blood pressure to better levels."
"Do it," Sara said.
There had been a time when every clinical ward in a hospital had a small lab space where medical students, interns, and residents could do simple procedures themselves. At University Hospital, that space had long since been co-opted for other uses, so Rip and Sara ended up in the hospital's clinical laboratory.
"Let me do that," the head technician said. "I do this every day. Neither of you has done it for years."
It seemed to take an eternity, but finally the tech gestured to a binocular microscope. "There it is. Want to take a guess before I tell you what you've got?"
Sara looked through the eyepieces and frowned. When she stepped away, Rip removed his glasses, adjusted the 'scope, and felt his heart skip a beat as red rods came into focus. He couldn't be certain based on the microscopic picture alone, but he'd looked at hundreds of slides with dozens of organisms, and he was almost sure of the diagnosis. "What do you think? E. coli?"
The tech nodded. "Yep. Escherichia coli. I plated out some of the sample you brought, and in a couple of days I'll have a culture confirmation and some preliminary antibiotic sensitivities."
Rip looked at Sara. They both knew what that meant. They didn't have thirty-six or forty-eight hours to wait before starting treatment. They had to begin antibiotic therapy now.
Sara thanked the tech and they both began to make their way back to the ICU. "Does your drug, whatever the name is, have any effect on E. coli?"
"It's EpAm848, and the answer is that nobody knows for sure. We've only used it against Staph luciferus. But look at it this way. If it were effective against E. coli, we wouldn't be having this conversation. This wouldn't have developed."
Sara bit her lip. "I'm at fault here. I didn't keep an eye out for other causes of Chelsea's fever and all her other symptoms. She's probably had that urinary infection for several days. If I'd remembered to do repeated urine cultures, we'd have caught this earlier."
"Don't beat yourself up. We can't be perfect. No doctor can. The important thing is that we've caught it before she went into profound shock and developed multiple organ failures. We can still treat her and bring her through this."
"Okay. You're the ID specialist. What empiric antibiotics would you use for E. coli infection like this?"
Rip ran through the index cards of his mind. "I'd go with an IV quinolone like levofloxacin. And, even though we
don't see any evidence of anaerobic infection, I'd add clindamycin until we get the results of the cultures, both urine and blood."
"I agree. Do you want to write the orders?"
"Sure."
"Does this mean you have to stop the Ep whatever?" Sara said.
"I don't know. It's never been given with other antibiotics, so I don't know what could happen. But if we stop EpAm848 now, the Staph luciferus could start up again."
"I have to leave the decision to you," Sara said.
And whatever I choose will probably be wrong. Putting aside the question of one antibiotic rendering the other useless, what was Jack Ingersoll going to say when he found that one of his precious study patients had been compromised? What if there were complications? How could a researcher tell if they were due to the EpAm848, the other medications, the disease itself? The patient would be dropped from the study. And to Ingersoll, every patient in the study was pure gold.
If he were here, Rip was pretty sure what Ingersoll's decision would be: Don't give anything more. He'd argue that EpAm848 was a strong antibiotic. It might be enough by itself to combat the sepsis. Just give supportive care, use IV fluids and vasopressors, administer oxygen. Give the drug a bit of time and it could pull the patient through. Another triumph for EpAm848. Another feather in the cap of Jack Ingersoll.
Rip could call Ingersoll's cell phone. Tell him the situation. Leave the decision up to him. Doing this on his own would expose Rip to his mentor's wrath big-time. He might even lose his fellowship because of it.
They reached the ICU and pushed through the doors. Both doctors were silent as they approached Chelsea's bedside. Rip nodded to Mrs. Ferguson, who continued to maintain her bedside vigil, one hand lightly touching her daughter's arm. The mother's lips moved in what Rip took to be silent prayer. He added one of his own. Please, Lord, help me make the right choice.
He looked at Sara. Then he reached down and smoothed the hair that had fallen onto Chelsea's forehead. He took a deep breath. "Mrs. Ferguson, Chelsea has another infection—a serious one in her urinary tract. It's caused her blood pressure to go down. If the infection is left unchecked, it could put her in grave danger. I think we can get on top of it, but to do that, we're going to have to use some additional medications."
"Does that mean she won't get any more of the drug you've been giving her? Until today, it seemed she was getting better."
"No," Rip said. "I promise you, she'll keep getting the EpAm848 as well." He hoped he could deliver on that promise.
The phone dragged Dr. John Ramsey up from a dream of walking through a field of bluebonnets with Beth. No, please, I don't want to leave. I just got her back. The ringing continued, and gradually reality took hold. Beth was gone. He'd never see her again this side of heaven. Sometimes—actually, often—he wished he could go there now. He'd never gone further than the idle thought, but now he understood why men and women who'd lost their spouses after many decades of marriage might find their will to live gone.
He pushed himself up offthe sofa and blinked at the TV. The program he'd been watching had long since given way to two people arguing in front of a judge. With one hand he used the remote to silence the set; with the other he lifted the receiver. "Dr. Ramsey."
"Dr. Ramsey, please hold for Dr. Schaeffer." The female voice was much too perky for John. His mood was dark, so everyone's should be. He grunted a response and flexed his aching back muscles.
"John, this is Donald Schaeffer. I hope I didn't catch you at a bad time."
John's nerve endings tingled, and suddenly he was fully awake. "No, no. Just sat down to let my lunch settle and began watching a documentary on the Learning Channel." There was no need to let Schaeffer know the TV had been tuned to a MASH rerun.
"I've pulled every string I could, but there's no way I can swing an extra faculty member at this time."
John's stomach did a back flip, and for a moment he was afraid the few bites of grilled cheese sandwich he'd choked down at lunch would come right back up. "Thanks, anyway," he mumbled. "I guess—"
Schaeffer continued as though John hadn't spoken. "But I believe I can manage a part-time position for you. We're short in the GIM clinic, and you could pick up that slack for the next six months or so. By that time, we'll be into the next fiscal year, and I think I can swing a full-time appointment if it works for both of us."
"General Internal Medicine sounds right up my alley, Donald. After all, that's what I did for forty years. How soon can I start?"
"Why don't you come by tomorrow and see Kim, my department administrator? She can work out all the details."
"I don't know how to thank—" John realized he was talking to a dead phone. Schaeffer must have moved on to another of the message slips on his desk. He probably wouldn't think about this one again until he saw John in the halls of the department. But John would think about it constantly. Maybe this was the rope he could use to pull himself out of the depths of depression. He bowed his head. Okay, God. You came through on this one. But I still don't think we're even.
4
LADIES AND GENTLEMEN, WELCOME TO FLIGHT 1084, FROM SAN FRANCISCO to Dallas."
Jack Ingersoll ignored the instructions that followed. He closed his eyes and prepared to enjoy the flight. Jandra had sprung for a first-class ticket, and when he got to the gate he was happy to see that the aircraft was a 757. Although there'd been a time when he enjoyed travel, with familiarity had come first boredom and then actual distaste. Now, when travel was necessary, he wanted as many creature comforts as possible for the journey.
As soon as he felt the plane lift offthe runway, Ingersoll reclined his seat and settled back. He brushed aside the flight attendant's offer of a drink. He hadn't slept last night, replaying in his mind his conversation with Wolfe, but alcohol wasn't going to be the answer. Besides, he didn't want to be muzzyheaded when he reached Dallas. He'd need his wits about him as he tried to impress Dr. Pearson with the importance of making sure no adverse data crept into the reports of the EpAm848—that is, the Jandramycin cases. He was going to have a hard time getting used to the name, but he supposed it would help remind him of how much was riding on the success of this drug.
He checked his watch. Mid-morning in San Francisco. With the two-hour time difference and the length of the flight, there was no reason to consider going to the medical center after he landed. Even Pearson, never one to punch a time clock, would be gone by then. Tomorrow would have to be soon enough.
Ingersoll pushed the call button.
"Yes, sir?" One nice thing about flying first class. The service was much better than what one got back in coach.
"I've changed my mind. I'll have a glass of white wine."
He really should have called Pearson yesterday afternoon to check on the progress of his latest patient, but after his meeting with Wolfe, all Ingersoll wanted to do was go somewhere and clear his mind. He'd wandered the streets of San Francisco aimlessly for hours, had something totally forgettable from room service, and had fallen into bed to stare at the ceiling for most of the night. At least Jandra had been decent enough to put him up at the Sir Francis Drake. On previous trips, his hotel was a La Quinta in Berkeley. He should have known something was up when they gave him his travel itinerary and he saw first-class travel and a nice hotel. First the carrot, then the stick.
In addition to Wolfe's veiled threats, Ingersoll already had something to worry about, something he had to keep forcing from his consciousness. Even though Jandramycin—there, he remembered the word—Jandramycin was considered a true wonder drug, the Jandra researchers had only been able to postulate its mode of action. Not unusual, since sometimes the mechanism of action of a drug was clarified months, even years after its introduction, as data accumulated. Well, that suited him just fine. He knew exactly why it worked, and that knowledge was something he meant to keep to himself as long as possible. That and a few other things as well. Meanwhile, he would continue to build his reputation.
He reac
hed for his headset, ready to dial in some music, when an announcement rang through the aircraft. It was distorted a bit by a less-than-perfect PA system, but the message was clear. "Ladies and gentlemen, is there a doctor on board?"
Ingersoll was always careful to balance the perks that might go with being recognized as a doctor with the responsibilities that accompanied that recognition. He reached into his shirt pocket and sneaked a glance at the name on his boarding pass: Jack Ingersoll. No MD after his name, no Dr. before it. He was safe.
Five minutes later, there was another announcement, and this time the flight attendant's voice had an edge. "Ladies and gentlemen, this is urgent. If you're a doctor, please make your way to the aft galley. Thank you."
The passengers in the first-class cabin stirred and looked around, each one apparently wondering if there was a doctor among them. No one moved. Ingersoll felt, almost heard, a collective sigh of relief go up. Not just that they were spared the responsibility of tending to someone who'd fallen ill, but that they'd escaped that fate themselves. They'd survived for one more hour, most likely for one more day, God willing for one more month or year. But life was fragile, and never seemed so much so as when someone else's life was threatened.
From his seat in the last row of first class, Ingersoll craned his neck and looked down the aisle. A stocky black man on the aisle ten or twelve rows back beckoned a flight attendant over and said, loud enough for Ingersoll to hear him, "I'm not a doctor, but I'm an EMT. Can I help?"
"Yes, please. We think one of the passengers is having a heart attack. I was about to get the AED and take it back."
Great. A heart attack, and apparently they'd be using the automated external defibrillator. Ingersoll could almost write the scenario that was about to play out.
Twenty minutes later, his fears were confirmed. "Ladies and gentlemen, this is your captain. I'm sorry, but we're diverting to the nearest major city, Las Vegas, for a medical emergency. Please remain in your seats for the balance of the flight. We'll give you more information as soon as it's available."
Lethal Remedy Page 4
