"Oh, we always have to worry, all of us. Doctors might as well have targets painted on their backs, with signs saying 'Sue me.' You definitely could be named in a suit. If so, your lawyer should be able to mount a good defense. That would cost you some legal fees and some time, but you'd have a decent chance of coming out okay."
"And if I need a lawyer?"
Mark took a bite of his neglected sandwich, chewed, and swallowed. "Lucky for you I'm still licensed to practice law. And I'm running a special right now: defense of one lawsuit in return for lunch. So I guess you've got a free one coming."
John only managed to choke down half his sandwich, but Mark seemed to have no difficulty finishing his, following it with a trip to what John had heard his colleagues call the "sin bar"—a table laden with tempting desserts.
Mark returned with a piece of pecan pie. "Sure you don't want something?" he asked.
"No, I think I'd better just watch you." John waited while Mark took a bite. "Tell me honestly. Do you miss practicing law? Do you ever wonder if it was a mistake to give that up, go to medical school for four years, and have to start all over again building a practice?"
Mark chewed his pie and swallowed. "Sometimes I think that being a lawyer is sort of like being a member of the Mafia. You know, 'Once in, never out.' As it turns out, I'm sort of melding medicine and law. I have a small family practice, but I also review malpractice cases for insurance companies that cover doctors. I do a little consulting for pharmaceutical companies." He grinned. "And I help out old friends who have legal problems."
Mark finished his pie and pushed the plate aside. "Why don't I drop by your clinic next week? You can give me your malpractice policy, and I'll have a chance to see how the faculty operate their private clinics. Remember, all my medicine clinics were at Parkland."
"Honestly, the surroundings may be nicer, but we pretty much practice the same brand of medicine we teach the residents. Anyway, you're welcome to drop by. Monday is my next day in the clinic, and I'll bring the policy then. If you come around noon, maybe I can talk Donald Schaeffer into springing for another lunch at the Faculty Club."
Outside, the two men stood in front of the elevators when John heard, "Dr. Ramsey. How are you?"
John turned and saw Sara Miles standing behind them. "Sara, were you in the Faculty Club?"
"Hardly. I had a sandwich in the food court. I'm just waiting for Rip—er, Dr. Pearson to bring some papers for me to fill out. I have a patient in his drug study." She looked pointedly at Mark, and when neither of the men moved, she stuck out her hand. "I'm Sara Miles, one of John's colleagues."
"Mark Wilcox. Dr. Ramsey was sort of a mentor to me while I was in med school. And it's a pleasure to meet you."
"He mentored me, too, so we have that in common." Sara looked at her watch. "Well, Rip must have gotten delayed. I guess I'll have to track him down." She extended her hand again. "Dr. Wilcox—"
"Please, it's Mark."
"Mark, it was nice to meet you. John, I'll see you Monday." Mark ignored the ding of the elevator and moved away from the opening door. "So that good-looking lady is one of your colleagues?"
"Yes. But she's a little young for me."
"I wasn't thinking about you," Mark said. He stepped into the elevator. "See you Monday."
It was Monday morning, and Sara was trying without success to get her engine revved up for the week ahead. She slumped in a chair at the doctors' dictation station in the clinic. Her second cup of coffee was at her elbow while she looked over the charts for her appointments that day.
Gloria tapped on the doorframe, entered, and handed her a pink phone message slip. "You have a call from one of your Jandramycin patients. Mrs. Ferguson. She's worried about Chelsea."
"Chelsea's been out of the hospital for over a month. This is probably something entirely different." She dropped the slip on the desk and picked up her pen. "I'll call her at noon, after I've finished seeing patients."
Gloria didn't move. "I'd call her now. Mrs. Ferguson was almost hysterical."
Sara had come to trust Gloria's assessment of situations like this. She nodded, picked up the phone, and punched in a number. Mrs. Ferguson answered on the first ring.
"This is Dr. Miles. My nurse said you had some concerns about Chelsea."
The normally calm woman was obviously distraught. "This morning, she couldn't get out of bed. It was like the muscles in her legs wouldn't work. I had to carry her down the stairs. She's lying on the sofa right now, crying."
"Did this come on suddenly?"
"Yes. She was fine yesterday. This morning, she can't walk."
"And nothing out of the ordinary happened to her yesterday? No injury, even a slight one? She didn't eat something unusual?"
"No. We went to church in the morning. I remember telling friends I was so thankful Chelsea was back to normal."
Sara's mental Rolodex began to flip. "Is she in pain?"
"Not really. She says her legs tingle and feel numb. Mainly she's scared and frustrated."
"Any other signs? Headache? Nausea? Visual symptoms?" She went through a list of symptoms, getting a negative response to all her questions.
"What is it? Is she having a stroke? Could she have been poisoned or something?"
Sara shook her head until she realized the woman on the other end of the phone couldn't see it. "We don't know," she said. "I'll have to see her. Can you get her here, or do we need to call an ambulance?"
"I'll bring her in the car. Shall I bring her to the clinic?"
Sara checked her watch. Her patients for the morning were already arriving. The odds of having to admit Chelsea for evaluation and treatment were pretty good. "No, bring her to the Emergency Room here at the medical center. I'll let them know you're coming so they can call me."
Fortunately, Sara's first few patients were follow-ups that required very little concentration on her part. While she adjusted medication doses, reviewed lab reports, and took care of a few minor problems, her mind churned with the differential diagnosis of sudden and unexplained weakness.
Finally, at mid-morning, Gloria tapped on the exam room door, as Sara was finishing with a patient. "Excuse me, Doctor. The ER just called. They're ready for you."
"Thanks. Would you tell the patients who are waiting to see me that I've been called away for an emergency? I should be less than an hour. Offer to reschedule them if they don't want to wait."
Sara hurried through the tunnels connecting the buildings in the medical center, turning right and left without conscious thought until she reached the Emergency Room. She found Chelsea on a gurney in one of the exam rooms, her mother beside her.
"Can you help?" Mrs. Ferguson asked. Sara forced a smile. "Don't worry. We'll get to the bottom of this."
A quick neurological exam confirmed what Mrs. Ferguson had said: Chelsea had very little strength in the muscles of her lower limbs, and her reflexes there were diminished. Her upper extremities seemed to be working normally. Sara had been thinking about this and was ready with her decision. "We're going to need a number of tests, and we can get started on those right now. But I'm also going to ask one of our neurologists to consult on the case."
Mrs. Ferguson's face fell. "Neurologist? So is this a stroke? Or a tumor?"
"I don't really know what it is yet. But something has affected this set of muscles. Dr. Pearl is more experienced in this area, so it's a simple matter of two heads being better than one." Sara addressed Chelsea: "They're going to draw some blood from you. Then you'll be going to the radiology department for an MRI. That's sort of scary, because you're in a tunnel kind of thing and have to hold still for about fifteen minutes. I don't want to give you anything to sedate you, because we don't know what's going on yet. Think you can handle it?"
Chelsea bit her lip, then nodded. A frightened child had once more replaced the smiling teenager, and it tore at Sara's heart.
Sara decided not to mention some of the other tests. A spinal tap. Electromyography and
nerve conduction studies, with needles in the muscles to check their function. Probably more blood tests—a lot more. Chelsea and her mother had been through so much, and now this. It wasn't fair. God, why did this happen?
Sara saw the agony on Mrs. Ferguson's face, and her mind drifted to her own loss. No mother should ever suffer the death of a child, and this woman wasn't going to if Sara could do anything to prevent it. But first she had to find out what was going on.
She answered a few questions, then stopped at the nurses' desk to write some orders. She'd call Dr. Pearl later today, after some of the reports were back. For now there was only one thing Sara could do. There in the midst of the busy ER, clutching Chelsea's chart to her heart, she closed her eyes and voiced a silent prayer.
8
YOU LOOK LIKE YOU'VE LOST YOUR LAST FRIEND."
Rip Pearson's voice startled Sara out of her reverie. She gestured to the empty chair across from her in the hospital cafeteria. "I'm not sure how many friends I have, but you're probably my best one, and I need you now."
Rip settled his tray onto the table but didn't unload it. Instead, he braced his elbows on the table and leaned toward Sara. "I'm here, ready to listen."
"I just saw Chelsea Ferguson in the ER and admitted her. She awoke this morning with severe weakness of both legs. I've ordered some tests. Anna Pearl's going to see Chelsea this evening."
Rip raised his eyebrows. "What's your best guess?"
"Oh, the differential's a mile long, but I'm betting on Guillain-Barré syndrome."
Rip shook his head. "That's too much of a coincidence."
"What do you mean?"
"I've had calls this week about two other patients who received Jandramycin. Their private doctors saw them with some pretty serious problems."
"And they have Guillain-Barré, too?" Sara asked.
"No, one of them has severe headaches and visual disturbances. The other has developed early kidney failure. But the common link is Jandramycin." He pushed his tray aside, untouched. "If you're through eating, let's go somewhere quieter where we can talk about this. I think there's a connection between our 'wonder drug' and these complications."
Sara stood. "I can't eat, especially now. And I imagine that when we let Jack know about this, he'll lose his appetite, too."
"That's another thing we need to talk about," Rip said as they moved toward the exit. "If we tell him about what's happening, is he going to investigate it . . . or deep-six it?"
Jack Ingersoll's fingers lingered over the keyboard as he mulled his next sentence. He was scheduled to present this paper to the World Conference on Infectious Diseases in Frankfurt. Then he planned to submit it to a prestigious journal—maybe the Journal of Infectious Diseases or the Journal of the American Medical Association—and with a little push from Jandra it should end up as the lead article.
"Dr. Ingersoll, Drs. Miles and Pearson are here to see you." His secretary's announcement carried through the open door like Gabriel's trumpet.
He picked up his phone and punched the intercom button. "How many times have I asked you—Never mind. Send them in."
He rose from behind his desk and gestured his visitors to chairs. "What can I do for you?"
Sara opened her mouth, but Pearson gave her an "I got this" look. "Some of the Jandramycin patients are having some problems. We wondered if you had any information that would help us figure out what's going on."
Ingersoll's smile never wavered. "What kinds of problems?"
"Chelsea Ferguson has Guillain-Barré syndrome," Sara said.
"And two other patients are having problems," Pearson added. "One of them has severe headaches and visual symptoms; the other is in early kidney failure."
Ingersoll spread his hands. "I'm sorry to hear that. Are any of these patients just offthe medication?"
Pearson shook his head. "No. Chelsea's more than a month out. The other two have been offthe med for six weeks or so."
"Then we can't assume their problems are due to Jandramycin. Sorry."
"Jack," Sara said,"you've kept all the data on this study very close to your vest. And I can't find any information from the animal studies on the compound. Is there anything there that might suggest the likelihood of late complications?"
"That data is proprietary, and until Jandramycin is released, it's going to be available to only a few people on a need-toknow basis." He rose. "Now, if you'll excuse me, I have a paper to write. And, Pearson, I believe you have some patient data to compile."
"Sure, I'll get on that right away." Rip pushed back his chair and took a step toward the door. "But first, can you tell me why Jandra has already filed an NDA? I thought they wanted a total of a hundred patients, forty from us. The NDA was filed before we reached our target number. Where did the others come from?"
Ingersoll didn't need this. He was too close. "Look, you don't have the big picture. Nobody does except me. You just have to trust me. When Jandramycin launches, there'll be enough credit to go around, and I'll be sure you get some." He looked at Sara. "That goes for you, too. I appreciate your furnishing patients for the study. How many of yours do we have?"
Sara rose and moved toward the door. "I know of five. But given what I'm hearing, the number may be entirely different when this is all over."
After three sharp taps on the exam room door, it opened just wide enough for Verna to peep in. "Dr. Ramsey, there's a Dr. Wilcox here to see you."
John didn't look away from the man who perched on the edge of the exam table. "Have him wait in the doctors' dictation room. I'll be out in a minute."
He waited until the door closed before he continued. "Sorry. As I said, your blood pressure's a bit high, but I think we can get it under control. I want you to see our dietitian. If you can lose twenty pounds, odds are that the pressure will come right back down."
The man's face fell at the mention of a diet. He frowned. "Why don't you just put me on some pills?"
John had heard this a hundred times, but he tried to make his reply sound fresh. "Pills shouldn't be a permanent solution. They're great to attack the problem acutely, and I'll probably put you on something for now, but you need to be concerned with your long-term health." He went on to mention the benefits of a healthy lifestyle, but as the patient's eyes began to glaze over, John decided not to fight the battle right then. There'd be plenty of opportunities later.
"Get dressed and meet Verna outside. She'll have a prescription for your medication. She'll also set up an appointment with the dietitian. I want to see you back in three weeks, and we'll see what your blood pressure is then." The patient smiled, but it vanished when John added, "And we'll check to see how much weight you've lost."
John paused at the door and asked the same question he'd been asking patients for forty years: "Are there any questions I've left unanswered?" There rarely were, but it never hurt to ask.
After giving Verna a few instructions, John moved to the dictation cubicles where he found Mark Wilcox thumbing through a journal. "Sorry to keep you waiting."
"Not at all. I'm just reading this paper by Jack Ingersoll. It's a preliminary report on the use of Jandramycin to treat Staph luciferus sepsis." Mark put the journal aside. "Isn't he on the faculty here?"
"Yes, he's head of the Infectious Disease section and apparently quite a rising star. I heard the other day that he's about to be fast-tracked to full professor."
"Well, someday maybe I can meet the great man, or at least touch the hem of his garment."
John frowned. "You sound a little bitter."
Mark pulled a ballpoint pen from his pocket and began clicking it. "I'm not sure that's it so much as just cynical. At the time the article was submitted, he'd treated thirty-two patients with Staph luciferus sepsis with 100 percent cure and no side effects. John, we both know that the medication doesn't exist that has both those qualities. It either works most of the time and is very safe, or is effective all the time but there are risks. Call me a doubter, but I won't believe this un
til I see the work duplicated by another investigator."
"Let's see." John picked up the journal and found the paper in question. "Accepted for publication . . . hmm. They must have rushed this into publication, because it was accepted only three months ago, so the figures have to be fairly fresh."
A hushed, earnest conversation just outside the door made John turn to look. Rip Pearson was talking with Sara Miles. "Well, you're in luck. There are a couple of people who should be able to give you a little insight."
John stuck his head into the hall and waited for a lull in the conversation. "Rip, do you have just a second?"
There was a moment for an exchange of the usual pleasantries. Then John asked, "Rip, how many patients are in the Jandramycin study now?"
Rip took a deep breath and let it out as a barely audible sigh. "You know, based on what I've heard this morning, I couldn't begin to hazard a guess."
Sara stirred her chef 's salad and speared a small piece of tomato. "Mark, it was nice of you to take us all to lunch." Mark made a deprecating gesture. If you only knew how happy I am that this worked out. "My pleasure. I owed John a lunch. And after what you and Rip hinted at, I had to hear the rest of that story."
The four sat in a back booth at one of the trendier eating places on McKinney Avenue. John looked at his watch. "Shouldn't we have stayed on campus for lunch?"
Sara smiled at John. "You're still new on the faculty. In private practice, you were always on call. Here, you're one small cog in a great big machine. None of us have clinic this afternoon, so we can take a longer lunch. As long as you have your cell phone and pager with you, you're fine."
John shrugged. "Guess you're right."
"Enough of that," Mark said. "I want to hear more about how the number of patients in the Jandramycin study is a moving target."
It was impossible for Mark to miss the look that passed between Sara Miles and Rip Pearson. Who is this guy? Why should they trust him?
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