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. Clément 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 f
ine. 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.
Carter Resnick opened the door to his lab a crack and peered out at Rip with one eye. "What do you need? I'm collating data right now."
"We need to talk."
"I didn't think you had time to talk with a lowly research associate."
Rip bit back the reply that came to his lips. He needed this information, and maybe Resnick had it. "Carter, that's not true. I've always had time for you. Surely you can spare five minutes for me."
Resnick's visible eye blinked several times. Rip could almost hear him thinking. Finally, the door opened wide enough for Resnick to slip through, then closed behind him with a solid click. Resnick jiggled the knob to confirm the door was locked. He turned to face Rip and crossed his arms.
"Okay, talk."
"Carter, be reasonable. Can't we sit down somewhere like two colleagues and have a discussion? Why don't we go into the lab?"
Resnick was shaking his head before Rip finished talking. "No way. Dr. Ingersoll only allows two people in that lab: himself and me."
"I thought there was a lab technician, too."
"No. When we got to a critical point, Dr. Ingersoll discharged the tech. I do all the work now. It's a matter of security."
"Carter, most of that data you're collating came from me. What could be in there that I don't already know?"
Resnick grinned. "That's for me to know and you to find out."
Rip decided that Resnick's schoolboy response effectively closed the door—quite literally—on any hope of his getting into the lab. He leaned against the wall and fired his first salvo. "I need to know what exactly is in Jandramycin. I have to find out what its exact mode of action is."
"The main thing anyone needs to know is that it kills Staph luciferus. Some people postulate that Jandramycin works by attacking the bacteria's cell wall. Its real mode of action probably won't be revealed until Dr. Ingersoll and I publish that information."
There it was. Resnick figured that his work would get him co-authorship of the papers that were sure to come, papers certain to be the lead articles in JAMA and the New England Journal. Until that happened, Resnick would move heaven and earth to stay on Ingersoll's good side, and if that meant standing guard on the laboratory and the data it contained, so be it.
"Look, Carter, it's important that we know how the drug works. People who received it are turning up later with autoimmune disorders that are disabling and potentially fatal."
Resnick didn't seem surprised. "Everyone?"
"No." Rip did some quick calculations. "It seems like maybe 15 percent of the patients are at risk. But we don't know which ones they are."
There was a muted buzz from the pocket of Resnick's lab coat. He held up one finger to Rip. "I'd better get this."
It was a brief and mainly a one-sided conversation. Resnick said, "I can't tell you that" a few times and punched the button to end the call. He dropped the phone into his pocket and said, "That was Dr. Miles. She asked me the same question you did. You all should coordinate your efforts."
"Carter, listen to me. Lives are at stake here. Why won't you give me this information?"
"Actually, you already have enough clues. You're the diagnostician. Figure it out." With that, Resnick executed a quick about-face, opened the lab door with a key he produced from his pocket, and disappeared inside.
&nb
sp; Lillian grabbed the chart from the plastic rack and tapped on the exam room door. Without waiting for a reply, she opened it and walked in. "I'm Dr. Goodman. What kind of—"
Her usual greeting to patients died in her throat as her eyes registered the scene before her. John Ramsey lay on the exam table with an IV running into his arm. "John, what—"
"Easy, Lillian. I'm fine. I'm just getting my first dose of Jandramycin."
She glanced down at the name on the chart she held: John Matthew Ramsey, MD. Lillian had her finger inside the cover, ready to open the chart, when she stopped. No, John would tell her what he wanted her to know. She pulled over a stool and sat down beside John, covering his hand with her own, careful to avoid the small plastic cannula that carried medication into the vein in his forearm. "What's going on?"
"It all started when this lady doctor I know thought I might be getting an infection around a puncture wound of my hand and insisted I see someone about it." He grinned, trying to rob the words of any sting. "The culture grew Staph luciferus. So, now I'm on Jandramycin."
"John, I'm so sorry. But I'm glad Rip did the culture," Lillian said, "and even happier that we have something that will knock out the bacteria. I mean, just a few months ago we had nothing, and these infections were potentially fatal."
"Right. The drug should take care of the Staph luciferus infection, and that's good. What you don't know, and I guess it's okay to let you in on the story, is that some patients who received Jandramycin are turning up with various autoimmune diseases, most of which can be fatal. So there's a chance that I may save my hand at the risk of developing something just as bad—maybe worse—down the line."
That brought a dozen questions to her mind. "I thought Jandramycin was supposed to be so wonderful. One hundred percent effective against the most dangerous pathogen we've seen since the black plague, but with no side effects. Why didn't someone warn us before we began to use it?"
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