WEAPON OF CHOICE
Also by Patricia Gussin
FICTION
Shadow of Death
Twisted Justice
The Test
And Then There Was One
NONFICTION
What’s Next … For You?
(With Robert Gussin)
WEAPON OF CHOICE
A NOVEL
PATRICIA GUSSIN
Copyright © 2012 by Patricia Gussin
FIRST EDITION
All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review.
This book is a work of fiction. Names, characters, places, and incidents either are the products of the author’s imagination or are used fictitiously. Any resemblance to actual events or locales or persons, living or dead, is entirely coincidental.
ISBN: 978-1-60809-051-8
Published in the United States of America by Oceanview Publishing, Longboat Key, Florida
www.oceanviewpub.com
10 9 8 7 6 5 4 3 2 1
PRINTED IN THE UNITED STATES OF AMERICA
This book is dedicated to my fabulous parents
who gave so much so generously.
Joseph E. Plese (1904–1989)
and
Gerarda Farrell Plese (1916–2006)
ACKNOWLEDGMENTS
I would like to acknowledge three scientific pioneers who unknowingly contributed to Weapon of Choice.
The first is Louis Pasteur (1822–1895), a French chemist whose experiments supported the germ theory of disease. He is best known for inventing a method to kill harmful bacteria in milk, a process now called pasteurization. He is regarded as one of the three fathers of microbiology, together with Ferdinand Cohn and Robert Koch.
The second is Joseph Lister (1827–1912), a British surgeon and a pioneer of antiseptic surgery and sterile technique. He is considered “the father of modern antisepsis.”
I can’t claim to have known either of these gentlemen, but I did know the third of these prominent scientists: Dr. Grace Eldering (1900–1988). Dr. Eldering with Dr. Pearl Kendrick, developed the first successful whooping cough (pertussis) vaccine in 1938. During the previous decade, whooping cough caused an average of six thousand American deaths annually—mostly children under the age of five. The vaccine virtually eliminated fatalities. She was the director of the Department of Health’s Western Michigan Division Laboratory in Grand Rapids, Michigan, from 1951 until her retirement in 1969. My lucky break—she hired me as a bacteriology technician right out of high school, encouraged me through college and medical school, and modeled an incredible work ethic. I am thankful for her friendship and join all parents in gratitude for her efforts to prevent deaths due to whooping cough.
Thanks to the terrific folks at Oceanview Publishing: Frank Troncale, David Ivester, Susan Greger, Susan Hayes, George Foster, Joanne Savage, Kirsten Barger, and Cheryl Melnick. And a special thanks to my editor, Ellen Count. I am so fortunate to have such a spectacular team.
And a huge thanks—with hugs—to my husband, Bob Gussin, who reads everything first, makes my life a dream-come-true, and who happens to be an author and a gourmet cook and a vintner. How fantastic is that?
WEAPON OF CHOICE
CHAPTER ONE
SUNDAY, NOVEMBER 24, 1985
“This is Dr. Nelson.” Laura had just reached over to switch off the bedside lamp when her phone rang.
“Duncan Kellerman. Sorry to call so late, Laura, but can you see a patient, please.”
“Of course. First thing in the morning.”
“Could you see him tonight?”
“What’s the urgency?” Worn out after a weekend in Orlando chaperoning her son’s baseball team, she’d nodded off before the end of the eleven o’clock news.
“I have a thirty-two-year-old white male, febrile, with worsening respiratory distress. Bilateral pulmonary infiltrates—”
“Pneumonia,” Laura remarked. Pneumonia was Kellerman’s own specialty, so why would he be calling her, a surgeon?
“Undoubtedly. But he has a right hemothorax. We put in a chest tube, drained off the fluid, and found suspicious nodules. Radiology thinks he needs a biopsy to see what’s growing in there. Would you come in and check him out? Name’s Matthew Mercer.”
Laura sat up in bed. Despite her fatigue, she managed to focus.
“I have him on antibiotics,” Kellerman persisted, “broad spectrum, including methicillin, but those nodules—”
“I’ll be there in fifteen minutes,” she sighed.
Laura sank back on her pillow. She disliked leaving her kids alone, even though Natalie and Nicole were seventeen and Patrick was fifteen. Dilemmas of a single mother immersed in a surgical career. Whenever Laura did go out at night, her housekeeper, Marcy Whitman, always came from the apartment over the garage to stay in the house; just tonight, Marcy was visiting her sister in St. Petersburg, not to return until morning.
At least the hospital was close. Tampa City Hospital stood on Davis Island just over the bridge connecting Davis Island from Tampa proper, less than a five-minute drive for her. On her way out, Laura said good night to her twin daughters, checked in on her sleeping son, and grabbed an apple from the bowl on the kitchen counter.
Laura found Matthew Mercer in a private room on the fifth floor. On a cabinet just outside the door, she saw a supply of paper gowns, a box of rubber gloves, masks, and a plastic bag to collect the refuse. Good, the hospital’s infectious disease protocol had been activated. Laura donned the protective gear and stepped inside to find her chief surgical resident adjusting the patient’s chest tube connection.
“You put in the tube, Michelle?” Laura asked.
“Yes, Dr. Nelson.” Michelle Wallace looked too young to be inserting tubes into chests, but if patients reacted skeptically to her youthful appearance, her energy and good humor won them over. She reminded Laura of herself at Michelle’s stage. Right down to Michelle’s longish blonde hair, now tucked up inside the surgical cap, and green eyes almost the color of her own. But Michelle was single; when Laura was a resident, she’d had five kids.
“Sorry Dr. Kellerman dragged you in so late at night, but this patient’s condition is deteriorating fast,” Michelle said quietly. “And he is so young—”
As Michelle held up the patient’s chest x-ray to the light box, Laura planted her stethoscope on his chest and listened. Then she straightened up and draped the instrument around her neck. “Mr. Mercer,” she began, “I’m Dr. Nelson, the chief of surgery at Tampa City, and I’m a thoracic surgeon.”
How much of what she said could he make out with an oxygen mask covering his mouth and nose, and the constant bang of the positive pressure machine?
He flicked his eyes, nodded.
She assessed the patient’s physical appearance. Curly auburn hair with clumps sticking to his damp forehead. Thin to the point of emaciation. Lung cancer jumped to the top of her differential diagnosis. She took a moment to examine the x-ray. Definitely bilateral pneumonia. But too often she’d found tumors lurking behind the infected lung tissue, hidden from sight on the x-ray. But in someone as young as thirty-two?
“Did Dr. Kellerman tell you that he recommends a biopsy of your lungs?”
A slight nod. His eyelids rose, panic flashed across the blue eyes.
“I know you can’t talk with the oxygen running, but as soon as I finish my examination, I’ll take the mask off so we can discuss our next steps. All right?”
Matthew Mercer nodded again. Despite the oxygen, his breathing was ragged and his color grayish.
High-risk patient. Not too high risk for a biopsy, she hoped. And what were those raised purplish blotches on his face and neck? When she turned down the sheet to examine his chest and abdomen, something clicked, a suspicion. Red-purple lesions, some coalescing into plaques that marred his lower abdomen. Folding the sheet still lower, she saw how the lesions extended down both legs in an irregular pattern. When she checked his genitalia, she found more of the same purplish papules.
Laura pointed to one of the spots. “Michelle, did Dr. Kellerman go over this finding with you on rounds? Did he order a dermatology consult?”
“No, no one talked about these sores.” Michelle paused, correcting her terminology. “These lesions.”
Then probably no one’s made the diagnosis. Yet. Laura had to check one more site: the patient’s mouth. She removed his oxygen mask. Ready with a tongue blade from the bedside canister, she asked him to open his mouth. Indeed, angry-looking, raised lesions peppered his gum line: some of them covered with white cheesy material she knew was a fungal infection, candidiasis.
Medical school professors love to teach, but Laura held back. She had to be sure before she shared her clinical impression. Her presumptive diagnosis: Kaposi sarcoma—KSHV/HHV-8 infection. If this was Kaposi sarcoma, then there was a reasonable possibility that this patient had AIDS. As far as she knew, AIDS had not yet hit Tampa, and she was afraid that the diagnosis would throw the hospital staff into a panic.
Four years earlier, the medical literature had reported an epidemic of Kaposi sarcoma in the homosexual population. The Centers for Disease Control and Prevention, the CDC, named it GRID for “gay-related immune deficiency,” but now a retrovirus, HIV-1, had been isolated, and the outbreak was called acquired immunodeficiency syndrome—AIDS.
She’d been following the controversy swirling around the discovery of the virus: Dr. Robert Gallo at the National Cancer Institute claimed to have isolated the retrovirus HTLV-II; researchers at the Pasteur Institute in France claimed to have isolated the same virus. Still a running battle, but politics, legal battles, patents, none of that had been Laura’s concern. Except now, faced with an actual patient, she realized how little she—or anyone—knew about this aggressive virus that had now moved into the heterosexual population. And even pediatric patients. Wasn’t there recently a little boy, a hemophiliac, who’d been kicked out of school after the school found out he’d acquired the virus in a blood transfusion? Rock Hudson had died of AIDS just last month.
Now, as Laura stared into this patient’s mouth, she was even more thankful that the Tampa City Hospital infectious disease nurse had initiated the isolation protocol. In addition to Kaposi sarcoma, the patient most likely had a staph infection and who knew what other bugs would grow out of the cultures. Laura’s biopsy would likely reveal even worse pathology. Kellerman should have suspected this, but had said nothing. She wondered why? Had he missed the presumptive diagnosis of AIDS? Or was he trying to hide from it? Avoidance and denial, common defense mechanisms.
“Mr. Mercer,” Laura said, “we need to get you into the operating room so we can find out what’s causing all the fluid in your lungs. We see some spots in your lungs, too, and we need to know what they are. Could be an infection or a tumor. We need to know, so we can treat you properly. Are you okay with this? We’ll need your written consent.”
“No surgery! I have an infection,” he objected. “A staph infection, I heard the other doctor say. There are drugs to treat that.”
“Yes, that’s true,” Laura said, “but you’re not responding. We may identify other organisms.”
“Like what?” he asked.
“Like tuberculosis, fungal infections, Pneumocystis or—” Laura didn’t want to get too technical.
“I don’t mean to be difficult,” Mercer’s voice came in a raspy wheeze, “but my father, my biological father—he didn’t really raise me—is a doctor, Doctor Victor Worth. He’s a scientist at the National Institutes of Health. Would you call him? Tell him what you’ve found, ask for his opinion? I’ll go with what he says.”
Laura agreed. And she would call, but what she most wanted to do was to go home and sleep, so in the morning she’d be fresh. She’d open up this young man’s chest to find out what bad stuff lurked inside.
“Mr. Mercer, first may I ask, have you ever been diagnosed with any serious infectious disease? Either bacterial or viral? Tuberculosis?”
He hesitated, shook his head, and reached for the oxygen mask. Laura helped him situate it, then checked the settings on the positive pressure machine.
At the nursing station, Laura stopped to phone Matthew Mercer’s biological father. Mercer and Worth? Different last names. What was that all about?
A male voice answered on the first ring.
“Victor Worth?”
“Yes, this is Dr. Worth.”
Laura introduced herself as Matthew’s doctor, keeping her voice neutral as she detailed a dark medical picture, noted that conventional antibiotics were not working, and told him what she wanted to do. She held back her presumptive AIDS diagnosis, not sure what she could legally share, concerned about patient confidentiality. She waited for Worth’s answer.
A lung biopsy was indicated, he conceded. He was not a medical doctor, he informed her. With a Ph.D. in microbiology from Georgetown University, he had made an entire career of antimicrobial research at the National Institute of Allergy and Infectious Diseases—the NIAID—a division of the National Institutes of Health.
The man had an inflated self-image, Laura decided—but never mind. He’d agreed to her treatment plan. He seemed genuinely concerned about Matthew and promised to fly to Tampa the next day.
Worth did have one request that he insisted Laura pursue—an investigational drug trial. A clinical study was underway, he explained, at Keystone Pharma, a pharmaceutical company in Philadelphia. The drug was ticokellin for the treatment of drug-resistant staph. Could she contact a Dr. Norman Kantor at the pharmaceutical firm—and get that drug for Matthew? Worth told her that he used to work with Dr. Kantor, who may have retired, but who would vouch for him and convince his successor to provide the drug immediately under a compassionate IND—investigational new drug application. Worth offered to personally transport the drug, but he reiterated that the request must come from her, Mercer’s treating physician. At this time of night she wasn’t ready to explain that she was the surgeon and that Kellerman was Mercer’s primary physician.
What about a drug to treat the HIV virus? Laura thought as she terminated the call. Not likely in Matthew Mercer’s lifetime.
Before leaving the hospital, Laura booked the first operating room slot. Her chief of surgery rank did come with privileges. She would place the call to Keystone Pharma the next morning. On her way out, she looked in on Matthew. Still struggling to breathe, he nodded his assent as she told him she’d phoned Worth and they’d talked. Matthew was first on the operating room schedule tomorrow—seven o’clock.
CHAPTER TWO
MONDAY, NOVEMBER 25
At five thirty a.m., Laura arrived at Tampa City Hospital. She’d left notes in the kitchen for her kids. They were perfectly capable of making their own breakfast and getting off to school, but still, she felt guilty about leaving them last night and again this morning. Marcy Whitman, her housekeeper of fourteen years, would be back before noon, and all would be well in the Nelson household. Laura hoped. With twin seventeen-year-old daughters, you never knew for certain. One day you thought you did know, but the next day brought surprises, not always pleasant ones, like the birth control pills that had fallen out of Nicole’s purse last week.
Laura spent most of her professional time in Tampa City Hospital on Davis Island, but she also had an office and a research lab on the main campus of the University of South Florida Medical School. After graduating from medical school in Detroit and finishing her thoracic surgical residency in Tampa, she’d pioneered lung volume reduction surgery, considered experimental then, but now moving into the m
ainstream. And, a year ago, the University of South Florida Medical School named her head of the surgical department. She appreciated the title Chief of Surgery, but not the administrative burdens that came with it.
Laura’s research labs were located at the medical school complex in Tampa on Fowler Avenue, where she and her research fellows did experimental surgery. She dedicated Tuesdays and Thursdays to research, and usually operated at Tampa City Hospital on Mondays and Wednesdays. When all was said and done, Laura’s schedule was erratic.
Her Tampa City Hospital office was dark and empty when Laura arrived, paper cup of coffee in hand. A stack of charts awaited her signature, as did today’s hospital staff meeting agenda. As usual, she would present the surgical stats for the hospital: number of procedures, length of hospital stay, morbidity and mortality rates, wound infection rates, any quality control issues. Should she share Matthew Mercer’s presumptive diagnosis of AIDS with the hospital staff?
If she was right and her new patient had the HIV virus, there’d be a steep learning curve as the hospital coped with confusion and chaos—all while trying to prevent transmission to healthcare workers. She’d decided to wait for the biopsy result, to know for sure.
HIV, as an infectious disease, would come under the purview of the internal medicine service. But as chief of surgery, she needed to do everything she could to protect the operating room personnel from contamination, as well as patients in the recovery room and on the surgical floor. She had to do that now, this morning, before she raised what could be a premature alarm.
With a presumptive diagnosis of HIV, the issues were complex. Not much was known about the retrovirus, how it spread, what precautions should be taken, not even how to definitively diagnose it. A test had been recently patented, intended to test the blood supply, but was not yet commercially available. And, she’d read in the lay press about certain problems swirling around the issue of confidentiality. Because HIV was associated with homosexuality, afflicted patients clamored for anonymity. Was it even legal to chart the diagnosis? Activists already were challenging everything about the controversial HIV virus. Laura could be heading into a public health and a public relations nightmare.
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