Lethal Remedy (25 page)

"Maybe it's my misspent youth, filing away trivia about things that go 'boom,'" John said. "Perhaps it comes from working my way through pre-med as a clerk in the chemistry department stockroom." He pointed at a tiny area where dark brown crystals dotted the metal threshold that marked the junction of carpet in the outer and inner offices. "That's nitrogen triiodide."

"I remember that," Rip said. "My high school chemistry teacher did a demonstration with it. Man, that produced a bigger bang than anything I'd seen, even bigger than when we dropped a sliver of sodium metal into a bucket of water. But how did someone make this? And why put it here?"

"Nitrogen triiodide is the easiest thing in the world to make, if you don't care whether you lose a few fingers in the process," John said. "Mix a couple of common household chemicals, filter out the precipitate that forms, and as long as it's wet it's supposed to be stable. But when it dries, the slightest touch, sometimes even a drop of water landing on it or a strong breeze, can set it off. I've heard of snowflakes detonating nitrogen triiodide. Depending on the amount involved, you can do quite a bit of damage with it."

"Should we call the police?" Lillian asked.

"We can if you want to have the building evacuated while bomb-sniffing dogs go through it and the bomb squad detonates the rest of this stuff," John said. "If you just want to make the area safe, I suggest you call someone you trust in the biochem department. I seem to recall that you can deactivate this stuffwith chemicals like sodium hydroxide or sodium thiosulfate."

By this time, Sara had risen from the floor and stood next to Rip, leaning on him to take weight offher right foot. "Let's get this cleaned up and move ahead with our plans. I'm not going to let a ruined pair of shoes stop me. We're too close."

Lillian looked at her watch. "I'm due back in clinic, and Sara, you are, too. We need to take care of that first."

Rip had his cell phone out already. "I've got a friend in biochem that I think will handle this for us. I'll call him."

"And I'll stay here to keep you company," John said.

"Meet back here at five?" Sara said. "And Lillian, walk back with me, would you? I've got to come up with a story to explain this burned right shoe."

By five o'clock, an instructor in the biochemistry department assured the group clustered around the secretary's desk that they could safely enter Sara's office. "I neutralized the nitrogen triiodide, then disposed of it. You're good to go." He fixed Rip with a serious gaze. "Don't you think this should be reported to the police?"

"We're trying to keep it quiet."

"Well, I'll tell you. I've done some work with nitrogen triiodide, and this guy meant business. If your lady friend had stepped a little more to one side or the other, she'd be walking on crutches for a while. This was no prank."

"I know." Rip didn't want this conversation to go on much longer. He moved toward the door and was grateful when the visitor followed. "Thanks again, Fred."

"No problem. Makes a change from grading freshmen medical students' mid-terms."

"And you'll keep this under your hat?"

"Sure thing. Dinner at Ruth's Chris Steak House will get you all the silence you want. I'll call you to set it up." Fred touched his finger to his forehead in a mock salute and sauntered away.

The group shuffled into the office, eyes down, watching for telltale brown specks on the carpet. Finding none, they settled into chairs. Sara took the chair behind her desk. She leaned back and closed her eyes.

Rip broke the silence. "Who could have done this? And when?"

"When my secretary got back, I asked her about that," Sara said. "She said she got a call to go to Shipping and Receiving to sign for a package. When she arrived, there was no package, but because that's two blocks away from this building, the trip took her out of the office for almost forty-five minutes."

"And anyone could have had access during that time," Rip said.

"Let's try to refocus on the problem at hand," Sara said. "John, are you still feeling okay?"

"Now that my pulse is back to normal, I'm doing fine. I tolerated the OMAL with no problem. Of course, we don't know if I was in line to get a late complication anyway, and if I were, it would occur several weeks down the line, so this doesn't prove anything except that patients who've had their immune system modulated by Jandramycin can tolerate a dose of that drug."

"That's good enough for me," Sara said. "I told Mrs. Ferguson I'd give Chelsea her dose tomorrow, but I don't want to wait. I'm going over to her room and administer the OMAL now. I don't have anything else to do, so I'll stay with her tonight until I'm sure she's going to be okay. Then we just watch and wait, and pray for improvement."

"I'll stay with you," Rip said.

"Are you sure?"

"I don't have anything on the docket. Nobody is waiting for me at home either."

Lillian looked at John. "Actually, that goes for us, too. Want us to keep watch with you?"

Sara shook her head. "No, I don't think so. We can stay in touch by cell phone. You two go ahead home."

After John and Lillian departed, Rip said, "Okay, truth time. How are you feeling after all that?"

"Actually, other than a little soreness of my foot and being royally ticked at the damage to my favorite pair of shoes, I'm doing pretty well."

"Are you sure you don't want to go home and get some rest? Another day probably won't make that much difference in Chelsea's status."

Sara was on her feet before Rip finished speaking. "On the contrary, I don't think I can rest until I've given her the injection. But you don't have to hang around."

There's nothing I'd rather do than hang around.
"Call it professional curiosity if you want to, but I'd like to see this thing through with you." Rip pushed back his chair and stood. "Let's get going."

A
N ALARM BELL INTRUDED INTO SARA'S CONSCIOUSNESS, AND SHE WAS ON
her feet before she realized where she was. A quick glance brought it all back. She was in a corner of Chelsea Ferguson's hospital room. Rip dozed in another chair next to her. Chelsea was in her hospital bed. Her mother stood watch at her side.

The bell stopped as quickly as it began. Rip roused long enough to say, "Somebody accidentally unplugged something. Nothing to worry about." He yawned and stretched. "How long has it been?"

Sara needed no explanation. He meant, "How long has it been since we gave Chelsea the dose of OMAL?" She did a rapid calculation in her head. "Ninety-seven minutes."

They shared a glance and a silent message passed between them. Most reactions to this drug occurred within the first ninety minutes, all within two hours. They were almost home free. "Let's wait another half hour or so to be sure," Sara said.

Mrs. Ferguson tiptoed over to where Sara stood and whispered, "Can we talk outside?"

Sara moved toward the door. Mrs. Ferguson said, "Chelsea, I'm going to step outside for a minute. Dr. Pearson is here, and I'll be right back. Okay?"

Chelsea didn't break the silence she'd maintained for the past hour. Instead, she made the smallest of hand gestures to signal she'd heard.

In the hall, Mrs. Ferguson leaned close to Sara and spoke in a low whisper. "It's been almost two hours. What do you think?"

Sara kept her voice low as well. "She hasn't shown any signs of a reaction from the OMAL. That's the first hurdle. Now we have to see if the drug does what we hope it'll do."

"How long will that take?"

"We don't know. I'd guess at least a couple of days, maybe a week," Sara said.

"Tell me again why you think this may work."

"The drug is sometimes called 'anti-IgE.' The substances that carry out the body's immune responses are called immunoglobulins. There are five of them, named with letters of the alphabet, and immunoglobulin E—IgE for short—is the one that's involved in what most people think of as allergy. This compound, anti-IgE, was developed to block that immunoglobulin in susceptible individuals. It keeps it from attaching to the cells where it would ordinarily do its dirty work."

"What does that have to do with Chelsea?" Mrs. Ferguson asked.

"We think the Jandramycin has not only stimulated her immune system to produce special substances that kill the
Staph luciferus,
but also some that attack her own cells. In Chelsea's case, it's the nerves, and it leads to weakness and eventual paralysis. We hope that in this particular scenario, the anti-IgE will block those other substances as well."

"Do you have any reason to think this will work?"

Sara had turned that question over in her mind again and again since John proposed using OMAL for this purpose. The answer she gave was what she'd come up with. "We think there's a good chance—and we have nothing else."

John and Rip were in the back treatment room of the clinic that had become John's unofficial home for his Jandramycin infusions. This time there was no IV setup in view, no syringes and vials on the treatment table. John perched on the end of the treatment table; Rip sat on a rolling stool. It seemed that each was waiting for the other to speak.

Rip took in a deep breath through his nose and let it out through pursed lips. He guessed it was up to him to talk about the elephant in the room. "John, you've had six IV doses of Jandramycin. How are you doing?"

John held up his hand and turned it back and forth in front of Rip. The needle puncture wound had long since healed. No redness, swelling, or any of the cardinal signs of inflammation. "I think it's pretty much back to normal. Don't you?"

"I do, but as you know, all our success with Jandramycin has been based on a protocol of ten days of treatment. Admittedly, that number was chosen empirically, but so far it's worked. Theoretically, you need four more doses." Rip waited to see if John saw the same thing that was bothering him.

Apparently, he did. "But since I've had the IM injection of OMAL," John said, "my immune system has been tweaked, hopefully to the point that the Jandramycin won't have any further effect. The good news is that my chances of getting a late autoimmune problem may have been reduced, maybe even down to zero. On the other hand . . . "

"Yeah, on the other hand, any more Jandramycin you receive would probably be ineffective against
Staph luciferus
if there are some still in your body."

"So I'm stuck at this point. Just wait and hope the bug's been killed out." John shook his head. "Guess I can add that to worrying about whether that needle-stick exposed me to HIV."

Rip reached out and gripped John's hand. "So far, your labs look clean from that standpoint. But remember, I'm in this with you. And we won't go down without a fight."

Rip entered Randall Moore's room ready for almost anything, but not for the sight that greeted him. Jack Ingersoll and Donald Schaeffer had their heads together at Moore's bedside. Each doctor wore a white lab coat. A stethoscope dangled from Ingersoll's neck, while Schaeffer held his at his side. Their demeanor suggested serious consultation, such as would befit two heads of state rather than two physicians at a medical center.

Rip turned his eyes from them to Moore. His previously pale skin was darker now, but not with a healthy tan. His lips had a bluish cast. The man wasn't getting enough oxygen into his blood, even with pure oxygen flowing into the mask that covered his face. His respirations were slow and shallow. Moore was dying before Rip's eyes.

"What's going on?" Rip asked, trying to keep his voice level.

"I was in the bacteriology lab and the chief technician showed me the final results from this patient's sputum culture. He has a
Staphylococcus luciferus
pneumonia, which is why the nafcillin you ordered has been ineffective."

"I suspected as much," Rip said. "I just phoned the lab and got the final culture report myself. I've already talked with Dr. Miles about it, and she's on her way to meet me here. We plan to discuss treatment alternatives with her patient." He pointed to the man in the bed. "But I don't think he's in any shape for a discussion. We'd better—"

Dr. Schaeffer turned to face Rip. "Dr. Pearson, the reason I'm here is that Dr. Ingersoll thought it best, given the high

Rip knew exactly what was going on. Moore was the plaintiff in a huge suit against the medical center. Currently his treatment was under the supervision of a junior faculty member and a fellow in training. Schaeffer wanted his high-profile professor treating Moore, in hopes that a good outcome, coupled with this display of the resources available at Southwestern, would convince the man to drop his suit.

"I can't speak for Dr. Miles. Personally, I don't care whose name is on the chart." Rip pointed to the small device on Moore's index finger. "But look at the pulse oximeter. His oxygen saturation has dropped to dangerous levels. We need to get him intubated and on a ventilator."

"I've already put in a call for someone to do that," Ingersoll said. "And I plan to write the orders to add Mr. . . ." He consulted the chart in his hand. "Add Mr. Moore to the Jandramycin study. You will, of course, draw the necessary blood work, administer the drug, all the things you've been doing so well."

"What about permission?" Rip asked. "He's too far out of it to give informed consent. Let me contact his next of kin. Maybe they can sign."

"Not necessary," Ingersoll said. "Given Mr. Moore's inability to make that decision right now, Dr. Schaeffer and I will sign the permission, which, as you know, is possible in the case of a medical emergency where delay is unacceptable."

Rip's guts began to churn. This was wrong, all of it. There was no need to wait for an anesthesiologist or pulmonologist to do the intubation. Rip was perfectly capable of carrying out the procedure, but apparently, Ingersoll wanted it done by another specialist—under his direction, of course.

As for treatment with Jandramycin, Rip had come here with his mind made up. The only proper course was to lay out the risks and benefits of treatment with Jandramycin and let Moore decide. Unfortunately, Ingersoll was totally ignoring the risk that Rip felt the drug presented, a risk of late complications that would be life-changing in all cases and fatal in some. Since Moore was unable to make that decision, Ingersoll was taking the responsibility of deciding for the patient, and Schaeffer was going along with his division chief.

So be it,
Rip thought. He turned on his heel and left to gather the material he'd need. He was back to drawing blood, giving medications IV, and charting vital signs. And if he was later asked why he didn't protest Ingersoll's actions, he guessed his response would be that he was just following orders. Wasn't that the excuse of the prison guards at Dachau?

Sara sat in her living room, slumped in her favorite chair, when the doorbell brought her up from a half-sleep. Was this Rip again? After he gave her the news about the decision of Ingersoll and Schaeffer to replace her as Randall Moore's primary physician, he'd asked if he could buy her dinner. She told him all she wanted to do was go home and relax with a hot bath and a pint of Cherry Garcia ice cream. Although she hadn't made it past the living room, she had a full-fledged pity party planned, and she resented this intrusion.

She tried to ignore the bell, but whoever was at her front door apparently had more persistence than a bill collector on commission. "I'm coming," she mumbled under her breath. She eased out of her chair and padded to the door on stocking feet.

Halfway to the door, she heard the distinctive splash of rain dripping from her roof. When had it begun to rain? She put her eye to the peephole, only to discover that while she was napping, darkness had covered the world. Sara snapped on the porch light and saw a thoroughly soaked and bedraggled Mark Wilcox standing there.