Lethal Remedy (4 page)

"Chelsea is very seriously ill." Ingersoll turned from the patient and addressed his words to Mrs. Ferguson. "She has an infection in her bloodstream that will almost certainly kill her if we can't eradicate it." If he saw the mother's shudder and the girl's grimace, he ignored them. "Our only chance for that is the administration of an experimental medication. We've had remarkable success—actually a 100 percent cure rate—with it. Although side effects and complications are possible, we've seen none of these. I need your permission to proceed."

"What if . . . ?"

"The details are spelled out in the consent forms that Dr. Pearson will go over with you. If you don't wish to sign them, of course, the choice is yours, including responsibility for the consequences. If you proceed with treatment, Dr. Pearson will administer the first dose today." Ingersoll looked at his watch. "I'm afraid I have to leave now, to attend a consultants' meeting. I'll look in again in a couple of days, should you consent to treatment for your daughter."

Rip watched Ingersoll turn on his heel and march out the door as though going into battle. He didn't know what this "consultants' meeting" represented, but he was certain of one thing. As of thirty minutes ago, it had not been on Ingersoll's agenda. It was a result of that phone call. And it was a command performance.

Sara frowned as she searched the chart rack at the ICU nurses' station. The slot for Room 6 was empty. Was it misfiled in the hurry of ICU routine? No, Chelsea's chart wasn't in any of the other slots. Maybe it was on the ward clerk's desk, awaiting execution of an order for lab tests or an adjustment of treatments. But no one except Sara or her resident, Luke Sutton, would have written such an order. And Luke was out today, at home nursing a lower respiratory infection that appeared to verge on pneumonia.

"Dr. Miles?" Sara turned to see Janice, one of the ICU nurses, holding out a chart. "Are you looking for Chelsea's chart?"

Sara took the proffered chart. "Thank you. Is there something new?"

"Dr. Ingersoll and Dr. Pearson were here earlier. They started Chelsea on EpAm848. Dr. Pearson drew her baseline labs himself, and then sat with her while she got the first dose of her medicine. You just missed him."

Sara took a deep breath. The good news was that Chelsea was now getting the antibiotic that could save her life. The double-barreled bad news was the possibility of a side effect or complication—all the reassurances notwithstanding—as well as the likelihood that her ex-husband's bedside manner hadn't improved. Sara hated to think of the psychological damage Jack Ingersoll might have inflicted on the sixteen-year-old girl in that bed.

Sara thanked Janice and carried the chart with her into Chelsea Ferguson's room. In stark contrast with her attitude when Sara left her this morning, Mrs. Ferguson seemed calm and serene. She was brushing her daughter's chestnut hair. Sara wasn't sure—maybe this was wishful thinking—but there appeared to be a bit of color in Chelsea's cheeks, color that had not been there since the day of her admission.

Sara smiled at the mother and daughter. "The nurse tells me that Dr. Ingersoll was here earlier, and that you decided to go ahead with the drug treatment he offered."

Mrs. Ferguson looked up from her task. "He made an appearance, acting like we should be grateful that he spared us a few moments. I know that he must be affected by seeing so many seriously ill patients, but that's not an excuse for just plain rude behavior."

"I'm sorry. Dr. Ingersoll is a very busy man nowadays, and I'm afraid his bedside manner isn't the best. But he's the sole source for . . ." Sara paused and tried to choose her words carefully. "Dr. Ingersoll controls the use of the experimental drug that gives us the best hope of licking this thing."

"He put it a bit more bluntly than that." Mrs. Ferguson gave a particularly vigorous swipe with the brush, and Chelsea flinched. "Sorry, dear."

"But Chelsea's receiving the medication. That's all that matters now."

"Thank goodness for that nice Dr. Pearson. He told us what to expect, answered our questions, and sat with Chelsea while she got her first dose of the medicine. I think he's the one we'll actually be seeing." She laid aside the brush and kissed her daughter's forehead. "At least, I hope that's true."

"Yes, I suspect Dr. Ingersoll will be by from time to time, but you'll see Rip—that is, Dr. Pearson—on a regular basis. If you need anything, ask the nurse to page him or me."

"I'll do that." She patted her daughter's arm, carefully avoiding the IV site. "Chelsea, I'm going to step out for a minute, maybe get a cup of coffee at the nurses' station. Are you okay?"

"I'm fine, Mama." The voice was weak, but these were the first words Sara had heard her patient speak in over twentyfour hours, and to her they were beautiful.

In the hall, Mrs. Ferguson took Sara's arm in a grip that was surprisingly strong for such a frail woman. "Is there anything I can do to report the way Dr. Ingersoll acted? He seemed to have no more feeling for Chelsea or me than he would for a lab animal."

"I'd wait until Chelsea's on her way to recovery. There'll be plenty of time to lodge a complaint with the right people in administration then." Sara thought about it. "I'll be happy to help you do it then."

"All right. But I'll hold you to that. Really, I don't care how important that man is. There's no excuse for being so callous."

Sara nodded her agreement while scenes unfurled in her mind, scenes she'd tried hard to put behind her.
If you only knew . . .

"What's so important?" Rip Pearson stirred his coffee, even though he took it black. He recognized it as a nervous habit, but in his stress-filled world nervous habits were the norm. He'd deal with them after he finished his fellowship.

Carter Resnick rubbed his head as though checking to see if his hair had grown back. Then he put both hands on the table, leaned forward, and whispered, "We should talk."

Rip put his hand behind his ear. The noise level in the hospital cafeteria was such that even the two nursing students at the next table had no chance of hearing this conversation.

"Speak up. We're not exchanging state secrets here. What's on your mind?"

"I think Dr. Ingersoll is lying about that second ID fellowship slot."

Rip shrugged. "How would you—how would anyone know? I mean, he applied for it and now it's up to the folks who make decisions like that."

"I'm getting a lot of computer experience in the research lab. After some digging around, I'm able to get into sites that are supposed to be protected. Anyway, I hacked the records of the Internal Medicine Board and there's no mention of such an application. Ingersoll never submitted it."

Rip was ashamed of the first question that popped into his mind, but he asked it anyway. "What about my slot? Is it approved? Will I be able to take my ID boards when I finish?"

Resnick's grin was almost evil. "I really ought to make you sweat, but I won't. Yes, your fellowship is on the up-and-up. But how does it make you feel, working for a liar?"

Rip didn't know what to think. His first reaction was that the research assistant was getting a little revenge on the man who'd beat him for the fellowship. Was Resnick trying to push Rip toward resigning so he could step into the slot?

The silence hung between them for what seemed like several minutes, although it was probably more like a few seconds. Finally, Rip said, "I don't believe you. And even if I did, I don't think I'd do anything about it. If I were you, I'd keep this to myself, especially the part about hacking into the Internal Medicine Board site. I doubt whether the administration of the medical center would condone such activity."

He left without another word. At the door, he looked back. Resnick was still sitting at the table, grinning.

I
DON'T SEE WHY THIS MEETING WAS SO IMPORTANT THAT
I
HAD
TO DROP my patient responsibilities and fly out here." Jack Ingersoll slapped the conference table, almost upsetting his coffee cup.

Bob Wolfe sat back in his chair, automatically withdrawing from Ingersoll's "in your face" attitude.

"Did you hear me?" Ingersoll asked through clenched teeth.

Wolfe worked to keep his voice level and his demeanor calm. No need to spook the doctor . . . yet. "Jack, I thought it was important that you understand what's going on. It's been made very clear to me from top-level management at Jandra that the fate of the company is riding on the success of Jandramycin."

"What's Jandramycin?"

"That's another thing. From now on, the drug is no longer to be referred to as EpAm848. We're calling it Jandramycin. The bigwigs want the public to identify the drug with our company when they hear about the preliminary results of our studies."

Ingersoll hit the table again, and this time his cup rocked in its saucer. A few drops of coffee sloshed onto the table. He stabbed at them with a napkin. "The public isn't going to hear about our preliminary results yet. That's why they're called 'preliminary.' Apparently you've forgotten how all this works. We're doing Phase II studies right now, seeing which dose works best, which ones might cause side effects. Then comes Phase III, where we compare EpAm848 with placebo or other drugs. Considering the severity of the disease we're treating, we may be given permission to omit the placebo, maybe even do a case-control study with only EpAm848—I mean, Jandramycin—as the active drug. But this stuffwon't be available for general use for a couple of years. Probably longer than that before the FDA approves it."

With the look of Santa pulling one last present, the big one, from his bag, Wolfe said, "I'm way ahead of you. We've pulled a few strings and made a deal or two—the FDA will accept the data from your work and the two European studies as fulfilling both the Phase II and the Phase III requirements."

Ingersoll leaned back as though he'd been hit. "How did you manage that?"

"You don't need to know the details. What you do need to know is that, as we speak, our factory is working twentyfour-hour shifts to produce and package Jandramycin. Our PR department has its best people creating a campaign that will blow the public's mind. And our detail men are poised to hit the streets and spread the word."

"But—"

"Now listen, and listen closely." Wolfe tapped the table in front of Ingersoll with his spoon to emphasize his words. "Up to now, Jandramycin looks like a miracle drug. That's why you're such a fair-haired boy in the medical community." He pointed to the bound journals on shelves that lined one wall of the room. "Your work is going to catch everyone's attention. Lead article in the major medical journals. Lots of interest from the press. That is, if you cooperate."

Ingersoll opened his mouth, then shut it again.

"From this point onward, there can be absolutely no hint of side effects, complications, or therapeutic failures with Jandramycin. It's up to you to make sure that happens." Wolfe's voice dropped to a near-whisper, but the words came out like steel darts: "You may think you're important because you stumbled onto a use for a compound we thought was useless, but if you foul up now, you can kiss that big research grant, your paid lectures, and all the other perks of your relationship with Jandra good-bye. Not only that, we'll see to it that you can't even get a job in an emergency room in Pocatello, Idaho. Provided you're still around to see it happen."

Sara yawned. Even the ultra-strong coffee of the hospital cafeteria wasn't enough to counteract the effects of a sleepless night. She looked at her watch. Time enough to finish breakfast and get a second cup of coffee to take to the conference.

"Mind if I join you?" The question was apparently rhetorical, since Rip Pearson had already pulled out a chair and was depositing his tray across the table from her.

"Actually, I've been wanting to talk with you. This is the second day that Chelsea Ferguson's been on your 'wonder drug'— what is it? EpAm something. She seems to be better, but how does Dr. Ingersoll think she's doing?"

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."