Lethal Remedy (5 page)

Rip looked at Sara. They both knew what that meant. They didn't have thirty-six or forty-eight hours to wait before starting treatment. They had to begin antibiotic therapy
now.

Sara thanked the tech and they both began to make their way back to the ICU. "Does your drug, whatever the name is, have any effect on
E. coli?"

"It's EpAm848, and the answer is that nobody knows for sure. We've only used it against
Staph luciferus.
But look at it this way. If it were effective against
E. coli,
we wouldn't be having this conversation. This wouldn't have developed."

Sara bit her lip. "I'm at fault here. I didn't keep an eye out for other causes of Chelsea's fever and all her other symptoms. She's probably had that urinary infection for several days. If I'd remembered to do repeated urine cultures, we'd have caught this earlier."

"Don't beat yourself up. We can't be perfect. No doctor can. The important thing is that we've caught it before she went into profound shock and developed multiple organ failures. We can still treat her and bring her through this."

"Okay. You're the ID specialist. What empiric antibiotics would you use for
E. coli
infection like this?"

Rip ran through the index cards of his mind. "I'd go with an IV quinolone like levofloxacin. And, even though we don't see any evidence of anaerobic infection, I'd add clindamycin until we get the results of the cultures, both urine and blood."

"I agree. Do you want to write the orders?"

"Sure."

"Does this mean you have to stop the Ep whatever?" Sara said.

"I don't know. It's never been given with other antibiotics, so I don't know what could happen. But if we stop EpAm848 now, the
Staph luciferus
could start up again."

"I have to leave the decision to you," Sara said.

And whatever I choose will probably be wrong.
Putting aside the question of one antibiotic rendering the other useless, what was Jack Ingersoll going to say when he found that one of his precious study patients had been compromised? What if there were complications? How could a researcher tell if they were due to the EpAm848, the other medications, the disease itself? The patient would be dropped from the study. And to Ingersoll, every patient in the study was pure gold.

If he were here, Rip was pretty sure what Ingersoll's decision would be: Don't give anything more. He'd argue that EpAm848 was a strong antibiotic. It might be enough by itself to combat the sepsis. Just give supportive care, use IV fluids and vasopressors, administer oxygen. Give the drug a bit of time and it could pull the patient through. Another triumph for EpAm848. Another feather in the cap of Jack Ingersoll.

Rip could call Ingersoll's cell phone. Tell him the situation. Leave the decision up to him. Doing this on his own would expose Rip to his mentor's wrath big-time. He might even lose his fellowship because of it.

They reached the ICU and pushed through the doors. Both doctors were silent as they approached Chelsea's bedside. Rip nodded to Mrs. Ferguson, who continued to maintain her bedside vigil, one hand lightly touching her daughter's arm. The mother's lips moved in what Rip took to be silent prayer. He added one of his own.
Please, Lord, help me make the right choice.

He looked at Sara. Then he reached down and smoothed the hair that had fallen onto Chelsea's forehead. He took a deep breath. "Mrs. Ferguson, Chelsea has another infection—a serious one in her urinary tract. It's caused her blood pressure to go down. If the infection is left unchecked, it could put her in grave danger. I think we can get on top of it, but to do that, we're going to have to use some additional medications."

"Does that mean she won't get any more of the drug you've been giving her? Until today, it seemed she was getting better."

"No," Rip said. "I promise you, she'll keep getting the EpAm848 as well." He hoped he could deliver on that promise.

The phone dragged Dr. John Ramsey up from a dream of walking through a field of bluebonnets with Beth.
No, please, I don't want to leave. I just got her back.
The ringing continued, and gradually reality took hold. Beth was gone. He'd never see her again this side of heaven. Sometimes—actually, often—he wished he could go there now. He'd never gone further than the idle thought, but now he understood why men and women who'd lost their spouses after many decades of marriage might find their will to live gone.

He pushed himself up offthe sofa and blinked at the TV. The program he'd been watching had long since given way to two people arguing in front of a judge. With one hand he used the remote to silence the set; with the other he lifted the receiver. "Dr. Ramsey."

"Dr. Ramsey, please hold for Dr. Schaeffer." The female voice was much too perky for John. His mood was dark, so everyone's should be. He grunted a response and flexed his aching back muscles.

"John, this is Donald Schaeffer. I hope I didn't catch you at a bad time."

John's nerve endings tingled, and suddenly he was fully awake. "No, no. Just sat down to let my lunch settle and began watching a documentary on the Learning Channel." There was no need to let Schaeffer know the TV had been tuned to a
MASH
rerun.

"I've pulled every string I could, but there's no way I can swing an extra faculty member at this time."

John's stomach did a back flip, and for a moment he was afraid the few bites of grilled cheese sandwich he'd choked down at lunch would come right back up. "Thanks, anyway," he mumbled. "I guess—"

Schaeffer continued as though John hadn't spoken. "But I believe I can manage a part-time position for you. We're short in the GIM clinic, and you could pick up that slack for the next six months or so. By that time, we'll be into the next fiscal year, and I think I can swing a full-time appointment if it works for both of us."

"General Internal Medicine sounds right up my alley, Donald. After all, that's what I did for forty years. How soon can I start?"

"Why don't you come by tomorrow and see Kim, my department administrator? She can work out all the details."

"I don't know how to thank—" John realized he was talking to a dead phone. Schaeffer must have moved on to another of the message slips on his desk. He probably wouldn't think about this one again until he saw John in the halls of the department. But John would think about it constantly. Maybe this was the rope he could use to pull himself out of the depths of depression. He bowed his head.
Okay, God. You came through on this one. But I still don't think we're even.

L
ADIES AND GENTLEMEN, WELCOME TO FLIGHT
1084,
FROM
S
AN
F
RANCISCO
to Dallas."

Jack Ingersoll ignored the instructions that followed. He closed his eyes and prepared to enjoy the flight. Jandra had sprung for a first-class ticket, and when he got to the gate he was happy to see that the aircraft was a 757. Although there'd been a time when he enjoyed travel, with familiarity had come first boredom and then actual distaste. Now, when travel was necessary, he wanted as many creature comforts as possible for the journey.

As soon as he felt the plane lift offthe runway, Ingersoll reclined his seat and settled back. He brushed aside the flight attendant's offer of a drink. He hadn't slept last night, replaying in his mind his conversation with Wolfe, but alcohol wasn't going to be the answer. Besides, he didn't want to be muzzyheaded when he reached Dallas. He'd need his wits about him as he tried to impress Dr. Pearson with the importance of making sure no adverse data crept into the reports of the EpAm848—that is, the Jandramycin cases. He was going to have a hard time getting used to the name, but he supposed it would help remind him of how much was riding on the success of this drug.

He checked his watch. Mid-morning in San Francisco. With the two-hour time difference and the length of the flight, there was no reason to consider going to the medical center after he landed. Even Pearson, never one to punch a time clock, would be gone by then. Tomorrow would have to be soon enough.

Ingersoll pushed the call button.

"Yes, sir?" One nice thing about flying first class. The service was much better than what one got back in coach.

"I've changed my mind. I'll have a glass of white wine."

He really should have called Pearson yesterday afternoon to check on the progress of his latest patient, but after his meeting with Wolfe, all Ingersoll wanted to do was go somewhere and clear his mind. He'd wandered the streets of San Francisco aimlessly for hours, had something totally forgettable from room service, and had fallen into bed to stare at the ceiling for most of the night. At least Jandra had been decent enough to put him up at the Sir Francis Drake. On previous trips, his hotel was a La Quinta in Berkeley. He should have known something was up when they gave him his travel itinerary and he saw first-class travel and a nice hotel. First the carrot, then the stick.

In addition to Wolfe's veiled threats, Ingersoll already had something to worry about, something he had to keep forcing from his consciousness. Even though Jandramycin—there, he remembered the word—Jandramycin was considered a true wonder drug, the Jandra researchers had only been able to postulate its mode of action. Not unusual, since sometimes the mechanism of action of a drug was clarified months, even years after its introduction, as data accumulated. Well, that suited him just fine. He knew exactly why it worked, and that knowledge was something he meant to keep to himself as long as possible. That and a few other things as well. Meanwhile, he would continue to build his reputation.

He reached for his headset, ready to dial in some music, when an announcement rang through the aircraft. It was distorted a bit by a less-than-perfect PA system, but the message was clear. "Ladies and gentlemen, is there a doctor on board?"

Ingersoll was always careful to balance the perks that might go with being recognized as a doctor with the responsibilities that accompanied that recognition. He reached into his shirt pocket and sneaked a glance at the name on his boarding pass: Jack Ingersoll. No MD after his name, no Dr. before it. He was safe.

Five minutes later, there was another announcement, and this time the flight attendant's voice had an edge. "Ladies and gentlemen, this is urgent. If you're a doctor, please make your way to the aft galley. Thank you."

The passengers in the first-class cabin stirred and looked around, each one apparently wondering if there was a doctor among them. No one moved. Ingersoll felt, almost heard, a collective sigh of relief go up. Not just that they were spared the responsibility of tending to someone who'd fallen ill, but that they'd escaped that fate themselves. They'd survived for one more hour, most likely for one more day, God willing for one more month or year. But life was fragile, and never seemed so much so as when someone else's life was threatened.

From his seat in the last row of first class, Ingersoll craned his neck and looked down the aisle. A stocky black man on the aisle ten or twelve rows back beckoned a flight attendant over and said, loud enough for Ingersoll to hear him, "I'm not a doctor, but I'm an EMT. Can I help?"

"Yes, please. We think one of the passengers is having a heart attack. I was about to get the AED and take it back."

Great. A heart attack, and apparently they'd be using the automated external defibrillator. Ingersoll could almost write the scenario that was about to play out.

Twenty minutes later, his fears were confirmed. "Ladies and gentlemen, this is your captain. I'm sorry, but we're diverting to the nearest major city, Las Vegas, for a medical emergency. Please remain in your seats for the balance of the flight. We'll give you more information as soon as it's available."

Ingersoll craned his neck to look at the rear of the aircraft in time to see the lead flight attendant replacing the AED in its case, and the EMT spreading a blanket over a form stretched out in the aisle. Good thing he hadn't volunteered his services. He probably couldn't have done more than the emergency medical technician, and undoubtedly the paperwork at Las Vegas would be a nightmare. He just hoped he wasn't going to be delayed too long. Then again, he supposed a night in Las Vegas wouldn't be all that bad.

Sara scanned the numbers on Chelsea's chart. Fever coming down. Blood pressure holding stable now. Twenty-four hours since adding the additional antibiotics to the girl's treatment regimen, and Sara could hardly believe how much improvement she saw. Had they made a good guess in choosing empiric therapy, or was EpAm848 making a definite difference in the septic shock, as well as the
Staph luciferus
infection?

"How are you feeling?" Sara put her hand to Chelsea's forehead and was gratified to note that it was much cooler.

"Okay, I guess." Was Chelsea's voice stronger, or did Sara imagine it because she wanted to see signs of recovery? No, she definitely seemed better.

As usual, Mrs. Ferguson was at her daughter's bedside. "Whatever that new medicine is, I think it's helped. She seems stronger. And she actually ate a little this morning." She forced out what was probably her best effort at a smile.

"How's the patient this morning?" Sara made room for Rip at Chelsea's bedside and handed him the chart.

"Seems better," she said. "Check out her temp and vital signs."

He nodded his approval. "Looking good."

With a promise to return that afternoon, the two doctors stepped outside and settled into chairs at the nurses' station. Rip said, "I need to get some follow-up labs."

"What do you want? I'll order them," Sara said.

"Nope, I've got to draw them myself. That way, I'll know the blood gets to the right places."

"Places?" Sara asked. "Where will it go besides the hospital lab?"

"Some of it goes to Ingersoll's lab. Those tests are part of the study, and apparently part of his deal with Jandra is that they fund his own private research lab."

"Where is it? I thought I knew where everything was in the internal medicine department."

Rip gestured vaguely to the north. "He negotiated for some space in the Parkland Hospital building. Nobody is allowed in but Carter Resnick and the one tech that works there. I have to call over and let them know I'm coming. Then I knock, hand over the tubes of blood, and have the door slammed in my face."

"Why all the secrecy?"

"Sara, you know Jack Ingersoll as well as I do—probably better. What's his first priority?"

Sara didn't even have to think about it. "Jack Ingersoll."

"Right. And the fewer people who know about his research, the more secure he feels. I maintain the case log, but all I do is chart the patient responses and enter the lab results I'm given."

Sara pondered that for a moment. "That makes me wonder. If Jack wanted to keep any data hidden . . ."

"No, there are two parallel studies going on in Europe. Jandra sends updates to Ingersoll on a regular basis. The results are pretty much the same as the ones we're seeing. Almost identical, in fact."

"But you don't correspond with those investigators?"

"Don't even know their names. Jandra is keeping all that under wraps."

Sara decided not to pursue the matter. For now, it was probably enough that Chelsea was improving. There might be a firestorm when Ingersoll returned and discovered that two antibiotics had been added to his patient's treatment regimen, but she'd deal with that when it happened. She'd handled Jack's tantrums before. As for the secrecy . . . well, if Jack was hiding anything, it certainly wasn't preventing the EpAm848 from working yet another miracle, this time for her patient. And for now, that was enough.

Sara was deep in thought as she emerged from the medical center library. The force of the collision made her head snap up, and she found herself looking into kindly gray eyes that the lenses of wire-rimmed glasses couldn't hide. The hair was a little grayer, a little sparser. But the smile was still there, the one that had calmed her when the world seemed ready to crumble around her. "Dr. Ramsey. I'm so . . . I mean, I . . . What are you doing here?"

"Are you all right?" John Ramsey asked. "I'm sorry I collided with you. I guess I'm sort of preoccupied."

"I'm fine." She paused a beat. "Do you remember me?"

"Of course. Sara Miles. Or is it Ingersoll now? How have you been?"

She flinched inwardly. "It's Miles. I kept my maiden name. Which made it easier when Jack—" She hurried on before he could ask about that. "Never mind. I'm fine. After I finished my residency here, I was invited to stay on as a faculty member. I'm an Assistant Professor in Internal Medicine."

"Wonderful. Then we'll be colleagues. I'm retired, but I'll be joining the faculty part-time, working in the General Internal Medicine clinic."

"That's where I spend most of my time. And I look forward to working with you."

As she watched Ramsey's retreat down the hall, Sara was transported back to her senior year in medical school, to a time when she sat in Ramsey's private office and cried until she thought there couldn't possibly be any more tears in the world.

"I didn't get the residency I wanted," she snuffled. "I thought my interview in New York went really well. My grades are top 10 percent of the class. My letters of recommendation were perfect. Why didn't I get it?"

Ramsey had leaned back in his chair and tented his fingers. "Sara, you matched here at Parkland. That's a fantastic internal medicine residency, and I suspect there are about a hundred medical students who'd give their right arm for the opportunity you now have."