The Perfect Predator

by Steffanie Strathdee

Tom slept a few hours, and at dinnertime I tried to rouse him. He groaned and waved me off, wanting to sleep.

  “Aren’t you feeling any better at all?” I asked him. He shook his head no. I tried to coax him to drink some soup, but he wouldn’t eat anything.

  His stomach was a distended balloon. Over the next few hours, he continued to vomit. He hadn’t eaten in nearly twenty-four hours, and this nonstop barfing seemed humanly impossible.

  “My back is killing me,” he whispered.

  “Your back?” That was surprising—definitely not a symptom related to food poisoning. Was the bed bothering him from lying in it so long, or was this something else? Tom grimaced.

  “Yeah, the pain, it’s—it’s like a band radiating from my stomach around to my back.”

  That rang a bell but I couldn’t remember where I’d heard it. Later, when I closed my eyes and tried to doze, it came to me. A few months earlier, one of our cats, Madame Curie, went off her food and started vomiting. After a few days, when I picked her up to put her in her cat kennel to take her to the vet, she wailed when I touched her stomach and her back. The vet’s initial diagnosis was pancreatitis, inflammation of the pancreas, although she could not pinpoint the cause. Poor little Curie died a few days later. Granted, a cat’s anatomy was a far cry from a human’s, but maybe Tom didn’t have food poisoning. Could he have pancreatitis? I did what anyone else would do in my shoes. I googled it. Within seconds, my cell phone lit up in the dark and listed the symptoms: vomiting, stomach pain, back pain. Shit.

  I texted Chip again.

  Got a min? Tom is worse & now has back pain. Could this be pancreatitis?

  Chip texted me back within five minutes and asked me to call him. After I brought him up to speed, his tone was no longer jovial.

  “It could indeed be pancreatitis, or it could be a twisted bowel—the other possibilities are worse. Get him to a hospital. Make sure they take you to wherever the expats and tourists go. And Steffanie—call now. Stat.”

  Shaken, I hung up to tell Tom he’d been overruled. He needed to get to a hospital, and there was no way I’d be able to get him down that spiral staircase, across those docked ships, and up those sloping steps in the dark to the landing and into a cab for a ride to the local hospital by myself. We needed an ambulance. But there was no calling 911 in Luxor. In fact, the town didn’t even have a hospital. I rang Khalid, who in turn called Dr. Busiri. He insisted on examining Tom again before we did anything further. By the time he arrived, it was eleven thirty p.m. Dr. Busiri took Tom’s vitals and frowned.

  “His heart rate remains elevated and his blood pressure is dropping. We need to get him to the clinic immediately,” he said to me, calmly and quietly. “Your husband is going into shock.”

  So was I.

  5

  LOST IN TRANSLATION

  Luxor, Egypt

  November 29–December 3, 2015

  Like pallbearers on a frantic midnight mission, the eight men gripped the gurney, Tom strapped to it, as they scrambled across the three ships moored between ours and the dock, then up the ancient stone steps to the loading dock. At the top, the ambulance waited in a glow of yellow flashing lights. A clutch of onlookers stood watching the scene before them, and some peered in after the men hoisted Tom and his stretcher into the back. Khalid had helped carry Tom up, but now darted to his tour company car to meet us at the clinic. I clambered into the ambulance next to Tom and Dr. Busiri.

  The roads across town to the clinic were ragged with potholes, and with each jolt, Tom howled in agony.

  “Can’t you give him something for the pain?” I asked Dr. Busiri.

  “Not until we know what the problem is,” he replied.

  Just the assumption that we’d soon have a diagnosis was reassuring in and of itself. By my thinking, once you know what a problem is, you can figure out how to solve it, right?

  It was one a.m. when the ambulance pulled up at the clinic. The street was mostly deserted, but it was clearly a major corridor for traffic during the day. Set in a small storefront, the reception area opened up to a series of smaller rooms and an operating theater that was accessed through a swinging set of double doors. I looked around the spartan surroundings with a sense of foreboding. Tom was wheeled into the operating theater on the stretcher, with me and Dr. Busiri close behind. The room was full of empty bed frames, a few of which were equipped with thin mattresses.

  Waiting to greet us were the clinic’s gastroenterologist, a radiologist, and a cardiologist, all of whom were bleary eyed, having been called to the clinic for this emergency case involving a tourist. They were all deferential to Dr. Busiri, the medical director of the clinic, which was only one month old. This makeshift space was a temporary treatment center until the full remodeling on the larger facility nearby was complete. Whether the stripped-down look of the place reflected limited resources or its temporary status wasn’t clear.

  The staff instantly went to work, taking Tom’s vitals, hooking him up to a cardiac monitor, and drawing blood.

  “Why are we in an operating room?” I asked, all the more unnerved by the sound of the fear in my own voice.

  “Because this is where our cardiac monitor is,” Dr. Busiri replied sheepishly. It was the only one in the clinic. “But here, he can also be carefully monitored since he is in front of the nurses’ station.” That was more reassuring.

  “What tests are you running?”

  “We are drawing blood to test for cardiac enzymes,” Dr. Busiri replied. I drew a blank and it must have registered on my face. “To rule out a heart attack,” he explained. “Judging by his size, he is at considerable risk.” He gestured to Tom’s stomach, which was even more distended than it had been just a few hours earlier. The possibility of a heart attack had not even occurred to me; inwardly I started to panic.

  “But we will also test for lipase, a pancreatic enzyme that can be diagnostic of pancreatitis. We will have these tests back within the hour.”

  Before leaving us, he motioned for the gastroenterologist, who inserted a short, flexible length of clear tubing into Tom’s right nostril.

  “What’s that for?” I asked.

  “It’s a nasogastric tube. It will prevent him from vomiting further,” Dr. Busiri replied, as his colleague finished the brief procedure, snaking the tube down through Tom’s esophagus to his stomach. Instantly, the tube began to siphon off a dark greenish brown fluid into a clear collection bag that hung by his side.

  “Bile,” Dr. Busiri said.

  I shuddered at the sight and then saw Tom watching me. He was always the first one to make a joke in the worst of circumstances, and feeling helpless to do anything useful at all, I tried to lighten the moment.

  “Hey, honey, just think of the god Anubis trying to suck out your brains through this tube.” Tom’s eyes widened in fear, as if he thought I was serious. With a rising sense of alarm, I realized that he did. He was growing delirious.

  Dr. Busiri looked incredulous at my poor attempt at humor and changed the subject.

  “You have health insurance, yes?”

  I nodded.

  “It would be good to call them.”

  We had each spent $36 on the university’s travel insurance for this trip. I could only hope it would be enough to get us through whatever lay ahead; we had never needed to use it before. I plugged my cell phone into the wall of the operating room to charge it before making the call, but the outlet didn’t work. I tried another outlet; no juice. I finally found one at the far end of the room, where I needed to prop the phone up so it would stay plugged in.

  At UC San Diego, I was a global health expert—a “muckety-muck” as Chip referred to me—but the professional was about to become the personal in this resource-stretched clinic. It was easy to take so much for granted in our medical system and institutions. Now we were in a country where many of the essential resources for a medical setting—resources like reliable access to electricity or some routine meds—were not a given. />
  An hour passed. Tom drifted in and out of sleep, the phone and internet reception flickered in and out, and my confidence began to waver, too, as I began to grasp the seriousness of the situation and my own limitations of knowledge and experience. Finally, Dr. Busiri burst through the double doors with a triumphant exclamation. “We have the diagnosis!”

  Tom’s lipase levels were three times normal, which confirmed acute pancreatitis. He would still need a CT scan to rule out a bowel obstruction, Dr. Busiri explained, but that would have to wait until morning. The only CT clinic was about ten minutes away, and we’d need to wait for a cancellation to fit Tom in.

  “In the meantime,” Dr. Busiri said, “get some sleep.”

  As he stepped out, a female nurse dressed head-to-toe in traditional garb stepped in and greeted me, in Arabic. The hijab covered her head, framing her face, which heightened the contrast with her dark, charcoaled eyes. With her help, I was able to find a sheet and a pillow for Tom. I rolled up my sweatshirt in a makeshift pillow for myself. I’d be sleeping on a gurney next to Tom’s. His and Hers.

  Once Tom was given morphine for his pain, he fell into a deep sleep. I watched him breathe and listened to the steady beeps of the monitors, the squeak and slam of the double doors as the nurses tended to other patients, and the swish of a mop from a young man who kept the clinic looking spotless. The sounds of suffering needed no translation. It would be a long night for us all.

  Periodically the nurses stepped in, took Tom’s vitals, and spoke among themselves outside the room. They spoke Arabic only, and I didn’t, so there was nothing I could glean from them about Tom’s condition. The doctors were fluent in English, having mostly been trained in Cairo, but even so, I was discovering that the technical medical terms for what was unfolding were another foreign language. Each round of tests brought a new glossary of terms. Blood tests were done to measure biomarkers, naturally occurring chemicals in the blood, and terms like bilirubin, and LFTs—liver function tests—were a continuing thread in the conversation. Troponin, a cardiac enzyme, was monitored regularly. The biomarker CRP—C-reactive protein—which is a sign of inflammation, was much higher than normal. In this crash course in medicalese, the vocabulary was spelling trouble.

  All of the nurses were female and wore the traditional hijab, with several of the youngest wearing shrunken sweaters on top of their flowing robes, a stylish Western accent to their wardrobe, along with high-heeled shoes. Although only their faces showed, their eyes were lined heavily with black kohl, mascara, and eyeshadow, and their lips glistened with bold red lipstick and gloss. They giggled coquettishly whenever the doctors were around and paid us little attention. Their appearance was a stark contrast to me with my bare face and dirty ponytail, wrinkled T-shirt, casual cotton skirt, and flip-flops. The Vogue magazine buried in my duffel was as close as I got to fashion these days.

  Retreating to the corner of the operating room to avoid waking Tom, I called the travel insurance company and explained our plight. I connected them with Dr. Busiri by email so that they could negotiate payment. Next, I texted Carly and Frances back home to tell them their pops was sick but that so far, everything was under control. I hoped I was right. Carly was in her early thirties and Fran in her late twenties, so both girls had plenty of prior experience with their intrepid dad’s run-ins. With any luck, Tom would be treated and we could fly home within the next day or two. His track record for luck made that a reasonable expectation, despite all appearances to the contrary. He’d seen worse and lived to tell the tales.

  I closed my eyes and said a little prayer. Please, God, please let Tom be okay. And please get us home safe and sound. I could hear a few other patients in the clinic down the hall, groaning and retching. It seemed like everyone was calling out in pain, Tom included. He woke every few hours and gripped his belly. If I didn’t request more pain meds, he wasn’t offered any. In the States, plentiful supply and routine overprescribing had helped create the opioid crisis. Here, they had to be frugal to a fault. I tried to limit my requests, but Tom’s pain was worsening.

  In the morning, Dr. Busiri paid us a visit. He looked like he hadn’t slept, either. He had managed to work out the payment with the travel insurance, which was a relief. He examined Tom and started him on a new round of antibiotics, which he described as a third-generation cephalosporin. I knew this drug was a riff on penicillin, the first antibiotic, discovered in 1928 by Scottish scientist Alexander Fleming. It happened to be one of my favorite stories in the history of science: how Fleming made the landmark discovery that would transform how bacterial infections would be treated in the twentieth century and forever, the world over.

  Fleming was already a respected scientist in 1928, but cleanliness was not his strong suit. I could relate. I had abandoned my early dream of being a microbiologist because, as a summer student, I kept contaminating my lab samples. In his lab, Fleming kept some Petri dishes filled with agar, a bench scientist’s version of Jell-O, and an ideal medium for growing bacterial cultures. According to Fleming’s account, he left the lids off when he went away on vacation, and when he returned a few weeks later, one of the Petri dishes was pocked with a hairy greenish fuzz. Mold. Most scientists would have just thrown the plates out, reminding themselves to be a little tidier but missing their significance. But Fleming was a keen observer and noticed something unusual. On the agar around the green mold was a clear zone where no bacteria were growing; he remarked later that it looked like the bacterial colonies nearby were dissolving. This discovery formed the basis for his paper on the inhibitory effects of Penicillium notatum mold on so-called Gram-positive bacteria, published in 1929, naming the active agent penicillin. Gram-positive bacteria, named for the scientist who created a test to classify them, include the staphylococci (staph), streptococci (strep), Bacillus anthracis (anthrax), and the bacteria responsible for diphtheria (Cornynebacterium)—some of the deadliest bacteria of the time. (Gram-negative bacteria include E. coli, Salmonella, Shigella, and Legionella.)

  You’d think a major discovery like Fleming’s would have had the drug developers tripping over themselves to scale up penicillin for the masses. But he had a hard time getting chemists interested in working on his strange “mold juice,” which was proving difficult to produce as a stable, consistent product that could be manufactured for wide-scale use—and profit. It was a classic case of the difficulty in taking novel scientific findings from bench to bedside, and a few years later, he gave up trying. Not having been the kind of guy to toot his own horn, his paper was scarcely noticed for nearly a decade. Meanwhile, millions of people were dying from what were later considered to be run-of-the-mill bacterial infections. Among them was my great-grandmother, who died of appendicitis around 1930, when my grandma was still a schoolgirl.

  By the late 1930s, efforts to isolate and purify penicillin were finally taken up by several other scientists, including Drs. Howard Florey, Ernst Chain, and Norman Heatley at Oxford University. They worked under austere conditions during the heart of World War II, growing penicillin in the likes of metal tins, tubs, and bedpans under the constant threat of Nazi bombing raids. Once it was realized that penicillin could potentially cure abscesses, gas gangrene, tetanus, and diphtheria, the mold was treated as a war secret. So dire was the threat of losing their potential miracle drug to the enemy or having the lab blown up in a blitzkrieg that Heatley thought of an ingenious way to save the culture: they rubbed the mold on their lab coats so that its spores could be recovered and recultured if necessary.

  After Florey and Heatley absconded to the US to seek help manufacturing penicillin, it was used to treat Anne Miller, a thirty-three-year-old woman in Boston dying of sepsis, a life-threatening complication of infection, following a miscarriage. Her miraculous recovery in 1942 signaled a new era of antibiotic therapy that was to revolutionize medicine. Fleming, after receiving the Nobel Prize in 1945 for his discovery along with Florey and Chain, warned that bacteria could become resistant to penicillin if t
oo little or too much were used. But his warning would go unheeded in the excitement over the first “broad spectrum” antibiotic that could successfully treat many infections before they were even diagnosed. Worse, the eventual large-scale use of antibiotics as growth enhancers in livestock, a vastly bigger commercial market than medical use, was a factor that ultimately triggered widespread antimicrobial resistance. Moving through the food chain from livestock to farm workers, meat, and then consumers, antibiotic-resistant bacteria shared their resistance genes with other bacteria everywhere along the way. Today, it is common knowledge that many bacteria have become resistant to penicillin and many other antibiotics. These superbugs have become a menace, especially in hospital settings, where the vulnerable patient population makes a fertile ground for bacteria. I could only hope that if it was an infection that had led to Tom’s pancreatitis, that this third generation of a World War II miracle drug would hold it at bay.

  Dr. Busiri seemed concerned but confident as he continued taking Tom’s medical history. Then he glanced around us, leaned in closer to Tom, and spoke in a hushed tone.

  “I need to ask you a sensitive question,” he said to Tom. “Do you drink alcohol, and if so, how much and how often?” He asked this the way a doctor back home might ask if we shot heroin. Tom rolled his eyes and motioned for me to reply in his stead. I was getting used to it.

  “Yes,” I said, a little too cheerfully perhaps, but it was the first easy question we’d come to. “We drink wine. Often. I can tell you exactly how much he drinks. Each day, we open a bottle, and I let him have one glass.” Dr. Busiri turned from Tom to me.

  “You let him?” He shook his head, as if in disbelief—whether over my role as a woman who gave orders to my husband or a wife who allowed alcohol consumption wasn’t clear. Regardless, he clucked disapprovingly. “Well, no more alcohol. The pancreas is very sensitive.”