“Listen, I already have something going on tomorrow afternoon, and I don’t know how long it’s going to take. Can we talk about this another day?” “Sure. And while I have you on the phone, have you discovered anything more about Jandramycin’s side effects?” John Ramsey’s words came back to her. “He’s sharp, he’s solid, and you can trust him.”
Maybe three heads would be better than two. “Listen, are you free tomorrow afternoon?”
“Dr. Ramsey, are you ready to start seeing patients?” John wanted to tell Verna that he wasn’t ready, might never be ready again. You work for forty years and never have a complaint lodged against you, much less a malpractice suit filed, and then one day, Bam! You’re sued for trying to save the life of a woman experiencing a non-survivable event. He was ready to walk out of the clinic, go home, forget about practicing medicine. Instead, John did what he’d been doing for years, rain or shine, good mood or bad. He followed his calling. “Sure. Who’s first?” Somehow John made it through the morning, pleased to find that he was still able to compartmentalize, putting his personal worries into quarantine while his professional self handled problem after problem. “That’s it. You had one more patient, but he was a no-show.”
“Thanks, Verna. I’m going to return these phone messages, then I’ll get some lunch.” John sighed when he saw the pink slips Verna had left in his dictation cubicle, held down by a paperweight advertising the latest wonder drug from some pharmaceutical company or other. But first things first. He dialed the number for Mark’s office. After four rings, he heard the rhythm of the rings change and realized the call was rolling over to an answering service or voicemail. Oh, it’s lunchtime. He hung up without leaving a message and dialed Mark’s cell phone. John let it ring until he heard, “This is Mark Wilcox. Please leave a message.” “Mark, this is John Ramsey. I’ve been��� I’ve been served. I guess we need to talk. Are you available this evening?
Call my cell and leave a message.” John had hardly hung up when his cell phone vibrated in his pocket. Was Mark getting back to him already? “Dr. Ramsey.” “Doctor, this is Bill Alexander.” He’d almost forgotten about his earlier call to his malpractice insurance carrier.
Maybe his coverage extended to the incident at the medical school.
Maybe things were going to work out. A spark of hope flared. “Yes.
Thanks for getting back to me.” “You won’t thank me after you hear what I’ve found out.” The spark flickered and died, leaving nothing in John’s heart but a chill that no sun could warm. “Let me guess. I’m not covered.” The conversation lasted another five minutes, but the upshot was what John originally feared. His malpractice coverage was not in force for new events. And it was the opinion of the company’s lawyers that it was unlikely the medical center would cover the actions of an employee who hadn’t even officially gone to work yet. In other words, John was on his own. He thanked Alexander and hung up. He wondered what would happen if he just walked out, packed a suitcase, and took off for parts unknown. “John, God’s in control. Hang on.”
Beth’s words were as real as though she were in the room with him.
Those words seemed to be her solution for everything bad that happened in their lives: an employee who embezzled a huge chunk of money from his practice, the sudden deaths of his parents in a terrible accident, the news that John’s brother had terminal cancer. All these were times when he wanted to walk away from it all. And Beth always reminded him-God’s in control. So he’d hung on. And sure enough, things worked out. Maybe they would this time, as well. He squared his shoulders and began to work his way through the message slips. He was wrapping up a conversation with an insurance claims representative, trying to keep his temper in check while convincing her that the presence of asthma in childhood didn’t constitute a pre-existing condition in the case of a patient with pneumonia, when Verna appeared outside his door. He held up one finger in a “just a minute” gesture and ended the conversation, gratified that he’d been able to convince the sentry on the other end of the phone to let his patient pass into the realm of the insured. “What’s up?” he asked. “That no-show is here. I’m not sure how he got into the general internal medicine clinic, though.
He’s got an infected wound on his arm that looks pretty bad. Probably needs debridement and some antibiotics. Want me to send him to general surgery?” John was already on his feet. “No, he’s here. I’ll take care of it. In forty years of practice, I’ve seen my share of infected wounds.” The patient was a middleaged man, lean and tough as a buggy whip. He wore a flannel shirt with the sleeves rolled past the elbows.
A folded baseball cap peeked out of the hip pocket of his jeans.
“Sorry I was late, Doc. Had trouble with those valet parkers out there.” He pronounced the word valett. “Told ‘em I was gonna have to pay to see you, pay for my medicine, and I wasn’t about to pay for some guy to park my pickup when I could do it myself.” John smothered a smile. He’d had the same thought a number of times. “No problem.
You’re here now. Let’s see that arm. What happened?” While the patient related a story of coming out second best in a fight with a piece of rusty machinery at his auto repair shop the preceding week, John slipped on a pair of gloves and examined the man’s left arm. It was swollen, hot to the touch, red from the elbow to the wrist. A weeping crust covered a six-inch gash on the side of the forearm. “Thought it would be okay if I kept a bandage on it and used some of that antee-beeotic ointment. Looks like I was wrong.” “I’m going to clean that up and get you on some pills to fight the infection,” John said.
“I may have to snip away some dead tissue, but I don’t think it will hurt enough to need a local anesthetic. Think you can take it?” “I’ve had worse,” the man said. While Verna cleansed the wound with peroxide and painted it with antiseptic, John took the dirty bandage from the treatment table and looked around for a spot to dispose of it. Blood, tissue, pus, and similar material were to be placed in a special container, one that was lined with a red plastic bag prominently labeled “biohazard.” “Over in the corner,” Verna said, nodding in that direction. “Thanks.” John opened the container to drop in the bandage, but it hung on the rim. He swatted the dirty gauze into the almost overflowing bag, but when he did he felt a sharp pain in his hand.
“Ow!” “What happened?” Verna asked. John took a pair of forceps from the treatment table and stirred the top layer of debris in the biohazard bag. His throat tightened when he saw the glint of a syringe and needle peeking out of the container. He tried to keep his voice calm. “Verna, I’m going to need to talk with someone in Infectious Disease. Could you page them while I finish cleaning up this wound?”
“Sure. Is it about the antibiotic for this wound?” “No, it’s about our needle-stick protocol. It’s for me.”
“Jandra Pharmaceuticals, how may I direct your call?” The voice was cheery, but the inflection told Sara that this was a message the woman repeated a hundred times a day. “This is a doctor in Dallas, calling about one of your new drugs. Is there someone there who can give me some details about Jandramycin?” There was a moment’s silence.
“I’m sorry. I don’t believe we have a drug by that name. Are you sure?” Sara shrugged to relieve the tension that had become a permanent fixture in her shoulder muscles. “I’m sure. Jandra Pharmaceuticals, Jandramycin. Think about it.” She decided on a different tack. “Who’s your public relations manager?” “That would be Mr. Olson, but he’s on vacation.” Sara waited, but apparently that was as much help as she was going to get. “Okay, your director of research?” “That would be Dr. Wolfe. Would you like me to ring him?”
“Please.” If she says, “Have a good day,” I’ll scream. Just before the telltale buzz of a phone ringing, Sara heard “Have a good-” and gritted her teeth. It apparently wasn’t going to take much to get on her nerves today. But if she wanted to coax any information out of this Wolfe guy, she’d better be on her best behavior. “Bob Wol
fe.” The voice was a deep baritone, the accent definitely East Coast. “Mr.
Wolfe, this is-” “Dr. Wolfe. I’m a Pharm D.” “I’m terribly sorry. Yes, the operator did give me your title. I apologize.” “No problem. Who’s this?” “This is Dr. Sara Miles. I’m on the internal medicine faculty of the Southwestern Medical Center in Dallas. I have a question about Jandramycin.” This time the pause was long enough that Sara thought she’d been disconnected. Finally, Wolfe said, “If you’re at Southwestern, I’d suggest you talk with our principal investigator, Dr. Ingersoll. He’s on the faculty there, too. Would you like his number?” I’ve got his number. I know more about him than you ever will, you self-important-” I know Dr. Ingersoll, and one of my patients is in his study. That’s why I’m calling. She’s developed what I believe is a late complication from Jandramycin, but Jack��� Dr.
Ingersoll won’t accept that possibility. I need to know if there’s anything in the basic research that would suggest an association with-” “Stop. I don’t want to hear about this. Dr. Ingersoll is in charge of the project, and if he doesn’t think your patient’s problem is related to Jandramycin, the matter’s closed.” “You mean-” “Listen, Dr. Miles, if that’s really your name. How do I know you’re not from one of our rival companies, sniffing around for dirt so you can sabotage our new drug application? What you’re asking for is proprietary information. And you’re not going to get it.” There was a loud click. Why that self-important, self-centered, pompous-Sara took a deep breath and blew it out slowly through pursed lips. Who says Lamaze training can’t be useful except in labor? The phone in her hand came to life, and she heard a familiar female voice. “Jandra Pharmaceuticals. How may I direct your call?” “I think I was disconnected.” “To whom were you speaking? I’ll be glad to ring them back.” “Never mind. This time, would you ring your CEO or COO or whoever’s in charge there?” “That would be Dr. Patel. I’ll ring his office. Please hold.” This time Sara said it before the operator could get it out. “Thanks. And have a nice day.”
Rip Pearson knew this was one of the most-feared situations faced by health care professionals, and he worked hard to keep his voice low and his manner calm. “John, this isn’t the end of the world. I’ve seen this scenario dozens of times, and the odds are so overwhelmingly against your getting infected in any way-” “I know, I know.” John Ramsey squirmed on the edge of the treatment table. “But it makes me so angry that someone, a health care professional, could dispose of a needle and syringe in such an unsafe manner. Besides, it’s not even one of the safety units they’re supposed to use, the ones you can recap with one hand after using them.” “What makes you think it was one of the staffthat did this? You said yourself this wasn’t one of the safety syringes we use here. If it were, we wouldn’t be having this conversation. This was most likely a patient, probably a drug user. They had the syringe in their purse or their pocket and saw a chance to get rid of it. The cap came offwhen they dumped it, and it sat there just waiting to bite you.” “Okay. I’ll stop fuming over something I can’t change. Now what do I do?” “Have you had hepatitis immunizations?” “Aren’t we going to talk about HIV exposure?” Rip made a calming gesture. “We’ll get to that, but your chances of getting HIV from a needle stick like this are less than 1 percent. What we worry about most is hepatitis, especially Hep B. Have you been immunized?”
“Yeah, the full series.” “Tetanus?” “Current on that, too.” “There’s the possibility of bacterial infection at the wound site, but we don’t usually give prophylactic antibiotics for that. We’ll just watch.”
John leaned forward a bit. “And last, but certainly not least?” “As I said, HIV isn’t much of a risk. As you know, we can’t do any kind of meaningful test on the needle or syringe, and we can’t HIV test the person who used them last. I’d call this a class 2 or 3 exposure.
We’ll draw a baseline blood test and retest you periodically. You’ll need to be on the standard twodrug regimen for at least a month. The odds are overwhelming that you’ll be fine.” John didn’t seem to relax despite the reassurance. That would probably take a while. He struggled with what was probably meant to be a smile. “Thanks for coming over so quickly, Rip. I appreciate it.” “Glad to do it. I’m sorry that Dr. Ingersoll wasn’t available. We generally like for a senior faculty member to take care of situations like this that involve our staff.” “Actually, I’m glad it’s you. I trust you. I’m not sure I can say the same about Jack Ingersoll.”
He’d wondered how long it would take for questions to arise.
Nothing is perfect, certainly not in medicine. He’d heard it all his life. “When something’s too good to be true, it isn’t.” There wasn’t a drug in the world that worked all the time with no potential for side effects. Penicillin had been a fantastic leap forward after Fleming made the accidental discovery in 1928. But now 2 percent of the people in the U.S. were allergic to this wonder drug, risking reactions that ranged from an uncomfortable rash to a violent death. Aspirin had been in use for over one hundred years, providing relief of mild to moderate pain. But over 5 percent of the population couldn’t take it because of sensitivity or ill effects that ranged from minor to fatal.
Nothing, however benign it might appear, was perfect. The same was true for Jandramycin. What he’d told the board of Darlington was true-sort of. Jandramycin had problems, and when they came out, Jandra Pharmaceuticals would go in the tank. But he’d known all along it wouldn’t be necessary for him to leak the information. The questions would be asked, and someone would eventually ferret out the truth. Of course, if that didn’t happen, he was still sitting pretty on the inside of a multi-billion-dollar enterprise with four million untraceable dollars. If it did, that amount swelled to ten million.
Not just a golden parachute-more like platinum or diamond. Enough to let him live for the rest of his life in comfort in a place he’d already picked out. For now, all he had to do was sit back and let matters take their course. And he was prepared to do just that.
John couldn’t hear the ring of his cell phone over the buzz of conversation and clatter of trays in the medical center’s food court, but the vibration finally caught his attention. “Dr. Ramsey.” “This is Mark. What’s up?” John Ramsey picked up his venti mocha in his free hand and said, “Let me move outside. I can’t hear myself think in here.” He walked quickly into the hallway and from there outside into the courtyard. He settled onto an unoccupied bench in a quiet corner.
“Better. Can you hear me okay?” “Loud and clear,” Mark said. John brought him up to date, feeling the lump in his throat grow larger as he worked through the details. His malpractice insurance was no longer in force. It was unlikely that the medical school would protect him from any suit. “And now I’ve been served with the papers. Can I get you to look at them? Maybe I can buy you dinner tonight?” “Um, well-”
Mark’s hesitation told John all he needed to know. “That’s okay.
Obviously you have something planned for tonight.” “Actually, I have a meeting at the medical center at five, but I don’t know how long it’s going to last. Why don’t I call you after that?” John finished his coffee and tossed the cup in a nearby waste container. “That’s fine.”
He rose and began to move slowly back toward the entrance. “What kind of a meeting do you have, if you don’t mind my asking?” “It’s about-”
John could almost see the gears turning in Mark’s head. “You know, you might want to be there as well. Here’s the deal.”
Sara heard the tap on her office door but didn’t look up from the journal she was reading. “It’s open.” “Am I early?” Rip said from the doorway. Sara looked at the clock on her desk. Five minutes to five.
“No, you’re fashionably on time. Come in and sit down.” Rip eased into a visitor’s chair and put a worn leather portfolio on the corner of Sara’s desk. “I have some pretty interesting information on the patients who’ve developed problems after receiving Jan
dramycin.” “Uh, let’s wait just a minute. I sort of invited Mark Wilcox to join us. I hope that’s okay.” It seemed to Sara that a frown flitted across Rip’s face. “I guess not. And John did vouch for him.” “Did I hear my name?”
Mark said. He ambled in, shook hands with Rip and Sara, and took the other visitor’s chair. “Is it still okay that I’m participating in this get-together?” “I was telling Rip that I invited you. And of course it’s okay. We can use all the help we can get.” “Good,” Mark said. “Because I’ve asked John Ramsey to join us.” As though on cue, John stuck his head in the doorway. Seeing that the chairs were occupied, he disappeared and returned in a moment with the chair from the secretary’s desk in the outer office. After more explanations and more assurances that everyone was welcome, Sara said, “I’ll start, I guess. I decided to call Jandra to see if I could get any information on possible late complications from Jandramycin. I thought they might have seen something in the preliminary animal studies.” “And?” Rip asked. “No dice. I spoke with their research director, a Pharm D named Wolfe, who stonewalled me. At first he said I should check with Jack, since we’re at the same institution. When I kept asking questions, he clammed up. He claimed that what I wanted to know was proprietary information. He even insinuated that I might be a spy from another pharmaceutical company.” “Not unusual. Paranoia is the norm in the pharm industry. They’re always looking over their shoulder for a competitor sneaking up on them,” Mark said. “Did you talk with anyone else there?” “I got as far as the secretary of somebody named Patel, who’s the CEO or COO, not sure of his title. What I am sure of is that she referred me right back to Wolfe. Wouldn’t even let me talk with Patel.” She picked up a pen from the desk and began to twirl it between her fingers. “I think Jandra is a dead end.” Mark raised a tentative hand like a fifth grader with the answer to a problem. “Why don’t I see if we can get any information from the New Drug Application Jandra has filed?” “Are NDA’s public record?” John asked.
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