Negative thoughts crowded out anything positive about the situation.
John must have sensed her struggle. “Look, I know everyone’s worried that I might be going from the frying pan into the fire with this treatment,” he said. “But look at it from my side. If we do nothing, we know what would happen. We’ve been over that. It’s either accept a 100 percent chance that the disease will kill me, or at least make me lose my hand, versus a 15 percent chance of some sort of autoimmune response that could possibly be controlled with steroids or something else.” He shrugged. “It’s a no-brainer.” Something clicked in Lillian’s mind. “You came out with that 15 percent figure awfully quickly. Where did that come from?” “Rip was able to contact almost all the thirty-nine patients in Ingersoll’s study. Of those, six had complications we think are due to the Jandramycin. Simple math. Six of thirty-nine. Fifteen percent chance of problems.” “Which poses the bigger question. What is it about that 15 percent of patients that makes them vulnerable to this sort of response?” Lillian pulled a straight chair to the side of the treatment table and sat down. “Has your group come up with any answers?” John recounted what had been done and the dead ends they’d encountered. Every time Lillian suggested a possible avenue of investigation, John countered with the roadblock that stopped them getting the information they needed. She stood and began to pace. “So it appears that we need to know how Jandramycin really works before we have any realistic chance to figure out how to prevent that 15 percent of patients getting late complications.” “Right. And if you have any ideas, you’re welcome to contribute them.” He raised himself on one elbow. “And would you please sit down? I’m getting dizzy watching you pace.” Lillian eased into the chair again. She reached into the pocket of her white coat and extracted a small notebook with a pen stuck into the ring binding.
“I’m going to do some investigating of my own. Do you happen to know the original name of the compound? Not Jandramycin. What they called it in the beginning.” “Not really. Why do you ask?” “Because I may be able to backtrack from there and get information about the mode of action of the drug. There’s usually a reason for the names investigators give these compounds.” She put the notebook back into her pocket. “Besides, unless you have a better idea, it looks like we don’t have anywhere else to go short of holding Ingersoll or Resnick at gunpoint until they give up their secrets.” John said something, but Lillian only half-heard it. Her mind pictured the scenario she’d mentioned so offhandedly, and wondered if it just might work. After all, her late husband’s gun was still at home in the back of a drawer under her winter sweaters. And how difficult could it be to use it?
19
“Does anyone there speak English?” Sara realized she was shouting into the phone and made an effort to moderate her tone.
Although reason told her that talking louder didn’t increase the chance the person on the other end of the line would understand her despite the language barrier, the longer she talked the more frustrated she became and the louder she spoke. The woman seemed calm enough, not at all flustered by the conversation or lack thereof.
Neither her tone of voice nor her answer changed. ” Bitte, Ich verstehe nicht.” By now, the phrase was familiar to Sara. The woman didn’t understand. This was the end of a tedious process, and it looked like it would be wasted effort. Sara had dug deep on the Internet to find that Drs. Gruber and Rohde were internal medicine specialists on the faculty of a medical school in Ulm, Germany. Then it was a matter of finding the contact information for that medical center, looking up the process for making an international call, calculating the time difference between Texas and Germany, and finally placing the call from her home phone because Southwestern Medical Center would undoubtedly look askance at an unauthorized transatlantic phone call from her office phone. Completing the call was only half the battle, though. She was transferred from person to person until she finally reached the proper department. Now, for the first time in the series of exchanges, she encountered someone who apparently spoke no English. For the past five minutes, a calculator in Sara’s mind toted up the charges for the call. This must be costing her a fortune, and she was getting nowhere. She was about to hang up when a new voice came on the phone. “Yes, may I help you?” “Oh, thank you. This is Dr.
Sara Miles at Southwestern Medical Center in Dallas, Texas. Who is this?” “I am Frau Schilder. I am the Chefsekretarin��� the head secretary for the Medizinklinik.” “And you speak English?” “I speak a little, yes.” Sara rolled her shoulders to relax the tension there.
Maybe this would work after all. “I’m a doctor, calling from the United States. I need to speak with Dr. Gruber or Dr. Rohde.” “I am very sorry, but the doctors are both with patients today. Shall I give them a message?” Would they really call back? It was a transatlantic call, and they had no idea who she was. Then it occurred to Sara that the mention of one word in her message might get a response. “Yes. My name is Dr. Sara Miles. And we need to discuss some important information about Jandramycin.” “Yes, and your phone number please?”
Sara gave it and rang off. She found it interesting that the woman hadn’t asked to confirm the spelling of Jandramycin. Apparently the word was familiar to her. Perhaps she’d even been called upon to type reports and collate data. Maybe the work of Gruber and Rohde wasn’t shrouded in as much secrecy in Ulm, Germany, as Jack’s was here in Dallas. Sara permitted herself a bit of hope. Funny. She couldn’t get the information she needed from her exhusband whose office was less than two hundred feet from her own, but she might be able to get it from two perfect strangers who carried out their medical practice and research five thousand miles away. She’d done what she could. Now there was nothing to do except wait, hope, and pray.
Her visit with John as he received his Jandramycin took most of Lillian’s lunch time, so she decided to pick up a sandwich in the food court and snatch a few bites between patients this afternoon. Lillian made her purchase and was on her way out when she saw Jack Ingersoll and Carter Resnick at a table by the wall, deep in conversation. As she watched, she realized it wasn’t really a conversation. It was a monologue, as Ingersoll held forth and Resnick listened, occasionally jotting a note in a dog-eared notebook. Lillian approached their table, but neither man appeared to notice. “Having a little instruction time, Jack?” She was surprised when Ingersoll turned, recognized her, and stood. Apparently his egocentric personality hadn’t totally overwhelmed principles of courtesy undoubtedly learned as a child. Maybe it was because she was a woman. Maybe it was the touch of gray she allowed to remain at her temples when she put the Clairol to work. At any rate, it was good to see a glimpse of humanity in Jack Ingersoll. “Lillian, good to see you,” he said. Ingersoll looked pointedly at Resnick, who struggled to his feet. “You know Dr.
Resnick?” “We’ve met,” Lillian said. “Please, sit down. I have a question for you both.” Both sat and looked up at her expectantly. “I believe you have three or four of my patients in your study of that new antibiotic. Of course, I’m grateful, as I’m sure they and their families are. After all, you cured them of an infection that would otherwise be a death sentence.” Ingersoll nodded gravely. “Happy that we could do it.” “But now I’m hearing rumors of some very serious late reactions in some of the patients that received Jandramycin.” Lillian hurried on, ready now to appeal to Ingersoll’s ego. “I don’t believe in rumors, of course, and I thought that if anyone could give me the straight word, it would be you.” “Thank you for your confidence. Yes, I’m probably the world’s authority on Jandramycin, so I’m glad you came to me instead of paying attention to those silly rumors that keep floating around.” He pulled a chair from the next table and motioned to her. “Please sit. This may take a moment.” Lillian looked at her watch and decided that being five minutes late for clinic was a fair trade for information that might save patients from some pretty terrible consequences. She sat. “As you may know, after I left Southwestern, I took an infect
ious disease fellowship at UC Berkeley.
While I was there, I did some research with a pharmaceutical company in the area. I was working on��� Never mind, it isn’t important.”
Lillian leaned forward to signal her interest. Get on with it, Jack. I don’t have time for your life history. “Go on.” “Anyway, some of the compounds that were supposed to be effective in that area turned out, at least in my lab experiments, to have a marked antibacterial activity. Specifically, they were effective against Staph.” Lillian saw her chance and took it. “What compounds were those?” Ingersoll shook his head vigorously. “Sorry, Lillian, I can’t say. Anyway, I put some of them together in various proportions and tried them out.” “In lab animals, I presume.” “Er, oh, yes. In lab animals at first.”
Ingersoll took a sip from the almost empty glass in front of him. “I have to admit, there were some unpleasant results at times, but I kept modifying the preparation until I came up with what we now know as Jandramycin. When the epidemic of Staph luciferus broke out, I got permission to try the drug on some patients. Since the infection was tantamount to a death sentence without treatment, there was no objection. Imagine how gratified we all were when it was 100 percent effective in eradicating the infection, with no side effects.” Lillian nodded and sneaked a peek at her watch. “So you never encountered any adverse reactions to the drug? Either during treatment or afterward?”
Ingersoll rubbed his chin, and Lillian could see he was choosing his words carefully. “Not once I developed the final compound. None at all.” “Does that hold true for the earlier compounds you put together?” He waved away the question. “Oh, that’s ancient history. As I recall, your question was about the safety of Jandramycin.”
Ingersoll pushed back his chair. “I really need to go, and I’m sure Carter should get back to the lab. Have I answered your question?”
“Yes, thank you.” And raised a bunch more. Lillian grabbed her purse and the bag with her sandwich, and hurried away, more determined than ever to find out what Jack Ingersoll was hiding. Somehow she had the feeling she’d just heard a clue, but she had no idea what it was.
“Okay, let me flush this out, and you can sit up.” Rip Pearson disconnected the IV tubing that had carried the Jandramycin into John Ramsey’s vein, then injected a small amount of solution into the tiny plastic catheter that remained in the vein, its end taped to John’s forearm. “You’ve got four more doses to go. Want me to change the site of your heparin-lock?” John touched the skin around the site. “No tenderness or redness. Let’s leave it for now.” He perched on the edge of the exam table and rolled down his sleeve. “My hand feels pretty much back to normal. Is there any chance we can discontinue the Jandramycin early?” Rip shook his head. “None of us know for sure how effective a shorter course would be. I’ll admit that ten days is an arbitrary number, but it’s worked in everyone so far. I’d hate to change that.” He took offthe thin rubber gloves he’d worn and flipped them into a waste container. “Besides, do you want to be the one to tell Jack Ingersoll that we changed his protocol?” “Don’t you think Ingersoll would just report that I’d had the full ten days of treatment? I mean, it sounds like he’s not above fudging his reports anyway.” “If you quote me I’ll deny it, but you’re probably right.”
Rip gestured for John to roll up the sleeve on his opposite arm.
“Let’s get your lab work drawn, then you can be on your way.” “What are all these labs, anyway? I know this is a study, but isn’t this overkill?” He pointed to the test tubes lined up on the treatment table beside the equipment for drawing the blood to fill them. “And why do you need lab work after every dose of the drug?” While Rip pulled on a fresh pair of gloves and busied himself with the blood draw, he considered John’s question. “You know, in the time I’ve been an infectious disease fellow I’ve probably helped run half a dozen of these studies. I get so used to doing things that are specified in a protocol for a study it never occurs to me to question them.” “To get back to my original question-” John flinched as the needle pierced his vein. “Ow, that one stung. Anyway, what lab studies are you doing?”
“Honestly, I don’t know. The hospitalized patients get the routine stuff-CBC and chemistries mainly. Those are done in the hospital lab and the results go on the patient chart, but there’s another set of tests that go to Ingersoll’s lab. I take the tubes to Resnick; he runs the tests and records the results. Then I guess he forwards the data to Jandra.” “And no one will tell you what the tests are?” “Never asked, but I suspect that I’ll be told I don’t need to know right now.” Rip removed the needle and put a square of sterile gauze over the puncture site. “Hold that for a minute, then I’ll put a bandage on it.” “You know, every one of those tubes is used to collect blood for a specific set of tests. I know that in our lab a red-top tube is for serology, a lavender-top is for hematology. Think we could figure it out from the tubes you collect for Resnick?” “Nope. These are special tubes sent from Jandra. The colors of the tops are different from any I’ve seen before.” Rip lifted the gauze from John’s arm. Satisfied that there was no bleeding, he applied a bandage. “That should do it.”
He tossed the gloves in a waste container and washed his hands. John shook his head. “So much for that. I was hoping that the lab tests would give us a clue to what the drug does and what can go wrong in patients receiving it. I mean, we’re pretty sure the problem is autoimmune, but we don’t know why some patients get it and others don’t. And we have no idea about prevention or treatment.” Rip shrugged. He eased the test tubes into the pocket of his white coat with a dull clank. “I’m trying to find out more, but so far it’s not working out. Maybe our best bet is to break into Resnick’s lab one night and get the data offhis computer.” Rip smiled at his attempt at humor. Then he looked at John, and noticed that he wasn’t smiling at all. “John, I wasn’t serious.” John slipped into his white coat. “I am.” He opened the door and strode away like a man on a mission.
Sara hurried down one of the main halls of the medical center, deep in thought and only peripherally aware of the people around her.
It was ten minutes after one, and like most of them, she was running late. She opened the back entrance into the general internal medicine clinic and almost ran over Lillian Goodman as she retrieved a white paper bag from the floor. “Oh, sorry.” “No problem,” Lillian said. “I was hurrying to get here and dropped my sandwich.” She straightened and the two doctors proceeded side by side toward the physicians’ dictation room that served as their office during clinic hours. “No time for lunch?” Sara asked. “No, I was talking with Jack Ingersoll.
When we have a break, I’ll tell you about it.” Lillian dropped her purse and the sandwich at the far end of the low communal counter where the doctors sat and dictated, made phone calls, wrote chart notes, and occasionally huddled in informal consultation. Sara followed suit. She glanced at the patient list Gloria had placed at her usual station. Busy afternoon, and she hadn’t helped by being late. She threw the clinic’s head nurse a look of apology before she entered the exam room where her first patient awaited her. “Mrs.
Truman, I’m Dr. Miles. So very sorry to keep you waiting. How can I help you?” For the next few minutes, the woman sat on the edge of the exam table and related a set of symptoms that immediately set offalarm bells in Sara’s head: slight weight gain, increasing fatigue, vague aches and pains, difficulty swallowing at times. Years ago, these would have been passed offas due to nerves, perhaps given the tag of “neurasthenia.” But now they suggested a definite diagnosis to Sara.
“Have you noticed any change in your hair or skin?” Sara asked.
“Actually, yes.” The woman seemed surprised that Sara would ask this, and happy that her symptoms fit. “My skin is dry. My hair is harder to manage. Matter of fact, my last perm was a disaster.” Sara stepped around behind the woman and put her hands on the front of her neck.
“Please swallow��� Again.” A g
lance at the vital signs recorded by the nurse on Mrs. Truman’s chart reinforced Sara’s preliminary diagnosis: slow pulse, blood pressure a bit lower than normal. “Mrs.
Truman, I think your problem is due to your thyroid. It’s not producing the amount of thyroid hormone that it should, even though it’s enlarged to try to keep up with the demand. That enlargement is pressing on your esophagus, making it difficult for you to swallow.”
“Do I need an operation?” The woman’s fear was reflected in her voice and on her face. “I don’t think so. We’ll need to do some lab work, and if it confirms my diagnosis, we’ll get you on some medicine to supply the hormone your own thyroid isn’t making.” Mrs. Truman’s shoulders relaxed visibly. “Oh, thank goodness. First I thought I was going to die two months ago when I got blood poisoning from that cut on my foot. And now this. I-” “Where were you treated for that ‘blood poisoning’?” “Why, right here at the University Hospital. The infection was from some sort of super-bacteria that nothing would touch. But they gave me an experimental antibiotic that cleared it right up. It was like a miracle.” Sara bit her lip and picked up the paperwork that lay on the side table. In the block for diagnosis, she crossed out “Hypothyroidism,” substituting “Hashimoto’s thyroiditis.”
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