"You know the deal," Ingersoll said. "You didn't get the Infectious Disease fellowship, but I agreed to take you on as a research assistant and promised you the inside track when the second fellowship slot opens next year. Your place this year is in the lab. And the longer you stand here like a schoolboy begging to avoid detention, the less time you're spending in that lab."
Without waiting for a reply, Ingersoll brushed past the young doctor and hurried away to the ICU. Idiot. He's good in Wthe lab, following orders, but he won't ever be any good at patient care. When I take on another ID Fellow, it certainly won't be him.
Dr. Roswell Irving Pearson III, generally known as "Rip," scanned his notes one last time. The position of Infectious Disease Fellow under Dr. Jack Ingersoll was a real plum, and Rip had overcome stiffcompetition to win this appointment. But Ingersoll was a stern taskmaster. He expected his ID Fellow to anticipate his every request and fulfill it perfectly. When Ingersoll said, "Meet me in the ICU at University Hospital," Rip knew that really meant "Find out which patient I'm seeing, review the chart, and be prepared to present the salient facts in the most concise fashion possible." Since this was a case involving Staph luciferus, that also meant making sure the teenage girl qualified for the EpAm848 study. Now Rip was ready.
He supposed he shouldn't feel sorry for himself. He could be poor Carter Resnick. Rip wasn't sure how Carter ever got through an internal medicine residency, or why he thought he had any chance at an ID fellowship, much less one as prestigious as this one. Anyone with half a brain could see that Ingersoll was just using Carter, delighted to have a specialty-trained MD running his research lab. Well, the Carter Resnicks of the world would have to take care of themselves. Rip Pearson had his own problems, and the first one on the agenda was presenting this case to his chief.
Rip looked once more at his watch. Martha had paged him less than fifteen minutes ago, catching him already at University Hospital making rounds. He'd sprinted up the stairs to the ICU and rapidly digested the chart information on Chelsea Ferguson. He hadn't introduced himself to Chelsea or her mother, though. He'd made that mistake once, and had learned quite quickly that Ingersoll expected his ID Fellow to be seen but not heard, like an obedient child.
The name of the attending physician on the case made Rip pause. He hadn't done more than nod to Sara as they passed in the halls since their last rotation as internal medicine residents. Now she was a staffmember, while his position as an Infectious Disease Fellow meant he was still in training. Would that make a difference? He and Sara had been close until she married Jack Ingersoll. Now all those relationships were topsyturvy. He wondered—
"What do we have?" Ingersoll's rubber-soled shoes allowed him to approach without warning, something Rip suspected he did, hoping to catch someone bad-mouthing him. The consultant pulled out a chair and took the page of neatly printed notes Rip handed him.
"Chelsea Ferguson, sixteen-year-old Caucasian female, had a dental extraction a week ago, without prophylactic antibiotic coverage. She developed progressive, severe cellulitis of the jaw, and her dentist referred her to an oral surgeon. He tried one change of antibiotics, but when he recognized early sepsis he sent her here. Pending cultures, Dr. Miles began empiric antibiotic therapy for presumed MRSA with IV vancomycin plus gentamycin. Intraoral cultures grew out Staph luciferus, and blood cultures have reported the same organism, resistant to all conventional antibiotics. The patient now has generalized sepsis, is spiking temps to between 40 and 41 degrees Celsius, and her condition is deteriorating."
"Eligibility for the study?"
Trust Jack Ingersoll to cut to the chase. Not "What else can we do?" Not "What about the white count, or sed rate, or blood sugar or any other lab test?" No other questions except, "Is this another case I can enroll in the EpAm848 study?" Rip swallowed the retort that was on the tip of his tongue. "Yes, sir. She meets all the criteria. And according to Dr. Miles's notes, her mother has been warned that there are risks and potential side effects."
"Nonsense. None of the patients treated so far have so much as turned a hair. This is really a wonder drug."
"Yes, sir. But there's always a first time."
"Negative thinking, Rip. We'll have none of that." Ingersoll stood. "We have to project a positive attitude. It's important that patients have confidence in their doctors."
A faint buzz issued from under Ingersoll's coat. He pulled an iPhone from his pants pocket, looked at the display, and frowned. "I have to take this."
Ingersoll hurried away from the nurses' station, ducked into the family room, and closed the door. Rip wondered what could have been so important. In his experience, nothing trumped enrolling another patient in the study.
Whatever it was, it didn't take long. In less than five minutes, Ingersoll was back. "Let's talk with these people," he said. "Then I have to leave and catch a plane. I'll be gone for a couple of days, so you'll need to administer the medication and gather the follow-up data. Think you can handle that?"
Rip swallowed the acid that boiled up in his throat. Since the study began, he'd been the one doing just that. He'd mixed every dose of EpAm848 and sat by the patient's bedside while the IV ran in. He'd drawn blood and taken it to Ingersoll's lab for all the necessary tests, made sure the vital signs were monitored, and logged the data that chronicled the patient's response. This might as well have been his study, not Jack Ingersoll's. It bespoke of his mentor's huge ego that he'd even ask such a question. He choked out, "Yes, sir," and managed to sound humble while doing it.
Ingersoll was already moving toward Chelsea Ferguson's room. Rip fell in step behind him like an aide-de-camp trailing a general at a respectful distance. A woman that he took to be Chelsea's mother was sitting at the bedside, systematically shredding a tissue.
"Mrs. Ferguson, I'm Dr. Jack Ingersoll. I believe Dr. Miles told you to expect me."
"Doctor, this is Chelsea." The girl on the bed opened her eyes, managed a weak nod, then closed them again.
The camera of Rip's mind's eye automatically recorded the patient's status: pale, slightly undernourished girl in her late teens, sweating profusely, movements slow and listless. An IV in her left arm was dripping at a regular rate. Her breathing was shallow, and a plastic cannula delivered what he assumed to be oxygen to her nostrils.
"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 lowe
r 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.
3
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?"
&n
bsp; "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?"
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