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 Jandramycin."
"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.
"No. Remember what I said about drug companies being paranoid. Keeping an NDA secret is supposed to prevent competitors from stealing information." Mark grinned. "But in my legal practice I made some contacts in Washington. Maybe one of them has connections with the FDA. I'll see what I can get."
"If we suspect that Jandramycin is causing problems, shouldn't we contact the FDA directly and ask them not to act on Jandra's application?" Sara asked.
Rip shook his head. "And tell them what? We have no proof. All the clinical data here is locked up tight in Ingersoll's lab, guarded by Resnick like a dog watching over a bone. The preclinical trials were done by Ingersoll when he was doing a research fellowship at Jandra, so if there's any useful data in those records we'll never see it. Whatever the FDA has is a sanitized version of the truth, and we have no facts to refute it."
Conversation stopped when John Ramsey's watch beeped. He shrugged and said, "Sorry, got to take my medicine. My doctor tells me it's important that I don't miss a dose." He looked at Rip and managed a weak grin. "Be right back." He pulled two pill bottles from his pocket and ducked out of the room.
As soon as John was back, Rip pulled a sheet of notes from his portfolio. "I've managed to contact most of the patients who received Jandramycin. Of the ones I've contacted, all but three got the drug more than six weeks ago. Out of that group, six have what I consider serious conditions."
Sara rose. "Let's move to the conference room for this."
An hour later, names, symptoms, and pertinent lab data covered the blackboard in the conference room. "To summarize," Mark said, "we have six patients. They've developed various complications: neurologic problems, kidney failure, muscle weakness, excessive bleeding, and headaches with vision loss. Is there the common denominator?"
"Let's put specific diagnoses on the groups where we can," John suggested. "Start with the neurologic problems. Sara tells me she thinks her patient has Landry's ascending paralysis— what you younger doctors would call GBS or Guillain-Barré syndrome."
Sara wrote "GBS" and underlined it.
"Kidney failure can be due to lots of things, so let's put that one aside," John said. "The same with muscle weakness and bleeding disorders. But the visual loss and headaches, associated with an elevated sed rate and some response to steroids suggest—"
"Temporal arteritis," Sara almost shouted. "Everyone agree with that?" There were murmurs of assent, so she wrote "Temp art" and circled it.
"Is there a common thread to those two disorders, one that could also apply to kidney failure, muscle weakness, and excessive bleeding?"
John and Mark looked at each other, and Sara could tell the answer was forming in their minds almost simultaneously. "Autoimmune disorder," they said in unison.
"If we accept that," Rip said, "then let's see if there's a link to the others. Muscle pain and weakness?"
"Polymyositis," Mark said. "It's autoimmune, and it fits."
Sara wrote "Polymyo."
"How about bleeding?" Sara thought for a moment. "Rip, did the patient with bleeding have any purpura?" she asked, referring to the red or purple spots sometimes seen on the skin of patients with blood disorders.
Rip checked his notes. "Yes. And that leads us to—"
"Idiopathic thrombocytopenic purpura," Sara said, scrawling "ITP" on the board. "And that's autoimmune."
"That leaves kidney failure. Which autoimmune disorder can cause that?" John asked.
They kicked that around for a bit and finally settled on kidney failure with an immune cause: IgA-mediated nephropathy. Sara added "Imm neph" to the board. She stepped back, nodded in satisfaction, and put down her chalk.
The discussion continued for a few minutes, but soon it was evident that they were in agreement. The complications from Jandramycin were autoimmune—the patients had literally become allergic to their own tissue. The effects were just manifested in different organ systems.
"Okay," Sara said. "We're dealing with an autoimmune problem. We don't know why, and we need to look at how that happens. But more important, how can we treat it? Steroids can help, of course, but their effect is temporary. Is there something that will reverse the process?"
Rip shook his head and yawned. "We've got more work to do." He looked around the room. "But we're all dog-tired. Let's get some rest and reconvene here tomorrow night."
They straggled out of the building and walked in loose formation across the nearly silent plaza toward the parking garage. Mark moved beside Sara and said, "I was hoping to take you to dinner. Is that offthe table for tonight?"
Sara had to smile at the way Mark phrased his invitation. "I'm afraid so. I'm exhausted, and I'll bet you are." She slowed and half-turned toward him. "As for another night, why don't you wait until things settle down a bit? Then call me."
All three men insisted on seeing Sara safely to her car, and soon she was on her way home. A few blocks from the medical center, she remembered that she needed cereal and milk. Sara was a creature of habit, and cereal for breakfast was one of them. She scanned the businesses around her. She was almost past the grocery store when she spotted it on the right. Sara swerved into the parking lot with only a light touch on her brakes. The squealing of her tires almost covered the sound of breaking glass. She screeched to a stop in the parking lot, looked behind her, and saw the rear window was shattered. Glass shards covered the backseat. To her right, a jagged hole marred the front passenger window. It took a few seconds for the reality of the situation to set in, and when it did, Sara seemed to implode upon herself like a blown-up balloon that's lost its air.
She was vaguely aware of a number of people in the parking lot pulling out cell phones. A few eased toward her car, apparently afraid to approach too near for fear the shooting wasn't over. One man, braver than the rest, shuffled forward and called, "Are you hurt?"
She shook her head. She was still sobbing, gripping the steering wheel in a death grip, when she heard the sirens approaching.
10
IN THE FACULTY PARKING GARAGE, JOHN RAMSEY BEEPED HIS CAR UNLOCKED and was about to climb in when he heard someone call, "John, wait up."
"Mark? Where are you?"
Mark Wilcox's head appeared over the roof of a nearby vehicle. "Glad I caught you. I think we need to talk."
"You're right," John said. "I got so wound up in this Jandramy
cin thing, I almost forgot that I was being sued."
"Then it's a good thing you have a lawyer to protect your interest." Mark gestured to John's Toyota. "I'm parked down in the visitors' lot. Can we climb in here and talk for a bit?"
Once they were settled, John reached into the glove compartment and pulled out a thick sheaf of papers. "Here it is. I didn't understand all the legal language, but it was pretty clear that I was being sued, along with just about everybody else in this zip code."
Mark scanned the first few pages and nodded. "I'll go over this in detail tomorrow, but as I see it, there are several strategies we can employ."
"You mean, other than telling these people they're idiots for bringing this suit in the first place? All I did was offer a helping hand to a woman who was in distress. For goodness' sake, I was just being a good Samaritan."
"Interestingly enough, that's one of the strategies I was going to mention. We could base your defense on the Good Samaritan Law."
"Would what I did qualify?"
"Probably, but I need to research it more. Why don't you try to put this out of your mind for now?"
John grimaced. "Oh, it probably doesn't matter anyway. If they win a judgment, they can just take it out of the proceeds of my life insurance."
"That's not funny. There's absolutely nothing here that's worth considering taking your own life."
"I don't have to do that. Some druggie who dropped a dirty syringe into the trash can in one of our treatment rooms will probably do it for me." He reached into his pocket, held up two prescription bottles, and shook them to rattle the pills inside. "Remember when I excused myself from the meeting to take my medicine?"
"Yes."
"Antiretrovirals. I'm on post-exposure prophylaxis for HIV. And the way things have gone lately, I don't think there's a way in the world I can avoid it."
Bob Wolfe looked around Patel's empty office and tried to relax, but his gut continued to churn. He wiped his palms on the handkerchief balled in his hand. Don't let them see you sweat, they say. Well, that wasn't so easy right now. The secretary's call had been terse: "Dr. Patel wants to see you in his office. He'll expect you in five minutes." There'd been no explanation of the summons then, and none when he showed up. Just "Go in, and close the door behind you."
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