"I really don't like—"
"It doesn't matter what you like. You're ours, bought and paid for. Don't ever forget it."
The informant was saying something, but he hung up, cutting him offin mid-sentence. Stay focused. Remember what's at stake. I can't stop now. Not when success was so close.
Morning rounds on the internal medicine floor of University Hospital found Sara frowning over Randall Moore's chart. Rip had started him on nafcillin yesterday, and he'd had four IV doses of two grams each since admission, but his fever remained high. True, it was early, but she'd be a lot happier if there was some evidence he was responding to treatment. If this were a run-of-the-mill Staph infection, even MRSA, she'd expect some improvement. Every hour that went by without that improvement made it more likely her patient was infected with The Killer, Staph luciferus.
"How's our guy?" Rip slid into the chair beside her and peered over her shoulder. "Still febrile?"
She handed over the chart. "I'd be a lot happier if his temp were a bit lower. Think it might be . . . " She let the words trail off, hesitant to give voice to her fears.
"I'm afraid so. We might have a preliminary culture report today, although tomorrow seems more likely. And once we know for sure, the fun begins. Should I give him Jandramycin, knowing there's a chance he might get a severe late complication?"
"Can't you simply inform the patient and let him make that decision?"
Rip shook his head. "It's not as simple as that. Ingersoll categorically denies that Jandramycin therapy carries any risk. And, based on what you've told me, the people at Jandra say the same thing. So if we tell Moore about the possible complications, there's no foundation to back up our story. Besides that, if Ingersoll finds out, I can kiss my fellowship good-bye."
"But if we don't tell Moore, and he's one of the unlucky ones—"
"Then there's another lawsuit against the medical center and a bunch of doctors, us included," Rip said. "Yeah, this is a tough call."
"Excuse me, do you both have a moment?" Lillian Goodman stopped several paces away, apparently not wanting to invade the space of the two doctors who sat with their heads together.
Sara motioned her to the chair on the other side of her. "Have a seat. We were just talking about Randall Moore's case. You really dodged a bullet when you asked me to see him yesterday."
Lillian made a dismissive gesture. "I'm really sorry I got you involved. In retrospect, I should have called Donald Schaeffer over to see him."
"Don't worry about it," Rip said. "Besides, I think we can agonize over his treatment plan as well as the department chair could. Maybe even better."
Lillian leaned across to address her remarks to both Sara and Rip. "You guys do know that—"
Sara stopped her with an upraised palm. "Yes, we know he's suing you and half the staffof the medical center. But that doesn't make any difference to me, and I believe Rip feels the same way."
"Suit? Has another lawsuit been filed?" John Ramsey slid into the chair beside Rip. "I'm seeing more of those since coming here than I ever saw in forty years of private practice."
"No, this is the same one you and I know about," Lillian said. "Sara, do you want to tell John what's going on?"
John sat quietly while Sara explained the situation. When she finished, he said, "Wow. I guess the best thing would be that the culture comes back as something other than Staph luciferus. Even MRSA would be better, I suppose."
"It would, but I'm not betting on it," Rip said.
Lillian held out her hand in silent request, and Rip passed her the chart. "What are you looking for?" he asked.
She thumbed through until she found the history sheet Moore had filled out when he first entered the clinic. "I'm looking for something in his history." Lillian frowned, flipped a page, frowned again. "Here it is. He has a history of hay fever and asthma, and both parents are allergic."
"What does that mean?" Rip asked.
"I'll give you my theory. Realize, this is all supposition," Lillian said, "but it makes sense to me, and it's all we have to work with right now. I began with your finding that about 15 percent of the people receiving Jandramycin ended up with late autoimmune complications. That's about the percentage of people in the U.S. with allergy."
"Yes," Rip said. "But so what?"
"I decided to look for a connection, and I think I found it. I took the original name of the experimental compound that became Jandramycin and searched for the components Ingersoll could have been working with to develop it. I started with 848 . . . "
John listened quietly as Lillian laid out what she'd found and knit together her hypothesis. Jandramycin stimulated a patient's immune system to form antibodies against Staph luciferus. Natural antibodies attacked the bacteria, destroying them and preventing them from multiplying. The action of this drug was different from that of other antibiotics, drugs that attacked bacterial cell walls or stopped their metabolism, but the end result was the same. The patient recovered.
Unfortunately, in patients with an underlying predisposition to allergy, the drug also did something to the immune system that turned it upon itself, making antibodies to the patient's own organs. For some reason, this was only seen in allergic patients. And he was allergic and had been treated with Jandramycin. The only question in his mind was which autoimmune disease he'd be stricken with, and how severe it would be.
"Assuming your hypothesis is correct," Rip said, "this still doesn't tell us how we can modify the process in vulnerable patients so they don't develop autoantibodies."
"Let's approach this logically," John said. "What do we use to treat autoimmune disorders?"
"Corticosteroids" came the reply from three mouths almost in unison.
"But that's a temporary measure at best. The patient with temporal arteritis may have to receive multiple courses of ste roids as the symptoms recur. Steroid therapy doesn't cure rheumatoid arthritis. It only alleviates the symptoms," John said. "What else?"
"Antimetabolites," Sara suggested. "Methotrexate, for instance."
"Again, a temporary measure," John said. "What if there were something that, instead of cleaning up the symptoms they produce, could block those antibodies from attacking the person's own tissues in the first place?"
Rip shook his head. "That would be perfect, but unfortunately we don't have such a drug."
Lillian and John exchanged glances. Maybe being older did translate into being wiser and able to think outside the box. In response to a faint nod from Lillian, John spoke up again. "I have a suggestion. Omalizumab."
He told them what he had in mind. Perhaps this compound, developed specifically to block the antibodies responsible for hay fever and asthma, would neutralize the abnormal antibodies made by the patients who'd received Jandramycin.
John watched expressions in the group change as disbelief gradually gave way to the realization that it might actually work.
"It's an off-label usage for a preparation that might—I emphasize might—do what we want it to do. It's expensive, and we don't know how many doses it might take. Most important, there's risk in using it on patients whose immune system has probably already been modified by Jandramycin."
Rip frowned. "Wouldn't we have to get the approval of the IRB?"
"It would take weeks to get a proposal before the Investigational Review Board," Sara said, "and if we did, they might not approve it." She looked down at her clasped hands. "And I have a little girl who, despite large doses of steroids, is losing a fight with ascending paralysis with each day that passes."
"That's why I'm making this suggestion. And it can't go beyond the four of us in this room." He waited until he'd received nods of assent from the others. "I want to volunteer to test it on me."
"But you haven't developed any complications," Rip said.
"No, but I have a history of allergy, so I'm in line to do just that. I'll take it. If there are no adverse effects, if it doesn't appear that the Jandramycin has set me up to react adversel
y to the drug, that's a big step. Then if I don't develop an autoimmune complication, that tells us even more." He spread his hands. "Sure, it's not a double-blind, placebo-controlled study, but it's all we've got."
"How soon do you think we'd know something?" Sara asked.
"It generally takes effect within a few days. But if there are going to be complications from it, they'll show up within an hour or two," John said.
"And if it works, maybe I could give it to Chelsea?" Sara asked.
"Do you have something better?" John asked.
The silence in the room effectively answered the question. Finally, Rip spoke. "Since I'm what passes for the secondin-command on this investigation, and none of us trust the principal investigator, I'll speak up. Go for it."
"I'm going to talk with Chelsea Ferguson's mother about giving it to her," Sara said. "I'm pretty sure she'll jump at the chance."
"Don't you want to wait—" Rip said.
"I don't think I can wait much longer. If John tolerates the test dose, Chelsea will be next," Sara said. "I just pray we're not already too late."
Sara wasted no time in going to Chelsea Ferguson's room. She told Mrs. Ferguson about omalizumab.
"What?"
"It's a long word," Sara said. "Just call it OMAL, like some of us do."
"Will it work?"
Sara decided to be blunt. "We don't know if it will work. But right now it's all we have."
Mrs. Ferguson grasped at the possibility like a drowning man reaching for a piece of driftwood. "Anything that might help Chelsea. Anything."
"You recognize that this is not only what we call off-label, but it's never been used in these circumstances. Frankly, it's a shot in the dark. It may not work, but—"
"But nothing else has. I know." Mrs. Ferguson cast a glance at Chelsea, who remained immobile, staring at the ceiling. For the past two days, she'd been virtually uncommunicative, withdrawn into her own private world. "I want you to use anything that might have a chance. And I know Chelsea does."
Sara nodded her understanding. She reached down to take Chelsea's hand and was pleasantly surprised to receive a weak squeeze in return. "Dr. Ramsey is getting his dose of the medication right now. If there are no ill effects, I'll plan on giving Chelsea hers. Of course, there'll be papers to sign—"
"Do you have them with you? I'll sign now. I just . . . " Mrs. Ferguson let the words trail off, but Sara knew what they were. The woman would do anything to make her daughter well.
Sara could identify with that. She'd feel that way about her child. She felt a tear form in her eye and turned away before
Chelsea could see it. "I have to get the papers ready. I'll see you soon." She hurried outside.
Sara was in the hallway when her cell phone vibrated in her pocket. She checked the caller ID and decided she was in no mood to talk with Mark Wilcox. He was a nice guy and obviously interested in her, but right now her total attention was focused on Chelsea. Besides, she was beginning to have her suspicions about Mark. Matter of fact, she was becoming positively paranoid about almost everyone with whom she came in contact, fearing they might be involved in the conspiracy to hide Jandramycin's side effects.
Time to focus on Chelsea. It was hard for Sara to imagine the teenager's growing fears as the weakness in her limbs progressed. She could no longer walk, and the strength in her arms diminished every day. It was harder and harder for Sara to present a smiling countenance when she entered Chelsea's room. She didn't know how Mrs. Ferguson managed it, but it was obvious that she was on the verge of exhaustion.
Sara hurried back to the clinic, where she found John Ramsey in a back room sitting on the edge of the treatment table. "Have you had the injection yet?" she asked.
John nodded toward the corner of the room, where Rip Pearson was withdrawing a clear, slightly thick solution from a vial into a syringe. Lillian Goodman stood beside him, holding several alcohol sponges and a couple of packaged injection needles.
"That's a full dose," Rip said. He went through the routine to eject residual air from the syringe, changed the needle, and stepped to John's side. "Ready?"
"Let's do it before I change my mind," John said.
Rip swabbed John's upper arm with one of the alcohol sponges, pinched the tissue between his left thumb and fingers, and plunged the needle into the soft tissue of the arm. "I have to inject this slowly because it's so thick. Hang with me."
John gritted his teeth, but said nothing. Sara began counting in her mind: one, two, three . . . She'd reached twenty-seven when Rip pulled the needle free and pressed a fresh alcohol sponge against the injection site. "Hold that for a moment, then I'll give you a Band-Aid."
Sara looked at her watch and did a quick calculation. The major risk with this drug was anaphylaxis—a massive allergic reaction that could cause the airway to close off, blood pressure to drop, resulting in death if not properly managed. In the rare instance this had happened after such an injection, the signs occurred within ninety minutes or less.
"I'll stay here with John for the next couple of hours," Rip said. "You guys go ahead to your clinics. I'll let you know if anything develops." He pointed to the emergency equipment on the table in the corner, and the message was clear. He was prepared to treat any allergic reaction that might develop. Expect the best, prepare for the worst.
"I don't think—" Lillian began.
"Please," John said. "Rip will be here with me. If you two both cancel your clinic this afternoon, someone's going to talk about it. Then word will get back to Ingersoll, and we don't know what might come of that."
Lillian squeezed John's hand. "I'll check on you as often as I can."
"No," John said. "We don't need a parade going in and out of this room. Rip told the nurses he needed the room this afternoon, but they don't know what's going on. So far as anyone knows, this is just another part of the Jandramycin study. Let's keep it low-key."
Sara looked at her watch. "It's a quarter to one now. We should know something in an hour and a half. Two hours at most. Why don't we meet in my office at three?"
There was grudging acceptance of the plan. Sara touched John's shoulder and whispered, "I'll be praying for you." As she slipped out of the door, butterflies gathered for a convention in her gut.
22
WELL, WE'VE GOT SOME TIME TO KILL," JOHN SAID. "DO YOU WANT TO catch up on your journals? Do chart work? Go ahead. I'll just lie here quietly and wait for my throat to start closing up and my blood pressure to plummet."
"Don't even joke about it," Rip said. "I know that we believe Jandramycin may have affected your immune system, but in regular patients the risk of anaphylaxis is tiny—maybe one chance in a thousand."
"Ah, but there's the rub. What happens in someone after Jandramycin resets some of the switches in the immune system?" John didn't voice the rest of what he was thinking. In his case, did that risk go up to one in a hundred? One in ten? A hundred percent?
"Enough of that." Rip made one more note on the pad in his lap. If this went well, he'd add the material to John's chart. If it didn't, he might end up shredding it to avoid losing his medical license. "Tell me about Randall Moore."
John shifted on the exam table, trying in vain to find a comfortable spot. Finally, he gave up and swung into a sitting position with his feet dangling over the side. "All I know is what I've been told. He and his sister are the only children of a wealthy family. He inherited a good bit of that money when his father died and has been living offit ever since."
"Why is he suing?"
"His mother was headed for the internal medicine clinic to see someone for a second opinion when she had a fatal stroke. Apparently, in Randall's world, when something bad happens, filing a suit is a reflex action. So he filed one against the medical center and every doctor involved with her from the time she hit the floor. I started an IV while we waited for the EMT's." John spread his hands. "So they threw me in for good measure."
Rip lowered his head and massaged his te
mples. "That's just dandy. If his culture comes back Staph luciferus—and the odds are that it will—I can give him Jandramycin and probably save his life, but there's a chance that he'll get a life-changing and possibly fatal complication later." He looked up. "But if I don't, he'll probably die. And as a physician, I can't deny him treatment that would prevent that." Even if it would put an end to his lawsuit against my friends.
"There's another possibility, you know."
"What?"
"This drug may work. If I don't get a late complication, if Sara's teenage patient starts to recover, we may have stumbled onto the answer. Give this to every Jandramycin patient after their course of treatment, and they'll do fine."
"Sounds too good to be true, John." Rip shook his head. "Don't get me wrong. I don't want you to get a complication from your treatment. I hope and pray that Sara's patient pulls through. But something inside me keeps telling me not to get my hopes up."
"I guess I hear a different voice," John said. "Beth drummed it into me so often I can still hear her saying it. 'God's in con trol.' We may not see His hand, but it's there. And I think He's got this covered."
Rip looked at his watch. "Well, in about an hour we'll know what He's got up His sleeve for you . . . and the rest of us."
The afternoon dragged, and Sara found it difficult to focus on her patients. As she walked out of every patient's room, her eyes were drawn to the closed door at the end of the hall. How was John doing? Any problems after the injection? Fortunately, no big diagnostic challenges presented themselves, and she was able to care for her patients without too much trouble. By five minutes to three, she was caught up.
"Glenda, my next patient isn't due for twenty minutes. I'm going to run over to my academic office for a minute." Although she didn't actually run, Sara moved quickly through the halls. She nodded a brief greeting to a few of the people she met and prayed that none of them wanted to stop and chat.
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