A Simple Cure

by Lawrence Gold

  “No, we’ll stay.”

  Terri presented Jennifer’s case in detail. She started with the early diagnosis and treatment, the recurrences and its treatment, and the Phase I trial with BCG vaccine.

  “Have they employed BCG before in the treatment of cancer?” one resident asked.

  “We’ve used BGC in bladder cancer for years, and investigators have used it locally in tumors with mixed results. In animal experiments, BCG has proven amazingly effective. I’ve looked at the data from one patient study in the UK that’s had good results in patients with terminal lung cancer.”

  “What’s going on with your patient, Dr. Powell?” another resident asked.

  “The constellation of events leads us to believe that she has the human form of Mad Cow Disease called variant Creutzfeldt-Jakob Disease (vCJD).”

  “How did that happen?” another woman resident asked. “How does a cancer patient get Mad Cow?”

  “I’m afraid we can’t get into that here,” Terri said. “I’m hoping for some other diagnosis, especially one that can lead to treatment.” She looked over the group. “You’re a well-trained intelligent group, how about a differential diagnosis of Mrs. Howe’s case.”

  “Just a minute, Dr. Powell,” the woman resident said, “did the vaccine cause this? Was it contaminated with prions?”

  “What part of ‘I can’t discuss this’, don’t you understand?” Terri snapped.

  “I just...” said the resident her eyes filling with tears.

  “Life’s complicated,” Terri said, “and so is experimental treatment for fatal diseases.”

  “Back to my question,” Terri said. “Your differential diagnosis.”

  “That’s the differential diagnosis of causes of dementia, isn’t?” a resident said.

  “Not quite. It’s dementia plus a whole range of neurologic abnormalities not normally seen in Alzheimer’s and diseases like it. Let’s run through them, and you can forget about the ones we can’t do anything about...the ones we can’t treat. Let’s start with common infections.”

  “HIV, syphilis, Tuberculosis,” one resident said.

  “Unusual organisms such as ameba, fungi, and Listeria,” said another.

  “I’m waiting,” Terri said as the residents looked at each other.

  Finally, another resident said, “Structural abnormalities of the brain like hydrocephalus, strokes, and brain hemorrhages?”

  “There’s an array of weird brain diseases, like Pick’s Disease or other demylenating diseases,” a resident said.

  “Yes,” Terri said, “but none of them are treatable. I’m searching for something we can treat.”

  “How about some kind of toxin or poison?” another asked.

  “Like what?” Terri asked.

  “Pesticides, heavy metals, ricin...who knows what else.”

  “Not ricin,” Terri said. “Ricin toxicity is primarily diarrhea and vomiting.”

  “Could this be psychiatric?” a resident asked.

  “Not with our objective findings,” Terri said.

  Terri looked at the group. “Make an exhaustive list. We’ll see if we can rule them out one by one. Now, if you’ll excuse me.”

  After they left, Terri shrugged her shoulders. “I’m sorry, but we can’t exclude the house staff at this hospital from cases like Jennifer’s.”

  “That’s okay,” Mickey said, “can they really help?”

  “Residents spend most of their time trying to one-up each other or impressing attending physicians like me. They’re up to date on everything, and yes, they might help.”

  “It’s ironic, isn’t it?”

  “What do you mean?” Terri replied.

  “That you cured her cancer, yet she died anyway.”

  “I’ll do anything to prevent that.” Terri stared at Jennifer, at Marlene, then back to Mickey.

  “What is it?” Mickey asked.

  “There’s one way to be sure of the diagnosis.”

  Mickey and Marlene remained silent.

  “This sounds worse than it is, but we can insert a small needle into Jennifer’s brain to obtain tissue for examination. We call that a brain biopsy.”

  Marlene gasped. “You want to take part of her brain?”

  “It’s a small needle biopsy.”

  “How do you get in her brain?” Marlene asked.

  “Let’s not get into the details,” Terri said. “It’s a safe medical procedure.”

  “Tell me,” Marlene said.

  “We drill a hole through her skull.”

  Marlene drifted, almost falling to the floor when Mickey caught her.

  “Mother, are you okay?” Mickey asked.

  “I’m fine, it’s just...”

  “I know,” Terri said, “but a brain biopsy is safe.”

  Mickey stared at Terri. “What good would it do to make a diagnosis of Mad Cow, CJD or whatever. You can’t treat it, right?”

  “That’s not what I’m hoping for. I’d like to find an infection of some kind, or even cancer. We might be able to treat those.”

  Mickey looked at Marlene, then back to Terri. “When will you do it?”

  “I’m not ready to go ahead with the biopsy yet. Let’s see what the rest of the workup reveals.”

  “There’s something else, Terri,” Mickey said.

  “What.”

  Mickey looked at Marlene. “When Jennifer first became ill, we talked about her wishes should all treatment fail. She signed an advanced directive for health care and told me that she didn’t want any part of aggressive treatment if she had no hope of meaningful survival. Specifically, she didn’t want to wind up in a persistent vegetative state, or worse, on a ventilator with IVs and tubes everywhere.”

  “That’s ridiculous,” Marlene said. “She said no such thing to me, Doctor.” Marlene turned to Mickey. “I can’t believe you’d do such a thing to Jennifer.”

  Mickey stared at Marlene. “It’s what she wanted, and it’s what I’d want too. I can’t think of anything worse than being kept alive when I had no hope of survival.”

  Marlene shook her head. “As long as she’s living, there’s hope. When she’s dead, there’s none.”

  “I’m sorry, Marlene,” Mickey said. “That may reflect your values, but they’re not Jen’s or mine. She made me promise to respect her wishes. I will. You should too.”

  Terri took both their hands. Let’s hope that this discussion is academic.”

  Chapter Fifty-Five

  Richard, Woody, and Eddie said nothing on their trip back to Chicago. It was a few minutes after seven in the evening when they arrived at Kendall.

  Richard looked at Woody and Eddie, but failed to meet their eyes.“Let me speak with our attorneys and we’ll get together.”

  Woody stared at Richard. “I hope it’s not necessary to remind you that we’re in this together.” Woody closed within three inches of Richard’s face. “Don’t do anything stupid. Eddie and I are resourceful people and we know how to protect our own interests. I hope you understand.”

  Richard felt his stomach cramp. He took two steps back. “Don’t be ridiculous. I wouldn’t do anything to compromise our mutual interests.”

  Afterward, back in Woody’s office, Eddie stared out the window. “I don’t trust that fucker. He’d burn our ass in a nanosecond to protect his own.”

  “There’s more to this whole thing than we know, especially about Richard’s relationship with PAT and David Birch—those two are deep into something.”

  “Do you want me to discuss this with Dr. Birch?”

  “No, Eddie. I have just the man for the job.”

  “Who?”

  “Mr. Brooks.”

  “Brooks? He’s Richard’s man, isn’t he?”

  “Brooks and I went through Special Forces training together. Who do you think put me onto the security job at Kendall Pharmaceuticals?”

  When Richard entered the executive suite, the lights were dimmed. He opened his office door and stopped
. Behind his desk sat Lionel Kendall, his father and the chairman of the board of directors.

  “Oh,” Richard said, “you startled me.”

  “How was your trip?”

  “I’m glad you’re here, Father. We have a problem...a big problem.”

  “You mean you have a problem,” the old man said as he relit the soggy cigar crushed in his teeth.

  “Everything I did, Father, was in service of Kendall Pharmaceuticals.”

  “Don’t give me that crap, Ricky. I warned you.”

  “Now, Father...”

  Lionel stood and pointed to the chair in front of Richard’s desk. “Sit.”

  “Don’t talk to me in that tone.”

  “Get your ass in the chair, Goddamn it. Don’t fuck with me now, sonny.”

  Richard had seen Lionel angry before, but nothing like this.

  “I want to hear it...every detail, every stupid mistake that put my company in jeopardy.”

  Richard sat, head down, staring at the floor and over the next fifteen minutes narrated the events beginning with the murder of Emile Gigot and the theft of the Laval BCG.

  “David Birch said that the BCG had a multimillion dollar potential...maybe multibillion. It was supposed to be a run-of-the-mill robbery...nobody was to be hurt.”

  “Go on.”

  Richard told Lionel about Lisa Gomez and her relentless interest in the origin of the research BCG. He told him about Woody Hawkins, Eddie Macy, and Karl Muller, and finally about his meeting with Quinn Conner, the Alameda County DA.

  “Is she going to charge you? Charge Kendall or its employees?”

  Richard swallowed. “Yes. We need to meet with our attorneys ASAP to prepare our defense.”

  Lionel crushed his cigar into the crystal ashtray. “Tell me where I’m wrong, Ricky. PAT was in possession of stolen goods. The BCG was obtained by theft and murder. Our agent, Karl Muller was responsible for the death of Lisa Gomez and the attempted murder of Terri Powell. Kendall pharmaceuticals has administered a vaccine contaminated with prions and is responsible for the death of one patient and perhaps another.”

  “You think I don’t understand what’s going on, Father. You didn’t create Kendall Pharmaceuticals by following all the rules. I was just following in your footsteps.”

  Lionel crimsoned. “My footsteps left no trace. Yours have led us to destruction.”

  “Father,”

  “Shut up, Ricky. There’s a difference between aggressive business practice and criminality, but you’re too stupid to know the difference.”

  “You mean you were lucky enough not to be caught, Father. I know how you obtained the patents that built this company—not exactly ethical.”

  “You’re pathetic, Ricky. Our competitors tried to screw us on those patents, but they couldn’t prove shit. That’s the difference between us.”

  Lionel moved around the desk and stood beside Richard. He placed his hand on Richard’s shoulder. “I want your resignation on my desk by tomorrow morning.”

  Richard threw Lionel’s hand off his shoulder. “You’re out of your mind. I’m not going to resign. You don’t have the power to force my resignation. I have friends on the board who owe me, who’ll stick with me.”

  “You’re deluded. You may have managed to do what all our competitors have tried for years to do, destroy Kendall Pharmaceuticals. Board members will be spending all their time disavowing you and your activities as a rogue, acting on his own and without the authority of the corporation. Make sure your resignation is on my desk.”

  “Father, please,” Richard said, crying. “I did all this for Kendall...for you and Mother. You can’t abandon me now.”

  “For your mother’s sake, I’ll buy you the best defense possible, for all the good it will do. I’ve made mistakes in my life, but none greater than allowing your mother to indulge your weakness and irresponsibility. What was I thinking when I allowed you to become CEO?” he said shaking his head.

  Chapter Fifty-Six

  Terri and Matt sat at Jennifer’s bedside that evening, their last stop before going home.

  “It’s the disconnect I can’t stand,” she said.

  “Disconnect? I’m not sure what you mean. You’re doing everything you can.”

  “I know. It’s not that. We’re going to shop for dinner. I’ll, or if I’m lucky, you’ll cook and we’ll try to have a pleasant evening. I’ll get up tomorrow and get Abbie ready for school while Jennifer, my friend, remains in a coma. It reminds me of the Iraq war, only those with boots in sand suffer.”

  “It’s one thing to suffer over your limitations as a physician. It’s another to take the blame for something you can’t control. If you’re into that, I have a whole list of things for you, like poverty, the war in Iraq, etc.”

  “I manipulated the study protocol to bring Jennifer in. I gave her the vaccine. She’s dying from Mad Cow Disease. How do you think I feel?”

  “Shitty. What would have happened if you hadn’t given her the vaccine? Where would she be now?”

  “She’d be dead, but it wouldn’t have been by my hand.”

  “Look, if you want to blame yourself, go ahead. Maybe there’s something in that for you.”

  “What are you talking about?”

  Matt shook his head. “The words sound inane to me even before I speak them. Your life is caring for your patients, helping them in any way you can. I wonder why you’re so willing to question your motives?” He grasped her hands and stared into her eyes. “You don’t need redemption—you’ve done nothing wrong.”

  Terri’s eyes filled with tears that ran down her cheeks. “I know, but I still feel guilty.”

  “I can’t recall a time in my life when I couldn’t have done better,” Matt said looking at the floor. “I could have been a better son, a better cop, a better partner to Ronnie, and even a better writer. I think it’s the curse of good people who rush toward the sublime, but remain mired in their humanity.”

  “We can always make things a little better, can’t we?” she said squeezing his hands. “I’m bad at professional detachment, and in the practice of oncology, the price is high.”

  Matt drew her close. “Our best people always suffer in an imperfect world. Ronnie worked long enough on the streets. He refused advancement that would put him in an administrative position and kept him safe. I marvel at his dedication, and yours, too, Terri.”

  “Let’s go to bed,” she said. “Just hold me—that’s all I need.”

  When Terri arrived the next morning at San Francisco General, she parked in her reserved space. She stood a moment beside her car and stared up between the gritty-grey buildings. Streaks of brown city smog and pure white steam crossed the gap. She hesitated a moment, took a half breath, and entered the battlefield.

  She locked her purse in her office, grabbed her lab coat, and walked to the residents’ room.

  The third year resident was grilling his team of interns and medical students, but stopped when Terri entered.

  “Dr. Powell. Good morning.”

  “Good morning. Have you made rounds on Jennifer Howe today?”

  “Yes,” she said. “I’ll ask one of the students to brief you.” She pointed to a young woman. “Abbie, go ahead.”

  “Abbie,” Terri said. “That’s my daughter’s name.”

  Abbie stood. “Jennifer had a bad night, Dr. Powell. She remained restless, yet the nurses were unable of getting more than a groan when they tried to stimulate her. Her temperature’s up to 100.8 degrees, but her other vital signs are stable.”

  “What about her lab?” Terri asked.

  “Everything’s out of whack.”

  “Abbie,” said the resident.

  “I’m sorry, Dr. Powell,” she said looking at her feet.

  “Please, go on.”

  “She’s mildly anemic and her white cell count is elevated suggesting some sort of infection. Her electrolytes...nothing’s normal. Her magnesium is slightly depressed while she has abnor
malities of her sodium, calcium, potassium, and many others. Her kidney function remains at about 50 percent of normal.”

  “What about her imaging studies, her EEG etc.?”

  “The MRI shows nonspecific abnormalities, Chest x-ray is normal and the electroencephalogram shows some slow waves consistent with her comatose condition.”

  “Let’s take a look,” Terri said as she stood and headed for Jennifer’s room.

  Marlene lay in the corner sleeping.

  Mickey sat by Jennifer’s side holding her hand.

  “Oh, Terri. I’m so glad to see you,” Mickey said. “Anything new?”

  “Not really. She has a low grade fever and her lab tests suggest an infection of some kind.”

  “Where?” Mickey asked.

  “That’s why we’re here. Maybe you’d prefer to wait outside.”

  “Okay, but we’ll talk before you go.”

  “Of course.”

  Mickey awakened Marlene and they stepped out.

  With the help of the house staff, Terri turned Jennifer over in bed examining her for any sign of a bed sore. Her skin was clean. After a complete examination, Terri said, “I can’t find anything. Let’s get a urinalysis and a culture to make sure her urine’s not infected.”

  “It’s pretty cloudy,” said one student, holding up the clear plastic tube that connected the bladder catheter to the urine bag.

  “Any bladder with a catheter will show bacteria,” Terri said. “We call that colonization and not infection. The urinalysis and the cultures will help us make the distinction.”

  After Terri had the house staff leave, she brought Mickey and Marlene back into Jennifer’s room. “We’re checking her urine to see if there’s an infection. I’m trying to adjust her electrolytes, but it’s difficult when the kidneys can’t help.”

  “Are you going to treat her infection?” Mickey asked.

  “No. Not as long as she’s stable clinically and we’re not sure if she’s really infected.”

  “What about the brain biopsy?” Marlene asked.

  “Not yet,” Terri said. “I’m not ready to make that recommendation.”