Weapon of Choice

by Patricia Gussin

  A few sips of coffee and she felt her brain function again. When she felt perplexed, Laura resorted to lists. Write down your priorities. What really must happen today, what can wait?

  6:00: call her friend, Dr. Stacy Jones, at her CDC office in Atlanta. With a Master’s in Public Health and an M.D. degree and working in the hub of cutting-edge research at the Centers for Disease Control and Prevention, Stacy would be as up-to-date as anyone on both the science and politics of HIV. She needed Stacy’s advice.

  6:15: call the O.R. nurse-supervisor to request that she personally supervise every detail of infection control in the operating suites that morning.

  6:30: call home, in case the kids overslept.

  6:31: check Matthew Mercer’s vital signs, labs, blood gases, x-rays, meds, and the patient himself before they wheel him into the operating room.

  6:45: scrub in for the procedure and reassure herself that every member of the team is properly gowned, gloved, and masked.

  6:55: brief the anesthesiologist and the surgical team, emphasize infection control—a valid concern, because the patient had an infection not responding to antibiotics, probably due to a resistant strain of staph.

  She had agreed to call that pharmaceutical company. If they had a new, better drug for resistant staph, now would be the time to get it to this patient, but she cringed at the thought of the administrative quagmire. Laura had been an investigator in experimental drug trials in the past—bronchodilators, anti-inflammatories, and an antibiotic—and she knew perfectly well how the massive paperwork would sabotage her schedule. Moreover, she knew that no one at the company would pick up the phone before eight o’clock. By then she’d be exploring Mercer’s lungs. The Keystone Pharma call would have to wait.

  Between now and 6:30: sign as many charts as possible to make the paperwork go away.

  Noon: chief of staff meeting, mandatory—unless life-and-death kept her confined to the O.R.

  How long would this morning’s procedure take? Not long. Get in, drain the fluid, biopsy whatever was in there, culture everything, and get out as fast as possible. On a surgical risk scale of one to ten, this patient was a nine. If he wasn’t so young, she’d put him at a ten. Losing him on the table would not be good for her statistics, but the only way they could help him was to get into his lungs and find out what lurked there.

  1:00 or 1:30: if her look inside Mercer’s chest and the micro and histology results more or less confirmed AIDS, she’d meet with her counterpart, the chief of medicine, and Kellerman, the infectious disease specialist. How to proceed with Mercer would be their decision. Maybe she could persuade one of them to call Keystone Pharma about the new drug; if not, she would, as promised.

  2:00: lung reduction procedure

  5:00: lung biopsy, suspected carcinoma, complicated by beryllium toxicity

  6:00: dictate surgical notes

  6:30: round with residents—critical patients, only

  7:30: home for dinner, go over Patrick’s and the twins’ homework; call Mike at Notre Dame, she’d missed his call yesterday from South Bend, but she had caught up with Kevin at the University of Michigan in Ann Arbor. Both would be home on Thanksgiving, only four days away.

  Patrick’s baseball game: She’d have to miss it—but she had spent almost the whole weekend with his team.

  CHAPTER THREE

  MONDAY, NOVEMBER 25

  Victor Worth had not slept at all after hearing from that woman doctor last night. Matthew, his son, dominated his thoughts. Victor only had learned of Matthew’s existence a month ago, but in that short time Victor’s life had turned around. No longer was he the self-focused individualist, caring for no one, convinced that no one gave a damn about him. Until that letter arrived from Cindy, Matthew’s mother, Victor had never had reason to consider how being a father could affect him—could dramatically change his life. How could he? Matthew, flesh of his flesh—a reality Victor had dismissed as impossible. If he’d only known in time about Matthew, his son’s life would have been so different.

  Cindy Mercer, a shy, unassuming girl, could not be expected to raise a manly son. Bereft of a male role model, Matthew had turned gay. Victor didn’t blame Cindy, but neither did he blame himself. He hadn’t even received her letter, introducing him to Matthew, until after her death. But he couldn’t help wondering what he’d have done had he known at the time, during the blackest moments of his life, that Cindy was pregnant? Back then he’d had to use every iota of his emotional and physical reserves to battle testicular cancer.

  The arrival of the posthumous letter transformed his life, shook him to his core. According to Cindy, he had a son. Now thirty-two years old. The birth year coincided with Victor’s only sexual relationship ever—in his senior year at the University of Virginia, with a student nurse named Cindy Mercer. In her letter, Cindy explained openly, yet sensitively, that their son was a homosexual, a sweet, vulnerable young man who was ill. She’d pleaded with Victor to help his son.

  With uncharacteristic impulsiveness, surprising even himself, Victor had traveled to Clearwater, Florida, to meet the boy. One glance had been enough. Victor felt an immediate surge of love and compassion for the thin young man with the curly auburn hair and the most amazing blue eyes. But thanks to Victor’s medical background, one look also made him suspect that his son was a victim of the disease known as AIDS.

  Infectious diseases—though not viruses, per se—had been his life’s work. Right out of his Ph.D. program at Georgetown, he’d started at the NIH, working first with staphylococcal organisms and then with pathogenic fungi. His government research position gave him access to the top resources in the D.C. area capable of treating AIDS. He planned to head back to Clearwater over Thanksgiving weekend and convince Matthew to transfer to George Washington University Hospital. Victor could get him the best of care. But before Victor could make the preliminary arrangements, first he’d have to broach the subject of AIDs with Matthew—in effect, deliver a death sentence to his own son. Victor had never envisioned Matthew ending up in a Tampa hospital so soon.

  The dire prognosis of AIDS notwithstanding, Victor vowed to do anything in his power to prolong Matthew’s life, to give them some time together. His son. He still was in disbelief. And during the night after Dr. Nelson’s call, Victor had charted his first step. Matthew’s immune system, damaged by the HIV virus, struggled to stave off other organisms, one of which Dr. Nelson thought was a resistant staphylococcus. With Victor’s connections, he could get his hands on a new, not yet commercially available, antibiotic against staph: ticokellin was the generic name.

  CHAPTER FOUR

  MONDAY, NOVEMBER 25

  Laura adjusted the water temperature, about to start her surgical scrub, when the operating room clerk handed her the phone. “Eileen Donovan.”

  “Just in time. What’s going on, Eileen?” Laura’s secretary was one of her three “moms.” Peg Whelan, her real mother; Marcy Whitman, her housekeeper; and Eileen, each in her early sixties. Laura knew she could hardly function without all three generous, smart women in her corner.

  “You must have been in before dawn to sign all those charts, Laura. Good girl. Sorry your schedule got all botched. I know Marcy is away, so I double-checked on the kids. All three are on schedule. Med school dean’s office left a reminder message: don’t be late for the noon staff meeting. And I’m going to call and tell the kitchen to make sure they bring you a big salad.”

  “I’ll eat whatever they serve. Just expedite those charts so Medical Records stops breathing down my neck. Seriously though, the case this morning has the potential to go bad in more ways than one. Did Dr. Stacy Jones at the CDC return my call? I left her a message early this morning.”

  “No. Do you want me to follow up? What’s it about?”

  “I’ll tell you about it later. Will you check with my research lab—make certain the bovine pericardial tissue arrived?”

  Laura stood in the operating room glare, scalpel poised to access t
he patient’s lungs through a left lateral incision. Matthew Mercer already had been intubated and placed on a ventilator. Over the past seven hours, his status had deteriorated to acute respiratory distress syndrome. Her mission was to retrieve lung tissue that would establish the cause—without the patient dying on the table, or in the recovery room, or afterward in the ICU. Her medical colleagues’ task would be to treat whatever she found in his lungs.

  Without explanation and ignoring their gripes, Laura had insisted that the operating team, including the anesthesiologist on his perch behind a screen at the patient’s head, be issued plastic face covers as a supplement to the masks they routinely wore.

  “Ready, Laura,” announced the experienced anesthesiologist. “Patient is as stable as he’s ever going to be. I’d suggest getting in and out fast.”

  Laura usually let her chief resident start a case and continue as far as he or she was capable, often all the way through the case. At the end, she would let a junior resident or a medical student take over, under close supervision. But not today.

  “I’ll do this.” She would run this case to minimize the hospital staff’s involvement. If they were dealing with HIV, she couldn’t be too cautious.

  “Michelle, spread the ribs,” she said, having made the incision through the intercostal space, exposing the thoracic cavity. “Use the retractors to hold it open.”

  To the fourth year med student standing across the table: “Maintain suction and get out as much of this fluid as possible. Note how purulent it is. I’m betting that it grows out staph and heaven knows what else.”

  Laura exposed the left lung, holding it in gloved hands, inspecting it. “An abscess,” she announced, “—focal point for the infection. Get a drain ready, please.” She had her usual team: Willa, scrub nurse; Cathy, circulation nurse. They’d worked together so long that they could communicate in a few curt phrases.

  “We’ve also got diffuse interstitial infiltrates. Let’s get all this cultured.” She didn’t know the medical student’s name. “Sorry, you—could you hold the culture tubes and then hand them to the nurse, specifying their origin. If you don’t know, ask me.”

  “Michelle, see—here, this bruised area. Much like the lesions on his face and the rest of his body. We’ll need a biopsy of these. Willa, are we ready with the instruments and the specimen containers? We are going to have to stop the ventilator long enough to do the biopsies. I only want to stop it once. Is everything ready?”

  “When you say go, Laura,” said the anesthesiologist, “I’ll halt the machine. But I’m having some problems holding pressure.”

  “Ready. Disconnect.” Laura used an automatic linear stapling device to harvest the ten biopsy sites she wanted.

  “Okay, reconnect! How much time?”

  “Sixty-one seconds,” a younger male voice said from beyond the drape separating the patient’s head from the operative site. “That was fast.” The anesthesiologist’s resident and his medical student stood alert, their stance as Laura had requested. These were bright kids; they all knew this was an unusual case, just not how it was different.

  “Let’s drain that abscess, put in two chest tubes—and get him to recovery. Keep him in strict isolation until we get those cultures back.”

  “Will he be able to come off the ventilator right away?” the medical student across the table wanted to know.

  “No,” the anesthesiologist answered. “When you open up a patient with acute respiratory distress, they usually need mechanical ventilation for hours, sometimes days. Until you control whatever is causing the lung disease. Let’s just hope that antibiotics will kick in for this one.”

  Laura inserted the chest tube herself, something she hadn’t done in years with all the eager house staff surrounding her whenever she operated. The entire procedure had lasted a mere thirty minutes. Now she was sorry that she had pushed back her original nine o’clock case to late afternoon. Another late night.

  “Michelle, will you get x-ray confirmation of the chest tube placement before the team leaves the room?”

  “Sure, Dr. Nelson, and I’ll go with the patient into the recovery room. Any relatives we need to talk to?”

  Laura knew why Michelle asked. Laura always included her residents when she reported the results of surgery to the patient’s loved ones. She’d tell them, “This may be the most important responsibility we have—to inform them truthfully, in a sensitive and understandable way.” Michelle had taken this direction to heart; she was fast becoming not only a skilled, but a compassionate, surgeon.

  “His father should be in later today,” Laura said. “Reminds me, I did promise him I’d try to get some experimental medication for his son.”

  “What med is that?” Michelle asked.

  “An antibiotic for resistant staph. I wrote down the name. Nothing familiar to me. May I ask you to do some research on that? Look at Keystone Pharma. It’s a new drug now in clinical trials. Let me know what you find. Before eleven thirty, if possible.”

  “You can get an unapproved drug?” Michelle asked.

  “Not without an extraordinary administrative hassle, but I agreed to give it a try.”

  Laura reached for the clipboard with the phone number and name of the drug, wanting to fulfill her pledge to the father, but not holding out much hope that she’d prevail over regulatory bureaucracy.

  “Dr. Laura Nelson, here,” she said, “I’m calling Dr. Norman Kantor in your research department.”

  Laura waited, forced to listen interminably to insipid music. The operator came back: Dr. Kantor was no longer employed at Keystone Pharma.

  “I’ll talk to your head of research.”

  She was told to be more specific.

  “Connect me to the director of infectious disease research.” This time she heard a voice message. She left her name, phone number, and told the machine that it was urgent.

  While she waited for the return call, she phoned the recovery room. Mercer had arrived. Isolation protocol in effect. On a ventilator. Condition: critical. Then she called the head of Pathology. The lung specimen biopsies would show Kaposi sarcoma, she told him, and suggested a methenamine silver stain for Pneumocystis carinii cysts on the lung infiltrate specimens. Prior culture results had documented staph, she said. Would Microbiology please include all known antibiotics in the sensitivity testing panel?

  She expected him to blurt out “AIDS?” but he didn’t. He merely sounded annoyed that a surgeon had any knowledge of cytology stains and sensitivity tests. She thanked him profusely for the extra tests.

  Laura took a breath and reached into her drawer, extracting her beryllium lung toxicity file. In an incredibly weak moment, she’d agreed to testify in a case against a metal machining plant about an hour away in Manatee County. The company used beryllium as a hardening agent in alloys. Beryllium is element number four on the element table, and because of its low density and atomic mass, valuable to many industries, particularly aerospace. Problem is, when inhaled, beryllium is corrosive to tissues, and when it leaks into the environment, well, that’s not exactly beneficial, either. Whatever had possessed her to get involved? As if her schedule weren’t off the charts already. Now she had to prep for what promised to be a vicious cross-examination by the defense.

  Not able to concentrate, Laura decided to abandon beryllium—she’d just polish off the article she had cowritten for the New England Journal of Medicine on her real research love, lung reduction surgery.

  At ten thirty, Stacy Jones called from the CDC. Laura briefed her friend on Mercer’s case.

  “Laura, I believe you’re looking at full-blown AIDS. Your patient’s prognosis is dismal. Send me a blood sample, and I’ll get some tests done. We’ve got Gallo’s test kit, the one the FDA is evaluating, and we’ll look at the patient’s T-cells and CD4 count. But with Kaposi and P. carinii, the prognosis can’t be good.”

  “I hope I didn’t send him over the edge, opening him up.”

  “You had to g
et the tissue, right? Make sure that in addition to those staph antibiotics, you get him on Bactrim. It’s the drug of choice, intravenous is your only option. Another thing, this AIDS situation is moving so fast that I doubt your local infectious disease specialist will be up-to-date, so keep me in the loop.”

  “Doctor Stacy, I can’t believe you used to be my protegé. How the tables have turned! When I advised you to go to Harvard, little did I imagine that you’d end up a hotshot public health expert.”

  Laura was proud. How many years had it been since she’d met Stacy, then a high school freshman in inner city Detroit? An easy calculation. Eighteen years. From the year she herself had entered University Medical School in Detroit. 1967, the year of the Detroit riots that decimated Detroit and nearly devastated her life, as well. So much bad fallout had come from those riots, but precious little good; Stacy Jones was an example of the good.

  “You already know you need to put some stringent public health precautions in place,” Stacy said. “I’ll fax you our recommendations. This disease is such a political hot potato that the limits of confidentiality are a science in their own right: what can be disclosed about HIV and what can’t. Your patient can have syphilis or gonorrhea or genital herpes and you can flag his chart; with HIV you have to keep secrets. Crazy, but that’s how it’s coming down. We have Dr. Koop, Reagan’s surgeon general, to thank for that.”

  Laura could not suppress a chuckle. She, a Grand Rapids Republican; Stacy, a Detroit Democrat. Some things never change.

  Stacy had the last, affectionate word. “You’re my guardian angel, Laura, always will be.”

  Laura hung up the phone, envisioning the dynamic about to play out: thirty-two-year-old Stacy Jones, an African American, handing down instructions to Kellerman, Tampa’s sixty-five-year-old prima donna senior infectious disease authority.