The President's Doctor

by David Shobin

  Nonetheless, the methodology and performance details had been worked out. Although there were expected variations in technique, the procedure most commonly employed called for direct injection of the fetal cells into the target area. Experimenters differed on the cellular amounts transplanted and the mechanics of injection. But having devoured every written report he could find, Jon became comfortable with how to proceed.

  There was also the very real issue of being doctor to one’s relative, particularly when it was a child. Those who disapproved pointed out that managing a sick child was an emotionally charged situation that could overwhelm a caring parent and thwart the objectivity of the most skillful physician. Because of this, medical ethicists frowned on situations were parent and doctor were one and the same. And yet, its proponents argued it was only the parent/physician who truly had the child’s best interests at heart. What ended the philosophical discussion for Jon was his knowledge that what he was doing was illegal. In Tommie’s case, not only could father and doctor be the same, they had to be the same.

  Of course, nothing could happen without Tommie’s knowledge and consent. The seed for Jon’s efforts was actually planted a year and a half ago, when the usually upbeat Tommie was lamenting things she’d never be able to do. As the months went by, Jon drew her out on this. Realistic though she was about her disability, Tommie regretted the unfairness of never being able to ski, or the finality of not being able to dance. It was then that her father gently broached the subject of what she was willing to do about it.

  Over the ensuing months, Jon explored the therapeutic options with his daughter. When he discussed a fetal stem cell transplant, he was careful not to sugarcoat the fact that it was an as-yet unapproved, experimental procedure. But Tommie was a child, and he was aware that she was relying on him. However bright she might be, and however much he might want her to be a full participant in the decision, she was still a ten year- old girl who depended on her father.

  Primum non nocere, went the medical dictum: above all, do no harm. This was always Jon’s primary consideration. He couldn’t deal with the idea of taking a bad situation and making it worse. But the beauty of the stem cell transplant was that it carried little risk. The injection might provoke a mild host immune response, but little more. It might not work, he reasoned, but it shouldn’t cause any harm. In the end, that knowledge carried the day.

  Yet although the cells themselves were harmless, the injection needle could cause trauma. Where it came to the spinal cord, a slip of even a few millimeters could lacerate delicate nerve tissue. Therefore, careful technique would be critical.

  It went without saying that this had to be a father-daughter secret not intended for sharing with anyone, particularly Victoria. Jon wound up saying it anyway. If his ex-wife ever got wind of what was about to occur, the results would be catastrophic. She’d go right to her lawyer. Once attorneys became involved, Jon would never see Tommie again.

  The time to proceed was now. It was a holiday week, and hospital staffing would be light. Victoria was out of town for several days visiting her parents, so no suspicions would be raised when Tommie stayed with her father. Most important, the purified cell culture was ready to go. Jon extracted an ample amount of fetal neural stem cells and placed them in an isotonic buffer for injection.

  In the various published reports, there was disagreement on how many cells to inject. Jon therefore relied on his own calculations and decided on a concentration of a billion cells per cc. This time—and he hoped it would be the only time required—he’d inject no more than one cc.

  They were going to perform the transplant that morning. It seemed rather silly calling a simple injection a transplant, but that was its technical term. Jon needed a trustworthy assistant. Earlier, when he’d tactfully sounded out Mireille, she was eager to help. She’d taken the morning off to assist.

  “Is it going to hurt, daddy?” Tommie asked after getting dressed in the guest bedroom.

  “Maybe the tiniest bit, princess. All you’re going to feel is a little pinprick from a baby needle. After that, all you’ll feel are my big thumbs.”

  “I’m really starving.”

  “Honey, as soon as we get back, Mireille’s going to make something special. Right now, just hang in there.”

  When they were ready, Jon peered out of the front window’s drawn blinds. He was still shaken by the attempt on his life. The police lab had confirmed traces of undissolved sodium cyanide in the bizarre generator; and ever since, police patrols were very much in evidence. The FBI notified him they wanted to interview him soon. Outdoors, there was no one in sight. Jon nodded to Mireille and opened the front door.

  Jon followed closely behind Mireille, who pushed Tommie in the wheelchair. Jon was wearing a long, lined raincoat. Neither Tommie nor Mireille was aware of the shotgun that hung under his armpit, attached to a strap. Outside, Jon quickly looked right and left and saw nothing suspicious. After the women were in the car, he got in the driver’s seat and set off. During the drive, his eyes had a cat burglar’s nervousness, flitting between the side and rearview mirrors. He didn’t think he was being followed.

  He’d decided to perform the transplant in his office at the medical center. In truth, the intra-spinal injection could have been done almost anywhere. Still, he was treading in poorly charted territory. In the event of an unforeseen emergency, the proximity of a hospital was reassuring. No matter how careful the operator might be, complications like a traumatic injection and allergic reactions were an inescapable part of medical life.

  He’d already taken the purified neural stem cell suspension from the NIH and placed it in his office. Living tissue didn’t keep well and had to be used within one-to- two days of harvest. Jon stored it overnight in an incubator, because lower-than-body temperatures would kill the cells. Once they reached the medical center, he dropped the women off in front and parked in the garage.

  Few patients had elective appointments that week, and there were relatively few staff. Jon gave warm but abbreviated greetings to those he met and wheeled Tommie to the office. To ensure privacy, he’d decided to do the procedure in his consultation room. After they took off their coats, Jon spoke to the women.

  “Let me go over what I’ll do once again,” he began. “It’s very simple.”

  “You sound like you’re in a hurry, Daddy.”

  “Do I? I certainly don’t mean to be. Everything’s going to happen slow and easy. Tommie, honey, you’re going to sit right in this chair.” He wheeled over a cushioned stool. After adjusting its height, he and Mireille helped Tommie onto it.

  “How can I help?” Mireille asked.

  “When I’m ready to go, you stand in front of her and hold her shoulders. All she needs is a little support. Then I’ll do the injection, and after that, we’re outa here, okay?” Tommie and Mireille nodded. Tommie’s chin was quivering. For all her good-natured strength, she was still a frightened little girl. Jon bent over and hugged her.

  “I know you’re scared, baby. But it’s going to be all right, you’ll see.”

  “It’s going to hurt, isn’t it?”

  “First, I’m going to numb up the skin. The needle won’t hurt, except for a little pinch. The injection might sting a little, but it’ll be over so fast, you won’t even notice it. I’ll be finished before you can say Rumpelstiltskin.”

  These were the words he’d used when he’d given her injections as a younger child. It was a deliberate ploy, but it usually worked.

  “You don’t have to say that, Daddy. I’m not a baby anymore.”

  “Don’t I know it. You’re a tough, butt-kickin’ senorita. Which is why I know you’ll be okay with this.” He kissed her cheek. “So, you ready?”

  She nodded bravely and managed a smile. Jon wished he were as courageous as she. Tommie had the kind of inner strength he’d never known. The fact was, he was a desperate father about to perform a desperate act. His confident words were all bluster; and if Tommie realized how
uncertain he really was, she would never have agreed to the procedure.

  “Mireille, if you would, just help her get her shirt up in the back. After that, Tommie, I want you to lean forward a little against Mireille’s hands. Remember, I’ll keep explaining as we go along. Okay, let’s do it.”

  Tommie took off her NSYNC tee shirt. She wore a tank top underneath, which Mireille helped pull up to the shoulders. Meanwhile, Jon opened a disposable lumbar puncture tray, which had all the required equipment. When he was ready to proceed, he removed the tissue culture vial and aspirated its contents into a sterile plastic syringe.

  “First, you’re going to feel something cold, princess. Here goes.” He swabbed her upper back with antiseptic.

  “That’s freezing!”

  “Told you. Now, I’m going to put something called a sterile drape on your back. It’s really just a big piece of paper. How’re you doing, honey?”

  “I can’t wait ’til this is over.”

  “Won’t be long. How about you, Mireille?”

  “I have her, Jon.”

  “All right.” With his leg, Jon moved another stool into position behind Tommie. He sat down and readied a syringe with local anesthetic, placing it beside the syringe containing the fetal cells. “Okay, Tommie, here comes that little pinprick.” He was using the tiniest needle available, a thirty-gauge. After raising a wheal on the skin, he switched to a twenty-five-gauge needle and numbed the deeper subcutaneous layers. “Does that sting some?”

  “A little.”

  “Now I’m up to the important part. All you should feel is a little pressure. Stay just like that.”

  Previous studies had shown that Tommie’s spinal cord injury was at the level of the second thoracic vertebra, T-2. The damage was as complete as if the cord had been severed with a knife. The purpose of the transplant was to place the new cells in a location where they could literally regrow neural connections across the gap. Therefore, the injection would be made at T-l. Jon lifted a long, slender spinal needle and checked the location on his daughter’s back.

  A tiny dot of blood marked where he’d made the wheal. He was satisfied with its anatomic location. The problem, and the challenge, lay in the precision of needle placement. Ideally, an intra-spinal injection should be performed with imaging guidance, like ultrasound. The illegality of what he was doing prohibited that. Not only would it get the technician in trouble, if one were foolhardy enough to agree to help, but the paper trail generated could be incriminating. Therefore, Jon would be working through his daughter’s back by sight, touch, and spatial orientation.

  “Keep very still, Tommie.” With the needle tip, he punctured the anesthetized skin and slowly advanced the needle. For a person his daughter’s size, he had to transverse three-quarters of an inch of subcutaneous tissue before reaching the cord’s protective covering. Once he went through it, he would come to a space containing cerebrospinal fluid before reaching the spinal cord proper. He intended to inject in the middle of the cord.

  To do that with precision, he couldn’t simply estimate the distance from the skin and then inject. He was working on his daughter here, and that would involve too much guesswork. Not only couldn’t he risk imprecision, but he might only get one chance at this. Therefore, he’d rely on a neurologist’s old tricks to reach the target area.

  He felt a little pop as the needle pierced the protective ligament. As with the president’s tap, a small drop of glistening spinal fluid appeared at the needle’s hub. That told Jon he was on the right path. He advanced the needle slowly, cautiously. Seconds later, Tommie gave a little yelp.

  “Daddy, I feel something hot on my leg.”

  “That’s okay, honey. It means the needle’s in the right place. Hold on.”

  Her voice had a nervous warble. “This is a lot worse than stinging!”

  “Don’t move. I’m almost finished.”

  “Daddy, hurry!”

  Jon carefully advanced the needle the final half-inch, directly into the center of his daughter’s spinal cord. His trembling hands reached for the syringe containing the fetal cells. Although he wanted to get this over with as quickly as possible, he realized he was on the edge of the medical envelope. What he was doing for such disastrous finality that he proceeded with utmost caution. Attaching the needle to the syringe, he took a deep breath and injected. “That’s it.”

  Tommie let out a high-pitched wail. “Daddy, stop, stop!”

  He quickly withdrew the needle. “It’s all over, honey. Everything’s out.”

  “No, it isn’t!” Tommie cried, a piercing shriek of pain. “I still feel it! Daddy, please, take it out!”

  Mireille pulled Tommie’s head to her chest, stroking the child’s hair. “It’s all right, Tommie, it’s over.”

  “Oh my God!” Tommie screamed. She reached up and started frantically pulling her own hair. Her body writhed in agony, and her screams became tortured cries that seemed to go on forever.

  Jon was beside himself. He jumped up, kicked his stool away, and grabbed his daughter’s shoulders. “What is it, Tommie? Tell me!”

  As tears streamed down her cheeks, Tommie babbled incoherently. She said something about her legs and burning and fire, but Jon couldn’t concentrate on the words. Seized with overwhelming panic, he couldn’t think straight. Menacing thoughts of intravascular injection and allergic reaction lurked in the back of his mind, but his overriding fear was that he was killing his own daughter. Not knowing what to do, he simply hugged her small body, holding her tight.

  For a short while, Tommie was inconsolable. Her heartrending shrieks continued for several more seconds before finally slowing. Thinking she might be losing consciousness, Jon abruptly shifted gears from parent to doctor, mentally racing through a checklist of emergency procedures. But before he could act, Tommie stopped crying altogether. Jon just kept holding her. Soon she was sniffling, and her head jerked with little spasms.

  Jon looked at her eyes, which were clear, the pupils focused. “Is it gone, honey?”

  “Yes,” she said softly, giving one last sniffle. “I’m sorry, Daddy.”

  He suddenly felt like crying himself. He leaned against Mireille, holding Tommie protectively between them. He wasn’t sure precisely what happened, but he did know that he was more relieved than he’d ever felt in his life. He slowly bent to Tommie’s level, wiping her tears with his finger.

  “You’re sorry?” he said, his tone somewhere between laughter and astonishment. “Believe me, the sorry one is me! I can’t believe I hurt you like that. Is the pain completely gone?”

  “It’s over,” Tommie said. “But it really, really hurt. I’m glad you didn’t tell me, because I never would’ve gone through it.”

  “Why was it so painful, Jon?” Mireille asked.

  He straightened up, taking a deep breath. “I didn’t expect it to be. It must have been a severe reflex irritation. When you’re in the middle of the cord, there are millions of sensitive synapses. I guess it takes less than I thought to trigger them.”

  “She’ll be all right, won’t she?”

  “She will now. It’s like sticking your finger in an electric socket. But if I’d known, I never would’ve put her through that.”

  Tommie looked up at him, tears drying, a trusting look on her face. “But Daddy, if the needle was in exactly the right place, that gives it a better chance of working, doesn’t it?”

  When Jon gazed into his daughter’s eyes, he could tell that all the pain was gone. Hope and love replaced it. He suddenly knew why they were all going through this, and he swelled with pride. Looking at Mireille, he affectionately stroked Tommie’s neck. “What did I do to deserve a kid like this?”

  Afterward, he insisted they remain in the medical center thirty minutes to guard against the unforeseen. While Mireille took Tommie to the bathroom and the food court, Jon retreated to the familiar comfort of his desk. Still teetering on the edge of emotional calamity, he sought refuge in the paperwork in his file
tray. Never again, he thought. The mixture of parenting and medicine could be a toxic brew.

  Unlocking his central desk drawer, Jon removed the president’s folder. With all the written tests and lab reports now in final form, he had to prepare a written report. Forbes continued pressuring him to do so. He idly leafed through the pages, still not completely satisfied. At best, his report would be medical speculation, an educated guess. His conclusion would draw as much from art as from science.

  Once his report was submitted, Jon would be on record contending that President Meredith was suffering from a prion disorder. He wished he were more certain of that. In reality, all he had was bits and pieces—hints, suggestions, likely possibilities in a long list of differential diagnoses. What he really needed to firm the diagnosis up was a medical smoking gun. He wanted something pathognomonic, incontrovertible evidence of a specific disease.

  He put down the printed reports and thought back to the president’s exam. The finding he most vividly recalled was Meredith’s irascibility. Jon forced himself to rethink the entire examination, especially the neurological details. He couldn’t think of anything he’d missed except, perhaps, for a rectal exam, which he didn’t think would add much. Organ system by organ system, he reviewed his findings. Meredith’s skin and hair, he recalled, were unremarkable. The oral exam was normal. The president’s breath was somewhat rancid, but….

  Knitting his brow, Jon dwelled on that a moment. He remembered that when he’d gotten close to examine Bob’s eyes, he’d been turned off by Meredith’s breath. And it wasn’t just from tobacco and alcohol. Jon couldn’t recall what about it bothered him, other than that it was foul. Breath odor was the province of the dentist, the pulmonologist, and the gastroenterologist. A navy internist had little expertise in the area.

  Removing several texts from the shelves, he leafed through their indices. There were occasional references to breath tests, such as for the heliobacter pylori related to gastric ulcers, but there was no general table of breath smells in various disease states.