Richard Mabry: Lethal Remedy

Ferguson said, "Chelsea, I'm going to step outside for a minute. Dr.

Pearson is here, and I'll be right back. Okay?" Chelsea didn't break the silence she'd maintained for the past hour. Instead, she made the smallest of hand gestures to signal she'd heard. In the hall, Mrs.

Ferguson leaned close to Sara and spoke in a low whisper. "It's been almost two hours. What do you think?" Sara kept her voice low as well.

"She hasn't shown any signs of a reaction from the OMAL. That's the first hurdle. Now we have to see if the drug does what we hope it'll do." "How long will that take?" "We don't know. I'd guess at least a couple of days, maybe a week," Sara said. "Tell me again why you think this may work." "The drug is sometimes called 'anti-IgE.' The substances that carry out the body's immune responses are called immunoglobulins. There are five of them, named with letters of the alphabet, and immunoglobulin E-IgE for short-is the one that's involved in what most people think of as allergy. This compound, anti-IgE, was developed to block that immunoglobulin in susceptible individuals. It keeps it from attaching to the cells where it would ordinarily do its dirty work." "What does that have to do with Chelsea?" Mrs. Ferguson asked. "We think the Jandramycin has not only stimulated her immune system to produce special substances that kill the Staph luciferus, but also some that attack her own cells. In Chelsea's case, it's the nerves, and it leads to weakness and eventual paralysis. We hope that in this particular scenario, the anti-IgE will block those other substances as well." "Do you have any reason to think this will work?" Sara had turned that question over in her mind again and again since John proposed using OMAL for this purpose. The answer she gave was what she'd come up with. "We think there's a good chance-and we have nothing else."

John and Rip were in the back treatment room of the clinic that had become John's unofficial home for his Jandramycin infusions. This time there was no IV setup in view, no syringes and vials on the treatment table. John perched on the end of the treatment table; Rip sat on a rolling stool. It seemed that each was waiting for the other to speak. Rip took in a deep breath through his nose and let it out through pursed lips. He guessed it was up to him to talk about the elephant in the room. "John, you've had six IV doses of Jandramycin.

How are you doing?" John held up his hand and turned it back and forth in front of Rip. The needle puncture wound had long since healed. No redness, swelling, or any of the cardinal signs of inflammation. "I think it's pretty much back to normal. Don't you?" "I do, but as you know, all our success with Jandramycin has been based on a protocol of ten days of treatment. Admittedly, that number was chosen empirically, but so far it's worked. Theoretically, you need four more doses." Rip waited to see if John saw the same thing that was bothering him.

Apparently, he did. "But since I've had the IM injection of OMAL,"

John said, "my immune system has been tweaked, hopefully to the point that the Jandramycin won't have any further effect. The good news is that my chances of getting a late autoimmune problem may have been reduced, maybe even down to zero. On the other hand… " "Yeah, on the other hand, any more Jandramycin you receive would probably be ineffective against Staph luciferus if there are some still in your body." "So I'm stuck at this point. Just wait and hope the bug's been killed out." John shook his head. "Guess I can add that to worrying about whether that needle-stick exposed me to HIV." Rip reached out and gripped John's hand. "So far, your labs look clean from that standpoint. But remember, I'm in this with you. And we won't go down without a fight."

Rip entered Randall Moore's room ready for almost anything, but not for the sight that greeted him. Jack Ingersoll and Donald Schaeffer had their heads together at Moore's bedside. Each doctor wore a white lab coat. A stethoscope dangled from Ingersoll's neck, while Schaeffer held his at his side. Their demeanor suggested serious consultation, such as would befit two heads of state rather than two physicians at a medical center. Rip turned his eyes from them to Moore. His previously pale skin was darker now, but not with a healthy tan. His lips had a bluish cast. The man wasn't getting enough oxygen into his blood, even with pure oxygen flowing into the mask that covered his face. His respirations were slow and shallow. Moore was dying before Rip's eyes. "What's going on?" Rip asked, trying to keep his voice level. "I was in the bacteriology lab and the chief technician showed me the final results from this patient's sputum culture. He has a Staphylococcus luciferus pneumonia, which is why the nafcillin you ordered has been ineffective." "I suspected as much,"

Rip said. "I just phoned the lab and got the final culture report myself. I've already talked with Dr. Miles about it, and she's on her way to meet me here. We plan to discuss treatment alternatives with her patient." He pointed to the man in the bed. "But I don't think he's in any shape for a discussion. We'd better-" Dr. Schaeffer turned to face Rip. "Dr. Pearson, the reason I'm here is that Dr. Ingersoll thought it best, given the high profile status of this patient, that he take over the case. After reviewing the situation, I tend to agree." He frowned. "I don't want you to think this is a criticism of Dr. Miles's clinical ability or of yours. I just think it's more… expedient that the Chief of the Infectious Disease Service assume Mr. Moore's care." Rip knew exactly what was going on. Moore was the plaintiff in a huge suit against the medical center. Currently his treatment was under the supervision of a junior faculty member and a fellow in training. Schaeffer wanted his high-profile professor treating Moore, in hopes that a good outcome, coupled with this display of the resources available at Southwestern, would convince the man to drop his suit. "I can't speak for Dr. Miles.

Personally, I don't care whose name is on the chart." Rip pointed to the small device on Moore's index finger. "But look at the pulse oximeter. His oxygen saturation has dropped to dangerous levels. We need to get him intubated and on a ventilator." "I've already put in a call for someone to do that," Ingersoll said. "And I plan to write the orders to add Mr…" He consulted the chart in his hand. "Add Mr.

Moore to the Jandramycin study. You will, of course, draw the necessary blood work, administer the drug, all the things you've been doing so well." "What about permission?" Rip asked. "He's too far out of it to give informed consent. Let me contact his next of kin. Maybe they can sign." "Not necessary," Ingersoll said. "Given Mr. Moore's inability to make that decision right now, Dr. Schaeffer and I will sign the permission, which, as you know, is possible in the case of a medical emergency where delay is unacceptable." Rip's guts began to churn. This was wrong, all of it. There was no need to wait for an anesthesiologist or pulmonologist to do the intubation. Rip was perfectly capable of carrying out the procedure, but apparently, Ingersoll wanted it done by another specialist-under his direction, of course. As for treatment with Jandramycin, Rip had come here with his mind made up. The only proper course was to lay out the risks and benefits of treatment with Jandramycin and let Moore decide.

Unfortunately, Ingersoll was totally ignoring the risk that Rip felt the drug presented, a risk of late complications that would be life-changing in all cases and fatal in some. Since Moore was unable to make that decision, Ingersoll was taking the responsibility of deciding for the patient, and Schaeffer was going along with his division chief. So be it, Rip thought. He turned on his heel and left to gather the material he'd need. He was back to drawing blood, giving medications IV, and charting vital signs. And if he was later asked why he didn't protest Ingersoll's actions, he guessed his response would be that he was just following orders. Wasn't that the excuse of the prison guards at Dachau?