Richard Mabry: Lethal Remedy

"Now, how have you been? We don't see much of each other anymore."

Sara remembered when she'd first met Rip. She was sitting with a hundred other freshmen undergoing orientation at Southwestern Medical School. The Dean, resplendent in three-piece suit with a chain draped across the vest to display his Phi Beta Kappa key, had just said, "We didn't ask you to come here. But we may be asking some of you to leave." She heard a muffled chuckle to her right and looked at the man sitting there. His wavy blond hair was fashionably long. In contrast with the casual dress of others in the class, he wore a button-down collared blue oxford cloth shirt open at the neck. His khakis sported ironed creases that could cut cheese. Top-Siders worn without socks completed the Ivy League look. He leaned toward Sara and whispered,

"Sorry. Actually, they did ask me to come here. They recruited me, so I doubt they'll be asking me to leave." After the lecture, he'd invited her for coffee, where she learned he was indeed the product of an Ivy League background. Roswell Irving Pearson III graduated magna cum laude from Yale. He broke the family tradition of working in investment banking, choosing instead to come to Southwestern to study medicine. "And please call me Rip. I'm trying to adapt to my new surroundings, and Roswell doesn't fit that image." Thinking back on that encounter, Sara decided that was probably when he began to put salsa on his eggs. It was more Texan. "Sara? You went quiet on me. How have you been doing?" "I've been staying busy. Isn't that the recommended method for getting over a loss in your life? I think I recall that from the lecture on depression." Rip reached across the table and touched her hand. "It's been two years since the baby died and Jack left you. Don't you think you should be over it by now?"

Rip's words were soft, his touch even softer. "Please, let's not talk about it. There's just so much-" The buzz of a pager cut through the din of the cafeteria. Both of them consulted the tiny boxes they carried. "It's me," Sara said. "The ICU." "Funny, I've got the same call," Rip said. They looked at each other for a moment before Sara said, "Chelsea." They left their dishes on the table and headed for the stairs at a brisk pace.

Rip pushed through the swinging doors of the ICU a half step ahead of Sara. The crowd of people in Chelsea's room confirmed their fears.

The head nurse, holding a chart, stepped out of the room. She addressed both doctors, swiveling her head from one to the other. "We were helping Chelsea out of bed and into a chair so we could change her linens, and she fainted. Now her blood pressure's down to eighty over sixty, pulse a hundred. I paged you both and drew blood for some stat blood work. They're getting her back into bed now." Rip hesitated. Technically, Sara was still the doctor in charge of the case. But since Chelsea was in the study, Jack Ingersoll would undoubtedly insist he be involved in all treatment decisions. And in Ingersoll's absence, Rip had that responsibility. Sara made it easy.

She turned to Rip and said, "She's your study patient, and she's going into shock. Want to take the lead here?" "I can't see EpAm848 causing her blood pressure to drop. Never been a problem before, and we've given it to some pretty sick people. Let's have a look at her." Ten minutes later, Sara and Rip huddled in the hall outside Chelsea's room. "I think it's septic shock," he said. "She's had an indwelling catheter for a while, and my money's on sepsis from a urinary infection." Catheters in the bladder could eventually cause infection, and sometimes those bacteria spread to the bloodstream with disastrous results. Sara opened the chart she held. "I'll order blood cultures, a urinalysis and culture, along with the lab work Janice already requested, but those will take a while. Why don't we get some urine, spin it down, do a Gram stain, and see what we've got?" "That's scut work, Sara. You're faculty. I'm a fellow. I'll do it." Sara shook her head. "If you hadn't decided to get postgraduate training, you could be on the faculty as well. We're equals, Rip. We've been together through four years of med school and three years of residency. I don't want to hear any more of that." "Okay. You get the sample. I'll speed up the IV's and tweak the medications. Want to start a vasopressor drip?" "What do you think?" "Let's piggyback some Dopamine into her IV and run it as needed to get her blood pressure to better levels." "Do it," Sara said. There had been a time when every clinical ward in a hospital had a small lab space where medical students, interns, and residents could do simple procedures themselves. At University Hospital, that space had long since been co-opted for other uses, so Rip and Sara ended up in the hospital's clinical laboratory. "Let me do that," the head technician said. "I do this every day. Neither of you has done it for years." It seemed to take an eternity, but finally the tech gestured to a binocular microscope. "There it is. Want to take a guess before I tell you what you've got?" Sara looked through the eyepieces and frowned. When she stepped away, Rip removed his glasses, adjusted the 'scope, and felt his heart skip a beat as red rods came into focus. He couldn't be certain based on the microscopic picture alone, but he'd looked at hundreds of slides with dozens of organisms, and he was almost sure of the diagnosis. "What do you think? E. coli?" The tech nodded. "Yep. Escherichia coli. I plated out some of the sample you brought, and in a couple of days I'll have a culture confirmation and some preliminary antibiotic sensitivities."

Rip looked at Sara. They both knew what that meant. They didn't have thirty-six or forty-eight hours to wait before starting treatment.

They had to begin antibiotic therapy now. Sara thanked the tech and they both began to make their way back to the ICU. "Does your drug, whatever the name is, have any effect on E. coli?" "It's EpAm848, and the answer is that nobody knows for sure. We've only used it against Staph luciferus. But look at it this way. If it were effective against E. coli, we wouldn't be having this conversation. This wouldn't have developed." Sara bit her lip. "I'm at fault here. I didn't keep an eye out for other causes of Chelsea's fever and all her other symptoms.

She's probably had that urinary infection for several days. If I'd remembered to do repeated urine cultures, we'd have caught this earlier." "Don't beat yourself up. We can't be perfect. No doctor can.

The important thing is that we've caught it before she went into profound shock and developed multiple organ failures. We can still treat her and bring her through this." "Okay. You're the ID specialist. What empiric antibiotics would you use for E. coli infection like this?" Rip ran through the index cards of his mind.

"I'd go with an IV quinolone like levofloxacin. And, even though we don't see any evidence of anaerobic infection, I'd add clindamycin until we get the results of the cultures, both urine and blood." "I agree. Do you want to write the orders?" "Sure." "Does this mean you have to stop the Ep whatever?" Sara said. "I don't know. It's never been given with other antibiotics, so I don't know what could happen.

But if we stop EpAm848 now, the Staph luciferus could start up again."

"I have to leave the decision to you," Sara said. And whatever I choose will probably be wrong. Putting aside the question of one antibiotic rendering the other useless, what was Jack Ingersoll going to say when he found that one of his precious study patients had been compromised? What if there were complications? How could a researcher tell if they were due to the EpAm848, the other medications, the disease itself? The patient would be dropped from the study. And to Ingersoll, every patient in the study was pure gold. If he were here, Rip was pretty sure what Ingersoll's decision would be: Don't give anything more. He'd argue that EpAm848 was a strong antibiotic. It might be enough by itself to combat the sepsis. Just give supportive care, use IV fluids and vasopressors, administer oxygen. Give the drug a bit of time and it could pull the patient through. Another triumph for EpAm848. Another feather in the cap of Jack Ingersoll. Rip could call Ingersoll's cell phone. Tell him the situation. Leave the decision up to him. Doing this on his own would expose Rip to his mentor's wrath big-time. He might even lose his fellowship because of it. They reached the ICU and pushed through the doors. Both doctors were silent as they approached Chelsea's bedside. Rip nodded to Mrs.