John Ramsey wasted no time getting to Sara's office, where he found her and Rip talking in low tones. He pulled up a chair and winced at the pain that shot through his hand. He took a deep breath and said, "Whoever dumped that syringe in the trash gave me a really nice gift, didn't they? Staph luciferus. Where do we go from here?"
"Until recently, I think the decision would be clear," Rip said.
"Jandramycin is the only antibiotic that works against it. No other drug can touch it." John nodded in agreement. "But a certain percentage of patients receiving Jandramycin develop late complications-autoimmune disorders that are potentially fatal." "I know about the late problems," John said. "We've discussed them a bit already. But fatal?" "One of the Jandramycin patients, one who'd developed nephropathy, died with renal failure. There are other autoimmune disorders that can be lethal as well. We don't know how many treated patients have developed them already. The risk is real, and it's significant," Rip said. "So we have a big decision to make."
Four decades of practicing medicine had made John a realist regarding treatment decisions. "We have three options: do nothing, try another antibiotic, or use Jandramycin. Option number one would undoubtedly allow a spread of the infection, necrotizing fasciitis or gangrene, and amputation of the hand if I didn't die first of sepsis. That's out." Rip started to speak, but John held up his hand. "We'll have the sensitivity reports tomorrow, but barring a miracle, none of the antibiotics tested will be effective against this organism. So trying another antibiotic would be an expensive way to get the same result as doing nothing." He waited to see if Rip or Sara had anything to say, but they simply nodded in silent agreement. He took a deep breath.
"Jandramycin will work. I'm not sure any of us truly believe that it's been 100 percent successful, but that's what the studies show so far.
And not every patient who received it has developed an autoimmune disorder… yet." "And suppose you're one of the unlucky few who do?" Sara asked. "There's always the option of treatment with high-dose steroids. That may not be a lifetime solution, maybe they won't work at all, but at least there's a chance. And in the meantime, someone may come up with the key that can reverse the process." John sat back in the chair, not particularly happy with the course of action to which he'd committed himself, but relieved that he'd been able to divorce his decision making from emotion and agree to what appeared to be the only viable solution. "Ordinarily, patients with this infection would be hospitalized," Rip said, "but unlike our other patients, you weren't treated unsuccessfully with one or two other antibiotics. There was no delay in administering proper treatment.
You're not toxic with the infection. I think we can do this as an outpatient." He lifted a sheaf of papers from his lap. "We might as well get you enrolled in the study, get some baseline blood work, and give you the first dose of Jandramycin. Let's go to the clinic and get started." As they filed from the room, John realized that Rip had held the papers for the Jandramycin study all along. It was truly the only option, but John was the one who had to decide to take that step. With his full knowledge of all that was involved, what he'd given was the very definition of informed consent. Very informed.
Carter Resnick opened the door to his lab a crack and peered out at Rip with one eye. "What do you need? I'm collating data right now."
"We need to talk." "I didn't think you had time to talk with a lowly research associate." Rip bit back the reply that came to his lips. He needed this information, and maybe Resnick had it. "Carter, that's not true. I've always had time for you. Surely you can spare five minutes for me." Resnick's visible eye blinked several times. Rip could almost hear him thinking. Finally, the door opened wide enough for Resnick to slip through, then closed behind him with a solid click. Resnick jiggled the knob to confirm the door was locked. He turned to face Rip and crossed his arms. "Okay, talk." "Carter, be reasonable. Can't we sit down somewhere like two colleagues and have a discussion? Why don't we go into the lab?" Resnick was shaking his head before Rip finished talking. "No way. Dr. Ingersoll only allows two people in that lab: himself and me." "I thought there was a lab technician, too." "No. When we got to a critical point, Dr. Ingersoll discharged the tech. I do all the work now. It's a matter of security." "Carter, most of that data you're collating came from me. What could be in there that I don't already know?" Resnick grinned. "That's for me to know and you to find out." Rip decided that Resnick's schoolboy response effectively closed the door-quite literally-on any hope of his getting into the lab. He leaned against the wall and fired his first salvo. "I need to know what exactly is in Jandramycin. I have to find out what its exact mode of action is." "The main thing anyone needs to know is that it kills Staph luciferus. Some people postulate that Jandramycin works by attacking the bacteria's cell wall. Its real mode of action probably won't be revealed until Dr. Ingersoll and I publish that information." There it was. Resnick figured that his work would get him co-authorship of the papers that were sure to come, papers certain to be the lead articles in JAMA and the New England Journal. Until that happened, Resnick would move heaven and earth to stay on Ingersoll's good side, and if that meant standing guard on the laboratory and the data it contained, so be it. "Look, Carter, it's important that we know how the drug works. People who received it are turning up later with autoimmune disorders that are disabling and potentially fatal." Resnick didn't seem surprised. "Everyone?" "No."
Rip did some quick calculations. "It seems like maybe 15 percent of the patients are at risk. But we don't know which ones they are."
There was a muted buzz from the pocket of Resnick's lab coat. He held up one finger to Rip. "I'd better get this." It was a brief and mainly a one-sided conversation. Resnick said, "I can't tell you that" a few times and punched the button to end the call. He dropped the phone into his pocket and said, "That was Dr. Miles. She asked me the same question you did. You all should coordinate your efforts." "Carter, listen to me. Lives are at stake here. Why won't you give me this information?" "Actually, you already have enough clues. You're the diagnostician. Figure it out." With that, Resnick executed a quick about-face, opened the lab door with a key he produced from his pocket, and disappeared inside.
Lillian grabbed the chart from the plastic rack and tapped on the exam room door. Without waiting for a reply, she opened it and walked in. "I'm Dr. Goodman. What kind of-" Her usual greeting to patients died in her throat as her eyes registered the scene before her. John Ramsey lay on the exam table with an IV running into his arm. "John, what-" "Easy, Lillian. I'm fine. I'm just getting my first dose of Jandramycin." She glanced down at the name on the chart she held: John Matthew Ramsey, MD. Lillian had her finger inside the cover, ready to open the chart, when she stopped. No, John would tell her what he wanted her to know. She pulled over a stool and sat down beside John, covering his hand with her own, careful to avoid the small plastic cannula that carried medication into the vein in his forearm. "What's going on?" "It all started when this lady doctor I know thought I might be getting an infection around a puncture wound of my hand and insisted I see someone about it." He grinned, trying to rob the words of any sting. "The culture grew Staph luciferus. So, now I'm on Jandramycin." "John, I'm so sorry. But I'm glad Rip did the culture,"
Lillian said, "and even happier that we have something that will knock out the bacteria. I mean, just a few months ago we had nothing, and these infections were potentially fatal." "Right. The drug should take care of the Staph luciferus infection, and that's good. What you don't know, and I guess it's okay to let you in on the story, is that some patients who received Jandramycin are turning up with various autoimmune diseases, most of which can be fatal. So there's a chance that I may save my hand at the risk of developing something just as bad-maybe worse-down the line." That brought a dozen questions to her mind. "I thought Jandramycin was supposed to be so wonderful. One hundred percent effective against the most dangerous pathogen we've seen since the black plague, but with no side effects. Why didn't someone warn us before we began to use it?" "It's an experimental drug, Lillian," John said. "When we get informed consent to administer those compounds, all we have to go on is the information the manufacturer gives us. And in this case, that didn't include the whole truth." "Surely Jack Ingersoll had some inkling about all this." John winced, and Lillian realized she was holding his hand tightly. She relaxed her grip, just lightly covering John's hand with hers.
"Sorry." "No problem. At least the drug is painless going into the vein. To address your question, we don't know what Ingersoll knows about all this. At first, everyone involved was happy that Jandramycin worked so well and had no apparent ill effects. That's why he and Jandra Pharmaceuticals were rushing to get FDA approval. Thousands of people have already died from Staph luciferus. Every day's delay condemns more." "Surely Jack suspected something," Lillian said. "When Rip and Sara first suspected that it might cause autoimmune problems, they confronted Ingersoll about it, but he denied that any problems exist. Now it's as though he has blinders on." Lillian squared her shoulders. "Let me do some reading. Maybe there's something we can do to prevent these complications." "We're already working on it, but we haven't had much luck so far." "Who's 'we'?" "Sara, Rip, and me. Oh, and another one of my former students, Dr. Mark Wilcox. He practiced law before he went to med school. Now he's an FP." "Well, like it or not, you just added another member to your group. When and where are you going to get together next?" She rose and gave John's hand a final, gentle squeeze. "You and I can supply something none of the other three have." "And that is?" She forced a smile. "Experience.
I've been practicing medicine for thirty-five years. I guess with you it's closer to forty. We've seen situations those young pups have only read about. They don't know it yet, but they need us."
"How are you today?" Sara Miles did her best to put a smile in her voice as well as on her face as she approached Chelsea Ferguson's bedside. "About the same," Chelsea said, her tone flat, her face expressionless. Mrs. Ferguson, seated on the other side of Chelsea's bed, shook her head and mouthed the words, "Not good." She took a tissue from her pocket and wiped the corners of her eyes. Sara's neurologic exam bore out Mrs. Ferguson's words. The weakness in Chelsea's legs was much worse, and the reflexes there were virtually absent. Even more worrisome, the girl was losing strength in her arms.
This was the reason clinicians had originally given GBS the name Landry's ascending paralysis. The paralysis might progress upward until the patient was unable to move and required the assistance of a ventilator to keep breathing. Sometimes the symptoms resolved, although it could take weeks or months. But sometimes they were permanent. Still at the bedside, Sara flipped open the chart and scanned it. Anna Pearl's last note was brief, and not at all encouraging. "Progression of weakness in lower extremities, early signs in upper extremities. Will discuss adding further Rx to steroids." Sara racked her brain to come up with something more to add. She'd have to call Anna and see what the neurologist had in mind.
Sara gave Chelsea's hand a final squeeze. "You hang in there. We'll lick this yet." As she'd come to do, Mrs. Ferguson followed Sara into the hall. "She's getting weaker. Can you do something?" "I'm about to talk with Dr. Pearl about adding another medication for Chelsea. You heard what I told her. We'll lick this thing." Sara patted the woman's shoulder and turned away, hoping she'd done it quickly enough that Mrs. Ferguson didn't see the tears that strained for release from her own eyes. Anna Pearl answered her page within a few minutes. "Anna, this is Sara Miles." "Oh, yes. We need to talk about Chelsea Ferguson.
Her paralysis is progressing." "I know. I just saw her. What do you suggest we do?" A name jumped into Sara's mind. "Could we add something like methotrexate?" "Interesting that you should suggest that. I thought about an antimetabolite, but when I did a literature search, these compounds have been tried and don't add much." Ideas were coming to Sara fast and furious, and she didn't try to filter them as they entered her mind. "What about immune globulin?" "That's what I was considering. Not every study supports its use, but sometimes it helps. And one dose IV should be sufficient… if it's going to work." "A milligram per kilo?" "Make it two," Anna said. "If we're going to hit this, let's hit it hard. And keep your fingers crossed." I won't just keep my fingers crossed. I'll be praying this works- because if it doesn't, I don't know what I'll do. I'm out of ideas.