Jack, this is Sara." Dr. Jack Ingersoll hunched his shoulder to hold the phone against his ear. He removed his glasses and polished them on the tail of his white coat. The closed door of his academic office couldn't quite block out the noise as one of his fellow faculty members read the riot act to a resident about his choice of a drug for bacterial endocarditis. "Sara, so good to hear from you. How have you been?" "You can skip the niceties, Jack. This is a professional call."
"I get the picture. So let's keep it professional. What can I do for you?" "I have a sixteen-year-old girl with generalized sepsis. No response to the usual empiric IV antibiotics. I got the blood culture results this morning. Staphylococcus luciferus." Ingersoll pursed his lips. "Another case. And, of course, the sensitivity studies-"
"Resistant to every antibiotic tested. So I thought of you and your study." Ingersoll's pulse quickened a bit. Every patient he enrolled strengthened the reputation he was building as the world's authority on EpAm848. It looked to be a wonder drug, and if he could hitch his wagon to that star, there was no telling where he could go. "Does she meet the enrollment criteria?" "Yes. I checked before I called you.
The mother's anxious to get her into the protocol, and I've laid the groundwork for you. Informed consent shouldn't be a problem." He found a blank slip of paper in the morass on his desk. "Thanks. What's her name and where is she?" "She's in the ICU at University Hospital.
Name's Chelsea Ferguson." Sara cleared her throat. "Jack, she's just a kid. And the mother's worried sick. Try to upgrade your usual bedside manner. Please." Ingersoll ended the conversation with a few mumbled assurances. He thought a moment, then punched the intercom button.
"Martha, page Dr. Pearson and tell him to meet me in the ICU at University Hospital. Then call over there and get the identifying info on a patient-her name is Ferguson-and give it to Dr. Resnick. Have him make up a set of enrollment papers for the EpAm848 study and bring them to the ICU." Ingersoll swiveled away from his desk and let his eyes sweep across the horizon. New construction was everywhere at Southwestern Medical Center, girders and columns rising alongside existing massive buildings. Although the economy was rough, there were still more than enough multimillionaires in Dallas who wanted to assure themselves of the best possible care by the brightest minds in the medical field. What better way to do that than to give money to the academic medical center in their hometown? Jack Ingersoll wanted some of that. He wanted to become Dr. Jack Ingersoll, John and Mary So-and-So Distinguished Professor of Infectious Disease, with offices in the Thus-And-Such Building, his salary and research expenses underwritten by the Bubba and Sue Somebody-Or-Other Foundation. And if the EpAm848 study kept going this way, that was exactly where he was headed-if not here, then somewhere. There were portraits scattered throughout the medical center of some of the distinguished faculty members. He wanted his to join that select group. He'd be wearing a white coat, holding a beaker of brightly colored liquid, looking into the distance, contemplating the discovery that put the medical school-and him-on the map. The artist would have to minimize his developing paunch and maybe enhance his scant brown hair into a handsome widow's peak, but that was the advantage of a painting over a photograph. He unlocked the bottom drawer of his desk and pulled out a rust-colored stiffcardboard accordion file closed with an elastic cord secured over a large button. Ingersoll unfastened the closure, peered inside the file, and counted the sets of stapled pages. Twenty-one.
Twenty-one patients willing to testify that he was a miracle worker.
Twenty-one instances where EpAm848 saved a life otherwise doomed because of infection by Staphylococcus luciferus- the Devil's own Staph, "The Killer." Patients were dying all over the world from this infection. It was turning into an epidemic, but the success rate of Ingersoll's treatment was 100 percent so far. Conventional wisdom in medicine held that no therapy was 100 percent effective. He felt like a pitcher, taking a no-hitter into the eighth inning. Somewhere out there might be a case that wouldn't respond. But so far, he was throwing a perfect game, and if he could keep it up, there was no limit to how far he'd go. Martha's voice startled him from his daydreams. She never used the intercom, no matter how many times Ingersoll asked her to do so. He'd finally given up on that fight.
"Dr. Pearson just called. He's at the ICU and is reviewing the chart now." Ingersoll resealed the file and locked it in his desk drawer.
"I'm on my way. Page me if there's something urgent." He transferred his stethoscope, pens, and pocket flashlight to a freshly laundered white lab coat. He slipped his arms in, flexed his shoulders a couple of times to loosen the starched fabric, and buttoned the coat over his pale blue cotton dress shirt, leaving just enough of his rep-stripe tie showing to make a fashion statement. Sometimes a good first impression on the family was the most important part of the consultation. As he exited his office, he almost bumped into Dr.
Carter Resnick, hurrying down the hall, head down, mumbling to himself. "Resnick, watch what you're doing." Resnick rubbed his hand nervously over his shiny dome. Ingersoll couldn't understand why some men shaved their heads, but apparently Resnick thought it made him look wiser. It didn't. If anything, it accentuated his geekiness.
"Sorry, sir. I just prepared the packet for Chelsea Ferguson and took it to Dr. Pearson. Would you like me to go with you to see her? Maybe I could help." He brought his eyes up for a millisecond, but dropped them again. Whatever expression they held was hidden behind thick horn-rimmed glasses. "You know the deal," Ingersoll said. "You didn't get the Infectious Disease fellowship, but I agreed to take you on as a research assistant and promised you the inside track when the second fellowship slot opens next year. Your place this year is in the lab.
And the longer you stand here like a schoolboy begging to avoid detention, the less time you're spending in that lab." Without waiting for a reply, Ingersoll brushed past the young doctor and hurried away to the ICU. Idiot. He's good in W the lab, following orders, but he won't ever be any good at patient care. When I take on another ID Fellow, it certainly won't be him.
Dr. Roswell Irving Pearson III, generally known as "Rip," scanned his notes one last time. The position of Infectious Disease Fellow under Dr. Jack Ingersoll was a real plum, and Rip had overcome stiffcompetition to win this appointment. But Ingersoll was a stern taskmaster. He expected his ID Fellow to anticipate his every request and fulfill it perfectly. When Ingersoll said, "Meet me in the ICU at University Hospital," Rip knew that really meant "Find out which patient I'm seeing, review the chart, and be prepared to present the salient facts in the most concise fashion possible." Since this was a case involving Staph luciferus, that also meant making sure the teenage girl qualified for the EpAm848 study. Now Rip was ready. He supposed he shouldn't feel sorry for himself. He could be poor Carter Resnick. Rip wasn't sure how Carter ever got through an internal medicine residency, or why he thought he had any chance at an ID fellowship, much less one as prestigious as this one. Anyone with half a brain could see that Ingersoll was just using Carter, delighted to have a specialty-trained MD running his research lab. Well, the Carter Resnicks of the world would have to take care of themselves. Rip Pearson had his own problems, and the first one on the agenda was presenting this case to his chief. Rip looked once more at his watch.
Martha had paged him less than fifteen minutes ago, catching him already at University Hospital making rounds. He'd sprinted up the stairs to the ICU and rapidly digested the chart information on Chelsea Ferguson. He hadn't introduced himself to Chelsea or her mother, though. He'd made that mistake once, and had learned quite quickly that Ingersoll expected his ID Fellow to be seen but not heard, like an obedient child. The name of the attending physician on the case made Rip pause. He hadn't done more than nod to Sara as they passed in the halls since their last rotation as internal medicine residents. Now she was a staffmember, while his position as an Infectious Disease Fellow meant he was still in training. Would that make a difference? He and Sara had been close until she married Jack Ingersoll. Now all those relationships were topsyturvy. He wondered- "What do we have?" Ingersoll's rubber-soled shoes allowed him to approach without warning, something Rip suspected he did, hoping to catch someone bad-mouthing him. The consultant pulled out a chair and took the page of neatly printed notes Rip handed him. "Chelsea Ferguson, sixteen-year-old Caucasian female, had a dental extraction a week ago, without prophylactic antibiotic coverage. She developed progressive, severe cellulitis of the jaw, and her dentist referred her to an oral surgeon. He tried one change of antibiotics, but when he recognized early sepsis he sent her here. Pending cultures, Dr.
Miles began empiric antibiotic therapy for presumed MRSA with IV vancomycin plus gentamycin. Intraoral cultures grew out Staph luciferus, and blood cultures have reported the same organism, resistant to all conventional antibiotics. The patient now has generalized sepsis, is spiking temps to between 40 and 41 degrees Celsius, and her condition is deteriorating." "Eligibility for the study?" Trust Jack Ingersoll to cut to the chase. Not "What else can we do?" Not "What about the white count, or sed rate, or blood sugar or any other lab test?" No other questions except, "Is this another case I can enroll in the EpAm848 study?" Rip swallowed the retort that was on the tip of his tongue. "Yes, sir. She meets all the criteria.
And according to Dr. Miles's notes, her mother has been warned that there are risks and potential side effects." "Nonsense. None of the patients treated so far have so much as turned a hair. This is really a wonder drug." "Yes, sir. But there's always a first time." "Negative thinking, Rip. We'll have none of that." Ingersoll stood. "We have to project a positive attitude. It's important that patients have confidence in their doctors." A faint buzz issued from under Ingersoll's coat. He pulled an iPhone from his pants pocket, looked at the display, and frowned. "I have to take this." Ingersoll hurried away from the nurses' station, ducked into the family room, and closed the door. Rip wondered what could have been so important. In his experience, nothing trumped enrolling another patient in the study.
Whatever it was, it didn't take long. In less than five minutes, Ingersoll was back. "Let's talk with these people," he said. "Then I have to leave and catch a plane. I'll be gone for a couple of days, so you'll need to administer the medication and gather the follow-up data. Think you can handle that?" Rip swallowed the acid that boiled up in his throat. Since the study began, he'd been the one doing just that. He'd mixed every dose of EpAm848 and sat by the patient's bedside while the IV ran in. He'd drawn blood and taken it to Ingersoll's lab for all the necessary tests, made sure the vital signs were monitored, and logged the data that chronicled the patient's response. This might as well have been his study, not Jack Ingersoll's. It bespoke of his mentor's huge ego that he'd even ask such a question. He choked out, "Yes, sir," and managed to sound humble while doing it. Ingersoll was already moving toward Chelsea Ferguson's room. Rip fell in step behind him like an aide-de-camp trailing a general at a respectful distance. A woman that he took to be Chelsea's mother was sitting at the bedside, systematically shredding a tissue. "Mrs. Ferguson, I'm Dr. Jack Ingersoll. I believe Dr. Miles told you to expect me." "Doctor, this is Chelsea." The girl on the bed opened her eyes, managed a weak nod, then closed them again. The camera of Rip's mind's eye automatically recorded the patient's status: pale, slightly undernourished girl in her late teens, sweating profusely, movements slow and listless. An IV in her left arm was dripping at a regular rate. Her breathing was shallow, and a plastic cannula delivered what he assumed to be oxygen to her nostrils. "Chelsea is very seriously ill." Ingersoll turned from the patient and addressed his words to Mrs. Ferguson. "She has an infection in her bloodstream that will almost certainly kill her if we can't eradicate it." If he saw the mother's shudder and the girl's grimace, he ignored them. "Our only chance for that is the administration of an experimental medication. We've had remarkable success-actually a 100 percent cure rate-with it. Although side effects and complications are possible, we've seen none of these. I need your permission to proceed." "What if…?" "The details are spelled out in the consent forms that Dr. Pearson will go over with you. If you don't wish to sign them, of course, the choice is yours, including responsibility for the consequences. If you proceed with treatment, Dr. Pearson will administer the first dose today."
Ingersoll looked at his watch. "I'm afraid I have to leave now, to attend a consultants' meeting. I'll look in again in a couple of days, should you consent to treatment for your daughter." Rip watched Ingersoll turn on his heel and march out the door as though going into battle. He didn't know what this "consultants' meeting" represented, but he was certain of one thing. As of thirty minutes ago, it had not been on Ingersoll's agenda. It was a result of that phone call. And it was a command performance.
Sara frowned as she searched the chart rack at the ICU nurses' station. The slot for Room 6 was empty. Was it misfiled in the hurry of ICU routine? No, Chelsea's chart wasn't in any of the other slots.
Maybe it was on the ward clerk's desk, awaiting execution of an order for lab tests or an adjustment of treatments. But no one except Sara or her resident, Luke Sutton, would have written such an order. And Luke was out today, at home nursing a lower respiratory infection that appeared to verge on pneumonia. "Dr. Miles?" Sara turned to see Janice, one of the ICU nurses, holding out a chart. "Are you looking for Chelsea's chart?" Sara took the proffered chart. "Thank you. Is there something new?" "Dr. Ingersoll and Dr. Pearson were here earlier. They started Chelsea on EpAm848. Dr. Pearson drew her baseline labs himself, and then sat with her while she got the first dose of her medicine. You just missed him." Sara took a deep breath.
The good news was that Chelsea was now getting the antibiotic that could save her life. The double-barreled bad news was the possibility of a side effect or complication-all the reassurances notwithstanding-as well as the likelihood that her ex-husband's bedside manner hadn't improved. Sara hated to think of the psychological damage Jack Ingersoll might have inflicted on the sixteen-year-old girl in that bed. Sara thanked Janice and carried the chart with her into Chelsea Ferguson's room. In stark contrast with her attitude when Sara left her this morning, Mrs. Ferguson seemed calm and serene. She was brushing her daughter's chestnut hair. Sara wasn't sure-maybe this was wishful thinking-but there appeared to be a bit of color in Chelsea's cheeks, color that had not been there since the day of her admission. Sara smiled at the mother and daughter. "The nurse tells me that Dr. Ingersoll was here earlier, and that you decided to go ahead with the drug treatment he offered." Mrs. Ferguson looked up from her task. "He made an appearance, acting like we should be grateful that he spared us a few moments. I know that he must be affected by seeing so many seriously ill patients, but that's not an excuse for just plain rude behavior." "I'm sorry. Dr. Ingersoll is a very busy man nowadays, and I'm afraid his bedside manner isn't the best. But he's the sole source for…" Sara paused and tried to choose her words carefully. "Dr. Ingersoll controls the use of the experimental drug that gives us the best hope of licking this thing."
"He put it a bit more bluntly than that." Mrs. Ferguson gave a particularly vigorous swipe with the brush, and Chelsea flinched.
"Sorry, dear." "But Chelsea's receiving the medication. That's all that matters now." "Thank goodness for that nice Dr. Pearson. He told us what to expect, answered our questions, and sat with Chelsea while she got her first dose of the medicine. I think he's the one we'll actually be seeing." She laid aside the brush and kissed her daughter's forehead. "At least, I hope that's true." "Yes, I suspect Dr. Ingersoll will be by from time to time, but you'll see Rip-that is, Dr. Pearson-on a regular basis. If you need anything, ask the nurse to page him or me." "I'll do that." She patted her daughter's arm, carefully avoiding the IV site. "Chelsea, I'm going to step out for a minute, maybe get a cup of coffee at the nurses' station. Are you okay?" "I'm fine, Mama." The voice was weak, but these were the first words Sara had heard her patient speak in over twentyfour hours, and to her they were beautiful. In the hall, Mrs. Ferguson took Sara's arm in a grip that was surprisingly strong for such a frail woman. "Is there anything I can do to report the way Dr. Ingersoll acted? He seemed to have no more feeling for Chelsea or me than he would for a lab animal." "I'd wait until Chelsea's on her way to recovery.
There'll be plenty of time to lodge a complaint with the right people in administration then." Sara thought about it. "I'll be happy to help you do it then." "All right. But I'll hold you to that. Really, I don't care how important that man is. There's no excuse for being so callous." Sara nodded her agreement while scenes unfurled in her mind, scenes she'd tried hard to put behind her. If you only knew…
"What's so important?" Rip Pearson stirred his coffee, even though he took it black. He recognized it as a nervous habit, but in his stress-filled world nervous habits were the norm. He'd deal with them after he finished his fellowship. Carter Resnick rubbed his head as though checking to see if his hair had grown back. Then he put both hands on the table, leaned forward, and whispered, "We should talk."
Rip put his hand behind his ear. The noise level in the hospital cafeteria was such that even the two nursing students at the next table had no chance of hearing this conversation. "Speak up. We're not exchanging state secrets here. What's on your mind?" "I think Dr.
Ingersoll is lying about that second ID fellowship slot." Rip shrugged. "How would you-how would anyone know? I mean, he applied for it and now it's up to the folks who make decisions like that." "I'm getting a lot of computer experience in the research lab. After some digging around, I'm able to get into sites that are supposed to be protected. Anyway, I hacked the records of the Internal Medicine Board and there's no mention of such an application. Ingersoll never submitted it." Rip was ashamed of the first question that popped into his mind, but he asked it anyway. "What about my slot? Is it approved?
Will I be able to take my ID boards when I finish?" Resnick's grin was almost evil. "I really ought to make you sweat, but I won't. Yes, your fellowship is on the up-and-up. But how does it make you feel, working for a liar?" Rip didn't know what to think. His first reaction was that the research assistant was getting a little revenge on the man who'd beat him for the fellowship. Was Resnick trying to push Rip toward resigning so he could step into the slot? The silence hung between them for what seemed like several minutes, although it was probably more like a few seconds. Finally, Rip said, "I don't believe you. And even if I did, I don't think I'd do anything about it. If I were you, I'd keep this to myself, especially the part about hacking into the Internal Medicine Board site. I doubt whether the administration of the medical center would condone such activity." He left without another word. At the door, he looked back. Resnick was still sitting at the table, grinning.