Weapon of Choice (3 page)

“No. Do you want me to follow up? What's it about?”

“I'll tell you about it later. Will you check with my research lab—make certain the bovine pericardial tissue arrived?”

Laura stood in the operating room glare, scalpel poised to access the patient's lungs through a left lateral incision. Matthew Mercer already
had been intubated and placed on a ventilator. Over the past seven hours, his status had deteriorated to acute respiratory distress syndrome. Her mission was to retrieve lung tissue that would establish the cause—without the patient dying on the table, or in the recovery room, or afterward in the ICU. Her medical colleagues' task would be to treat whatever she found in his lungs.

Without explanation and ignoring their gripes, Laura had insisted that the operating team, including the anesthesiologist on his perch behind a screen at the patient's head, be issued plastic face covers as a supplement to the masks they routinely wore.

“Ready, Laura,” announced the experienced anesthesiologist. “Patient is as stable as he's ever going to be. I'd suggest getting in and out fast.”

Laura usually let her chief resident start a case and continue as far as he or she was capable, often all the way through the case. At the end, she would let a junior resident or a medical student take over, under close supervision. But not today.

“I'll do this.” She would run this case to minimize the hospital staff's involvement. If they were dealing with HIV, she couldn't be too cautious.

“Michelle, spread the ribs,” she said, having made the incision through the intercostal space, exposing the thoracic cavity. “Use the retractors to hold it open.”

To the fourth year med student standing across the table: “Maintain suction and get out as much of this fluid as possible. Note how purulent it is. I'm betting that it grows out staph and heaven knows what else.”

Laura exposed the left lung, holding it in gloved hands, inspecting it. “An abscess,” she announced, “—focal point for the infection. Get a drain ready, please.” She had her usual team: Willa, scrub nurse; Cathy, circulation nurse. They'd worked together so long that they could communicate in a few curt phrases.

“We've also got diffuse interstitial infiltrates. Let's get all this cultured.” She didn't know the medical student's name. “Sorry, you—could you hold the culture tubes and then hand them to the nurse, specifying their origin. If you don't know, ask me.”

“Michelle, see—here, this bruised area. Much like the lesions on his face and the rest of his body. We'll need a biopsy of these. Willa, are we ready with the instruments and the specimen containers? We are going to have to stop the ventilator long enough to do the biopsies. I only want to stop it
once
. Is everything ready?”

“When you say go, Laura,” said the anesthesiologist, “I'll halt the machine. But I'm having some problems holding pressure.”

“Ready. Disconnect.” Laura used an automatic linear stapling device to harvest the ten biopsy sites she wanted.

“Okay, reconnect! How much time?”

“Sixty-one seconds,” a younger male voice said from beyond the drape separating the patient's head from the operative site. “That was fast.” The anesthesiologist's resident and his medical student stood alert, their stance as Laura had requested. These were bright kids; they all knew this was an unusual case, just not how it was different.

“Let's drain that abscess, put in two chest tubes—and get him to recovery. Keep him in strict isolation until we get those cultures back.”

“Will he be able to come off the ventilator right away?” the medical student across the table wanted to know.

“No,” the anesthesiologist answered. “When you open up a patient with acute respiratory distress, they usually need mechanical ventilation for hours, sometimes days. Until you control whatever is causing the lung disease. Let's just hope that antibiotics will kick in for this one.”

Laura inserted the chest tube herself, something she hadn't done in years with all the eager house staff surrounding her whenever she operated. The entire procedure had lasted a mere thirty minutes. Now she was sorry that she had pushed back her original nine o'clock case to late afternoon. Another late night.

“Michelle, will you get x-ray confirmation of the chest tube placement before the team leaves the room?”

“Sure, Dr. Nelson, and I'll go with the patient into the recovery room. Any relatives we need to talk to?”

Laura knew why Michelle asked. Laura always included her
residents when she reported the results of surgery to the patient's loved ones. She'd tell them, “This may be the most important responsibility we have—to inform them truthfully, in a sensitive and understandable way.” Michelle had taken this direction to heart; she was fast becoming not only a skilled, but a compassionate, surgeon.

“His father should be in later today,” Laura said. “Reminds me, I did promise him I'd try to get some experimental medication for his son.”

“What med is that?” Michelle asked.

“An antibiotic for resistant staph. I wrote down the name. Nothing familiar to me. May I ask you to do some research on that? Look at Keystone Pharma. It's a new drug now in clinical trials. Let me know what you find. Before eleven thirty, if possible.”

“You can get an unapproved drug?” Michelle asked.

“Not without an extraordinary administrative hassle, but I agreed to give it a try.”

Laura reached for the clipboard with the phone number and name of the drug, wanting to fulfill her pledge to the father, but not holding out much hope that she'd prevail over regulatory bureaucracy.

“Dr. Laura Nelson, here,” she said, “I'm calling Dr. Norman Kantor in your research department.”

Laura waited, forced to listen interminably to insipid music. The operator came back: Dr. Kantor was no longer employed at Keystone Pharma.

“I'll talk to your head of research.”

She was told to be more specific.

“Connect me to the director of infectious disease research.” This time she heard a voice message. She left her name, phone number, and told the machine that it was urgent.

While she waited for the return call, she phoned the recovery room. Mercer had arrived. Isolation protocol in effect. On a ventilator. Condition: critical. Then she called the head of Pathology. The lung specimen biopsies would show Kaposi sarcoma, she told him, and suggested a methenamine silver stain for Pneumocystis carinii
cysts on the lung infiltrate specimens. Prior culture results had documented staph, she said. Would Microbiology please include all known antibiotics in the sensitivity testing panel?

She expected him to blurt out “AIDS?” but he didn't. He merely sounded annoyed that a surgeon had any knowledge of cytology stains and sensitivity tests. She thanked him profusely for the extra tests.

Laura took a breath and reached into her drawer, extracting her beryllium lung toxicity file. In an incredibly weak moment, she'd agreed to testify in a case against a metal machining plant about an hour away in Manatee County. The company used beryllium as a hardening agent in alloys. Beryllium is element number four on the element table, and because of its low density and atomic mass, valuable to many industries, particularly aerospace. Problem is, when inhaled, beryllium is corrosive to tissues, and when it leaks into the environment, well, that's not exactly beneficial, either. Whatever had possessed her to get involved? As if her schedule weren't off the charts already. Now she had to prep for what promised to be a vicious cross-examination by the defense.

Not able to concentrate, Laura decided to abandon beryllium—she'd just polish off the article she had cowritten for the
New England Journal of Medicine
on her real research love, lung reduction surgery.

At ten thirty, Stacy Jones called from the CDC. Laura briefed her friend on Mercer's case.

“Laura, I believe you're looking at full-blown AIDS. Your patient's prognosis is dismal. Send me a blood sample, and I'll get some tests done. We've got Gallo's test kit, the one the FDA is evaluating, and we'll look at the patient's T-cells and CD4 count. But with Kaposi and P. carinii, the prognosis can't be good.”

“I hope I didn't send him over the edge, opening him up.”

“You had to get the tissue, right? Make sure that in addition to those staph antibiotics, you get him on Bactrim. It's the drug of choice, intravenous is your only option. Another thing, this AIDS situation is moving so fast that I doubt your local infectious disease specialist will be up-to-date, so keep me in the loop.”

“Doctor Stacy, I can't believe you used to be
my
protegé. How the tables have turned! When I advised you to go to Harvard, little did I imagine that you'd end up a hotshot public health expert.”

Laura was proud. How many years had it been since she'd met Stacy, then a high school freshman in inner city Detroit? An easy calculation. Eighteen years. From the year she herself had entered University Medical School in Detroit. 1967, the year of the Detroit riots that decimated Detroit and nearly devastated her life, as well. So much bad fallout had come from those riots, but precious little good; Stacy Jones was an example of the good.

“You already know you need to put some stringent public health precautions in place,” Stacy said. “I'll fax you our recommendations. This disease is such a political hot potato that the limits of confidentiality are a science in their own right: what can be disclosed about HIV and what can't. Your patient can have syphilis or gonorrhea or genital herpes and you can flag his chart; with HIV you have to keep secrets. Crazy, but that's how it's coming down. We have Dr. Koop, Reagan's surgeon general, to thank for that.”

Laura could not suppress a chuckle. She, a Grand Rapids Republican; Stacy, a Detroit Democrat. Some things never change.

Stacy had the last, affectionate word. “You're my guardian angel, Laura, always will be.”

Laura hung up the phone, envisioning the dynamic about to play out: thirty-two-year-old Stacy Jones, an African American, handing down instructions to Kellerman, Tampa's sixty-five-year-old prima donna senior infectious disease authority.

“Dr. L.” Eileen looked in. “Michelle Wallace is here. She has the report you requested.”

“Send her in, please.” Laura had forgotten that she had asked her chief resident to research that new drug.

Michelle glanced around Laura's office, taking in all the family photos. Laura's colleagues at the university and the hospital knew she had several kids, but for the most part, she'd kept her life compartmentalized. Career. Kids. Focus on one. Or the other. Fully. In real time. Do not take your career problems home. Do not take your kid problems to work. Usually, an effective policy. Not always.

“You have such attractive kids,” Michelle gazed at Laura as if she were supernatural. “I just don't think I could do it all.”

Laura was always taken aback when female medical students considered career and kids incompatible. She'd had two little boys before she even started med school. For the moment, she stifled the career counseling impulse, took Michelle's packet, and began perusing the pages. “So Keystone Pharma has a drug that outperforms methicillin and vancomycin. They've started phase three.”

“Yes,” Michelle said, “They've completed phase two trials, so we know the drug is effective. Now they're enrolling more patients to make sure that it's safe.”

“And is it?”

“The study is double-blind, so no one knows. Unless the code has to be broken for some reason.”

Laura was impressed. This girl knew her stuff, and Laura liked to give praise when praise was due.

“Excellent, Michelle, and I appreciate the fine job you did in the O.R. today.”

“I'm worried about the patient, Dr. Nelson.”

“Why don't you go check on him in the recovery area? Then check with Pathology, see what they've found. Just be sure to follow isolation protocol.”

“Oh,” Michelle said on her way out the door, “did you know that the CEO of Keystone Pharma got the Nobel Peace Prize this year?”

Indeed. Paul Parnell. Keystone Pharma was respected among pharmaceutical firms for good science, good medical community relations, and generous philanthropy. But their research director had not returned her call.

M
ONDAY
, N
OVEMBER
25

“No personal calls in the lab, isn't that the rule?” Charles Scarlett addressed Stacy Jones as soon as she put down the phone. “Who were you talking to?” Charles knew he sounded pissy, but he could care less.

On his way to the lab that morning, the boss had waylaid him in the hallway. Hadn't even invited him into his office to inform him that Dr. Stacy Jones was being promoted to director, Experimental Staph Section. Just like the CDC—hell, the entire government for that matter. Promote women. Promote blacks. They got a double whammy with Jones, who was both a woman and black. “Colored,” his parents would call her.

“Not a personal call,” Jones said, turning back her attention to her stack of petri dish cultures. “A friend in Tampa has a patient with probable HIV. Not that I'm an expert, but—”

“We're supposed to go through channels,” Charles said, “before we get involved.” He didn't know whether Jones had been told about her promotion yet, and he wanted to get in his jibes, petty as they were, before she technically became his boss. Even when that happened, she wouldn't be able to touch him. By the end of the week, he'll have requested a transfer to anywhere she wasn't.

Jones seemed to ignore him. “Tampa isn't San Francisco or D.C. or New York City,” she said, inspecting a plate under a scanning microscope. The exotic staph organisms that the lab handled were potentially lethal and access to their Center for Disease Control P3 Lab was restricted to scientists with doctoral degrees and intensive
training in antimicrobial technique. “My friend Dr. Nelson doesn't know whether her hospital ever has had a case. Well, you heard what I told her. Anything you'd have added?”