By The Book

No one knew the man’s name. White male, probably in his late seventies, found unresponsive in an alley about two o’clock in the morning and brought to the emergency room. Just another homeless derelict, another John Doe.

“Pneumonia, late stages,” the intern said. He yawned. “Happens all the time. Drank himself into a stupor, vomited, aspirated. Probably been lying in that alley for more than a day. Doesn’t look like he’ll make it.”

“Labs cooking? Got a sputum culture going?”

“Yeah, but it’ll take a day or two to get the results of the culture. The smear looks like Staph. Guess I’ll give him—”

“Wait. I’ve got access to an experimental drug that might help. Let me start him on that.”

The intern shrugged. It was two in the morning. He’d been on duty for more than twenty-four hours straight—why’d Johnson’s wife have to go into labor today?—and he was bushed. The bum probably didn’t have a snowball’s chance of surviving anyway. Why not? “You’ll be responsible?”

“I’ll take it from here. Even do the paperwork.”

“Deal,” the intern said, and ambled off to see the next patient.

Three hours later, John Doe lay on a gurney in a corner of the ER. An IV ran into one arm, a blood pressure cuff encircled the other. Spittle dripped from his open mouth and dotted his unshaven chin. His eyes were open and staring.

“Acute anaphylaxis, death within minutes. Interesting.” He scratched his chin. “Guess I need to make some adjustments in the compound.” He picked up the almost-blank chart. “I’ll say I gave him ampicillin and sulbactam. That should cover it.”

* * *

The woman’s look pierced Dr. Sara Miles’ heart. “Do you know what’s wrong with Chelsea?”

Chelsea Ferguson lay still and pale as a mannequin in the hospital bed. An IV carried precious fluids and medications into a vein in her arm. A plastic tube delivered a constant supply of oxygen to her nostrils. Above the girl’s head, monitors beeped and flashed. And over it all wafted the faint antiseptic smell of the ICU.

Chelsea’s mother sat quietly at the bedside, but her hands were never still: arranging and rearranging her daughter’s cover, twisting the hem of her plain brown skirt, shredding a tissue. Sara decided that the gray strands in Mrs. Ferguson’s long brunette hair were a recent addition, along with the lines etched in her face.

Sara put her hand on the teenager’s head and smoothed the matted brown curls. The girl’s hot flesh underscored the urgency of the situation. Since Chelsea’s admission to University Hospital three days ago, her fever hadn’t responded to any of the treatments Sara ordered. If anything, the girl was worse.

“Let’s slip out into the hall,” Sara said. She tiptoed from the bedside and waited outside the room while Mrs. Ferguson kissed her sleeping daughter and shuffled through the door.

Sara pointed. “Let’s go into the family room for a minute.”

“Will she be—?”

“The nurses will check on her, and they’ll call me if anything changes.” Sara led the way into the room and eased the door closed. This family room resembled so many others Sara had been in over the years: small, dim, and quiet. Six wooden chairs with lightly upholstered seats and backs were arranged along three of the walls. Illumination came from a lamp in the corner. A Bible, several devotional magazines, and a box of tissues stood within reach on a coffee table.

This was a room where families received bad news: the biopsy was positive, the treatment hadn’t worked, the doctors weren’t able to save their loved one. The cloying scent of flowers in a vase on an end table reminded Sara of a funeral home, and she shivered as memories came unbidden. She shoved her emotions aside and gestured Mrs. Ferguson to a seat. “Would you like something? Water? Coffee? A soft drink?”

The woman shook her head. “No. Just tell me what’s going on with my daughter. Do you know what’s wrong with her? Can you save her?” Her sob turned into a soft hiccup. “Is she going to die?”

Sara swallowed hard. “Chelsea has what we call sepsis. You might have heard it referred to as blood poisoning. It happens when bacteria get into the body and enter the bloodstream. In Chelsea’s case, this probably began when she had her wisdom teeth extracted.”

I can’t believe the dentist didn’t put her on a prophylactic antibiotic before the procedure. Sara brushed those thoughts aside. That wasn’t important now. The important thing was saving the girl’s life. Sara marshaled her thoughts. “We took samples of Chelsea’s blood at the time of her admission, and while we waited for the results of the blood cultures I started treatment with a potent mixture of antibiotics. As you can see, that hasn’t helped.”

“Why?”

Sara wished the woman wouldn’t be so reasonable, so placid. She wished Mrs. Ferguson would scream and cry. If the roles were reversed, she’d do just that. “While we wait for the results of blood cultures, we make a guess at the best antibiotics to use. Most of the time, our initial guess is right. This time, it was wrong—badly wrong.”

“But now you know what’s causing the infection?” It was a question, not a statement.

“Yes, we know.” And it’s not good news.

Hope tinged Mrs. Ferguson’s voice. “You can fix this, can’t you?”

I wish I could. “The bacteria causing Chelsea’s sepsis is one that . . .” Sara paused and started again. “Have you heard of Mersa?”

“Mersa? No. What’s that?”

“It’s actually MRSA, but doctors usually pronounce it that way. That’s sort of a medical shorthand for methicillin-resistant Staphylococcus aureus, a bacteria that’s resistant to most of our common antibiotics.”

Mrs. Ferguson frowned. “You said most. Do you have something that will work?”

“Yes, we do. Matter of fact, when Chelsea was admitted I started her on two strong antibiotics, a combination that’s generally effective against MRSA. But she hasn’t responded, because this isn’t MRSA. It’s worse than MRSA.” She started to add “Much worse,” but the words died in her throat.

Sara paused and waited for Mrs. Ferguson to ask the next question. Instead, the woman crumpled the tissue she held and dabbed at the corner of her eyes, eyes in which hope seemed to die as Sara watched.

“This is what we call a ‘super-bug,’” Sara continued. “It used to be rare, but we’re seeing more and more infections with it. Right now, none of the commercially available antibiotics are effective. These bacteria are resistant to everything we can throw at them.”

Mrs. Ferguson’s voice was so quiet Sara almost missed the words. “What do you call it?”

“It’s a long name, and it’s not important that you know it.” Matter of fact, we don’t use the proper name most of the time. We just call it “The Killer.”

“So that’s it?”

“No, there’s a doctor at our medical center doing trials on an experimental drug that might work for Chelsea.” No need to mention that Jack is . . . No, let it go.

“Can you get some of this? Give it to Chelsea?”

“I can’t, but the man who can is an infectious disease specialist on the faculty here at the medical center. Actually, he helped develop it. Notice I said ‘experimental,’ which means there may be side effects. But if you want me—”

“Do it!” For the first time in days, Sara saw a spark of life in Mrs. Ferguson’s eyes, heard hope in her voice. “Call him! Now! Please!”

“You realize that this drug isn’t fully tested yet. It may not work. Or the drug may cause problems.” There, she’d said it twice in different words. She’d done her duty.

“I don’t care. My little girl is dying. I’ll sign the releases. Anything you need. If this is our only chance, please, let’s take it.”

Lord, I hope I haven’t made a mistake. “I’ll make the call.”

“I’m going back to be with my baby,” Mrs. Ferguson said. She stood and squared her shoulders. “While you call, I’ll pray.”

* * *

“Mr. Wolfe, you can come in now.” The secretary opened the doors to Dr. Patel’s office as though she were St. Peter ushering a supplicant through the Pearly Gates.

Bob Wolfe bit back the retort he wanted to utter. It’s Doctor Wolfe. Doctor of Pharmacology. I worked six years to earn that Pharm D, not to mention two years of research fellowship. How about some respect? But this wasn’t the time to fight that battle.

He straightened his tie, checked that there were no stains on his fresh white lab coat, and walked into the office of the head of Jandra Pharmaceuticals as though he had been summoned to receive a medal. Never let them see you sweat.

Dr. David Patel rose from behind his desk and beamed, gesturing toward the visitor’s chair opposite. “Bob, come in. Sit down. I appreciate your coming.”

Not much choice, was there? Wolfe studied his boss across the expanse of uncluttered mahogany that separated them. Pharmaceutical companies seemed to be made up of two groups: the geeks and the glad-handers. Patel typified the former group. PhD from Cal Tech, brilliant research mind, but the social skills of a tortoise. Patel had been snatched from the relative obscurity of a research lab at Berkeley by the Board of Directors of Jandra Pharmaceuticals, given the title of President and CEO, and charged with breathing life into the struggling company. How Patel planned to do that remained a mystery to Wolfe and his co-workers.

Patel leaned forward and punched a button on a console that looked like it could launch a space probe. “Cindy, please ask Mr. Lindberg to join us.”

Steve Lindberg ran the sales team from an office across the hall. Lindberg could memorize salient scientific material and regurgitate it with the best of them, but Wolfe would bet the man’s understanding of most of Jandra’s products and those of its major competitors was a mile wide and an inch deep. On the other hand, Lindberg had his own area of expertise: remembering names, paying for food and drinks, arranging golf games at exclusive clubs. No doubt about it, Lindberg was a classic glad-hander, which was why he had ascended to his current position, heading the marketing team at Jandra.

Wolfe hid a smile. Interesting. The President of the company and the Director of Marketing. This could be big. The door behind Wolfe opened. He deliberately kept his eyes front. Be cool. Let this play out.

“Hey, Bob. It’s good to see you.” Wolfe turned just in time to avoid the full force of a hand landing on his shoulder. Even the glancing blow made him wince. Lindberg dragged a chair to the side of Patel’s desk, positioning himself halfway between the two men. Clever. Not taking sides, but clearly separating himself from the underling.

Wolfe studied the two men and, not for the first time, marveled at the contrast in their appearance. Patel was swarthy, slim, and sleek, with jet-black hair and coal-black eyes. His blue shirt had a white collar on which was centered the unfashionably large knot of an unfashionably wide gold-and-black tie. Wolfe wondered whether the man was five years behind or one ahead of fashion trends. He spoke with a trace of a British accent, and Wolfe seemed to recall that Patel had received part of his education at Oxford. Maybe he wore an “old school” tie, without regard to current fashion. If so, it would be typical of Patel.

Lindberg was middle-aged but already running to fat—or, more accurately, flab. His florid complexion gave testimony to too many helpings of rare roast beef accompanied by glasses of single malt Scotch, undoubtedly shared with top-drawer doctors and paid for on the Janus expense account. Lindberg’s eyes were the color of burnished steel, and showed a glimmer of naked ambition that the smile pasted on his face couldn’t disguise. His thinning blond hair was combed carefully to cover early male pattern baldness. The sleeves of his white dress shirt were rolled halfway to his elbows. His tie was at half-mast and slightly askew.

Patel, the geek. Lindberg, the glad-hander. Different in so many ways. But both men shared one characteristic. Wolfe knew from experience that each man would sell his mother if it might benefit the company, or more specifically, their position in it. The two of them together could mean something very good or very bad for Bob Wolfe. He eased forward in his chair and kicked his senses into high gear.

Patel leaned back and tented his fingers. “Bob, I’m sure you’re wondering what this is about. Well, I wanted to congratulate you on the success of EpAm848. I’ve been looking over the preliminary information, especially the reports from Dr. Ingersoll at Southwestern Medical Center. Very impressive.”

“Well, it’s sort of Ingersoll’s baby. He stumbled onto it when he was doing some research here during his infectious disease fellowship at UC Berkeley. I think he wants it to succeed as much as we do.”

“I doubt that.” Patel leaned forward with both hands on the desk. “Jandra is on the verge of bankruptcy. I want that drug on the market ASAP!”

“But we’re not ready. We need more data,” Wolfe said.

“Here’s the good news,” Patel said. “The FDA is worried about The Killer bacteria outbreak. I’ve pulled a few strings, called in a bunch of favors, and I can assure you we can get this application fast-tracked.”

“How?” Wolfe said. “We’re still doing Phase II trials. What about Phase III? Assuming everything goes well, it’s going to be another year, maybe two, before we can do a rollout of EpAm848.”

“Not to worry,” Patel said. “Our inside man at the FDA assures me he can help us massage the data. We can get by with the Phase II trials we’ve already completed. And he’ll arrange things so we can use those plus some of our European studies to fulfill the Phase III requirements.”

Lindberg winked at Wolfe. “We may have to be creative in the way we handle our data. You and I need to get our heads together and see how many corners we can cut before the application is ready.”

Wolfe shook his head. “You say this drug will save us from bankruptcy. I don’t see that. I mean, yes, it looks like we may be in for a full-blown epidemic of Staph luciferus, but we won’t sell enough—“

Lindberg silenced him with an upraised hand. “Exposure, Bob. Exposure. If we get this drug on the market, if we’re the first with a cure, our name recognition will skyrocket. Doctors and patients will pay attention to our other drugs: blood pressure, cholesterol, diabetes. Our market share will go through the roof in all of them.”

Wolfe could see the salesman in Lindberg take over as he leaned closer, as though to drive home his point by proximity. “We’re preparing a direct-to-consumer push on all those drugs, ready to launch at the same time we release Jandramycin.”

The name didn’t click with Wolfe for a moment. “I . . . Well, I’ll certainly do what I can.”

“Do more than that,” Lindberg said. “Jandra Pharmaceuticals is hurting. We’re staking everything on Jandramycin.”

That was the second time Wolfe had heard the term. “What—“

“Stop referring to the drug by its generic name,” Patel added. “From now on, the compound is Jandramycin. When people hear the name Jandra Pharmaceuticals, we want them to think of us as the people who developed the antibiotic that saved the world from the worst epidemic since the black plague.”

Lindberg eased from his chair and gave Wolfe another slap on the shoulder. “This is your project now. It’s on your shoulders. The company’s got a lot riding on this.”

And so do I. “But what if a problem turns up?”

Patel rose and drew himself up to his full five feet eight inches. His obsidian eyes seemed to burn right through Wolfe. “We’re depending on you to make sure that doesn’t happen. Are we clear on that?”

* * *

Sara leaned over the sink and splashed water on her face. The paper towels in the women’s rest room of the clinic were rough, but maybe that would put some color in the face that stared back at her from the mirror. Her brown eyes were red-rimmed from another sleepless night. Raven hair was pulled into a ponytail because she could never find time or energy for a haircut or a perm. Get it together, Sara. She took a deep breath and headed for the doctor’s dictation room, where she slumped into a chair.

“Something wrong, Dr. Miles?”

Sara turned to see Gloria, the clinic’s head nurse. “No, just taking a few deep breaths before I have to make a call I’m dreading.”

Gloria slid into the chair next to Sara. The controlled chaos of the internal medicine clinic hummed around them. The buzz of conversations and ringing of phones served as effectively as white noise to mask her next words. “Is it one of your hospital patients? Got some bad news to deliver?”

“Sort of. It’s Chelsea Ferguson.”

“The teenage girl? Is she worse?”

“Yes. The cultures grew Staph luciferus.”

Gloria whistled silently. “The Killer. That’s bad.”

“The only thing that seems to be working in these cases is that new drug of Jack Ingersoll’s.”

“Oh, I get it. That’s the call you don’t want to make.” Gloria touched Sara lightly on the shoulder. “When will you stop letting what Ingersoll did ruin the rest of your life? I can introduce you to a couple of nice men who go to our church. They’ve both gone through tough divorces—neither was their fault—and they want to move on. It would be good for you—”

Sara shook her head. “Thanks, but I’m not ready to date. I’m not sure if I can ever trust a man again.”

Gloria opened her mouth, but Sara silenced her with an upraised hand. No sense putting this off. She pulled the phone toward her and stabbed in a number.

* * *

Dr. John Ramsey found a spot in the Visitor’s Parking Lot. He exited his car and looked across the driveway at the main campus of Southwestern Medical Center. When he’d graduated, there were two buildings on the campus. Now those two had been swallowed up, incorporated into a complex that totaled about forty buildings on three separate campuses. Right now he only needed to find one: the tall white building directly across the driveway at the end of a flagstone plaza. The imposing glass façade of the medical library reflected sunlight into his eyes as he wove past benches where students sat chatting on cell phones or burrowing into book bags. He paused at the glass front doors of the complex, took a deep breath, and pushed forward.

There was a directory inside for anyone trying to negotiate the warren of inter-connected buildings, but John didn’t need it. He found the elevator he wanted, entered, and punched five. In a moment, he was in the office of the Chairman of Internal Medicine.

“Dr. Schaeffer will be with you in a moment.” The receptionist motioned him toward a seat opposite the magnificent rosewood desk that was the centerpiece of the spacious office, then glided out, closing the door softly behind her.

John eased into the visitor’s chair and looked around him. He’d spent forty years on the volunteer clinical faculty of Southwestern Medical Center’s Department of Internal Medicine. For forty years he’d instructed and mentored medical students and residents, for forty years he’d covered the teaching clinic once a month, and today was the first time he’d been in the department chairman’s office. He swallowed the resentment he felt bubbling up. No, John. You never wanted to be here. You were happy in your own world.

John couldn’t help comparing this room with the cubbyhole he’d called his private office. Now he didn’t even have that. The practice was closed, the equipment and furnishings sold to a young doctor just getting started. John’s files and patient records were in a locked storage facility, rent paid for a year.

He wondered how many of his patients had contacted his nurse to have their records transferred. No matter, she’d handle it. He’d paid her six months’ salary to take care of such things. What would happen after that? He didn’t have the energy to care. Things were different now.

For almost half a century he’d awakened to the aroma of coffee and a kiss from the most wonderful woman in the world. Now getting out of bed in the morning was an effort, shaving and getting dressed were more than he could manage some days. Since Beth died . . . He shook his head, trying to clear the cobwebs that clogged his brain. The knowledge that he’d never again know the happiness of having a woman he loved by his side made him wish he’d died with her. What was the use of going on?

But something happened this morning. He’d awakened with a small spark of determination to do something, anything, to move on. He tried to fight it, to roll over and seek the sleep that eluded him. Instead, he heard the echo of Beth’s words: “You’re too good a physician to retire. People need you.” He remembered that conversation as though it were yesterday. She’d urged, he’d insisted. Let’s retire. I want to get out of the rat race and enjoy time with you. Retirement meant the travel they’d put off, the time to do things together. Only, now there was no more together.

This morning, he’d rolled out of bed determined that today would be different. It would be the start of his rebirth. As he shrugged into a robe, as he’d done each day since her death he looked at the picture on their dresser of him and Beth. She’d been radiant that spring day so many years ago, and he wondered yet again how he’d managed to snag her.

He’d shaved—for the first time in days—with special care, and his image in the mirror made him wonder. When did that slim young man in the picture develop a paunch and acquire an AARP card? When had the thick brown hair been replaced by gray strands that required careful combing to hide a retreating hairline? The eyes were still bright, although they hid behind wire-rimmed trifocals. “You’re too old for this, John,” he muttered. And as though she were in the room, he heard Beth’s words once more. “You’re too good a physician to retire. People need you.”

Fortified with coffee, the sole component of his breakfast nowadays, he’d forced himself to make the call. He asked his question and was gratified and a bit frightened by the positive response. John dressed carefully, choosing his best suit, spending a great deal of time selecting a tie. He’d noticed a gradual shift in doctors’ attire over the past few years. Now many wore jeans and golf shirts under their white coats. But for John Ramsey, putting on a tie before going to the office was tantamount to donning a uniform, one he’d worn proudly for years. And he—

“John, I was surprised when I got your call. To what do I owe the pleasure?” Dr. Donald Schaeffer breezed into the office, the starched tails of his white coat billowing behind him. He offered his hand, then settled in behind his desk.

“Donald, I appreciate your taking the time to see me. I was wondering—”

“Before we start, I want you to know how sorry we all are for your loss. Is there anything I can do?”

Perfect lead-in. See if you can get the words out. “As you know, I closed my office four months ago. Beth and I were going to enjoy retirement. Then . . .”

Schaeffer nodded and tented his fingers under his chin. At least he had the grace not to offer more platitudes. Ramsey had had enough of those.

“I was wondering if you could use me in the department.” There. Not the words he’d rehearsed, but at least he’d tossed the ball into Schaeffer’s court.

“John, are you talking about coming onto the faculty?”

“Maybe something half-time. I could staff resident clinics, teach medical students.”

Schaeffer was shaking his head before John finished. “That’s what the volunteer clinical faculty does. It’s what you did for . . . how many years? Thirty? Thirty-five?”

“Forty, actually. Well, I’m still a clinical professor in the department, so I guess I have privileges at Parkland Hospital. Can you use me there?”

Schaeffer pulled a yellow legal pad toward him and wrote a couple of words before he pushed it aside. “I’m not sure what I can do for you, if anything. It’s not that easy. You have no idea of the administrative hoops I have to jump through to run this department. Even if I could offer you a job today—and I can’t— I’d have to juggle the budget to support it, post the position for open applications, get half a dozen approvals before finalizing the appointment.” He spread his hands in a gesture of futility.

“So, is that a ‘no’?”

“”That’s an ‘I’ll see what I can do.’ Afraid that’s the best I have to offer.” Schaeffer looked at his watch, shoved his chair back and eased to his feet. “Coming to Grand Rounds?”

Why not? John’s house was an empty museum of bitter memories. His office belonged to someone else. Why not sit in the company of colleagues? “Sure. I’ll walk over with you.”

As the two men moved through the halls of the medical center, John prayed silently that Schaeffer would find a job for him. With all his prayers for Beth during her final illness, prayers that had gone unanswered, he figured that surely God owed him this one.