Weapon of Choice (5 page)

He asked that Norman call his office at NIH, leave a message where he could be reached. “As soon as possible, Norman, this is urgent!”

Victor still had time to call Tampa City Hospital for information about Matthew. The last time he'd been told that Matthew was in the recovery room, listed in critical condition. No, Dr. Laura Nelson was unavailable—in a meeting. They informed Victor that Matthew was now in the surgical ICU, still listed as critical. That's all the hospital could disclose. For more information, he'd have to talk to the patient's doctor. Victor clanged the receiver into its hook and sprinted to the gate. He was the last passenger to board his Delta flight.

M
ONDAY
, N
OVEMBER
25

The Tampa City Hospital CEO and the chiefs: Medicine, Pathology, Anesthesia, Pediatrics, OB-GYN, Psychiatry, and Surgery sat at a large rectangular table, draped with white linen and brightened with fresh flowers in the center. Waiters presented a plate to each doctor and took a drink order. Laura had a big salad placed in fronof her. All the others had a Reuben sandwich and French fries. Eileen had intervened, as Laura had known she would. Eileen and Laura, each five feet, five inches, each fluctuating between five and ten pounds overweight religiously counted their calories, kept track of their exercise time, and struggled in their own little weight watchers support group to lose those infuriating last few pounds.

Before the staff meeting, Laura had forewarned the chief of medicine and the hospital CEO about the AIDS patient in the facility. The hospital CEO, a businessman with medical savvy, asked Laura to brief the group on Matthew Mercer's diagnosis. The faces around the table—all men—turned somber and concerned as she presented the facts, as she understood them. They were facing the first case of AIDS at their hospital. Everyone was aware that for many months, the lay press and medical journals had been publishing dire, even inflammatory, scenarios peppered with words like “death sentence,” “highly contagious,” “no cure,” even “God's punishment.” So many issues were intertwined: medical, epidemiological, social, psychological, not to mention legal. Laura had made the diagnosis—identified the problem—but, she made very clear, the patient's definitive care belonged to Medicine, not Surgery.
Indeed she would see to the patient's surgical recovery, but the HIV diagnosis—whatever that might portend—was not her direct problem. Having made the diagnosis, she now passed the baton to Medicine. She concluded by strongly recommending that the Hills-borough County Health Department be notified and by telling them that she had a CDC contact whom she'd called for preliminary advice.

Dr. Kellerman waylaid Laura as she left the dining room, pressing his case that she assume primary care for Matthew Mercer. “You did the surgery,” he persisted.

She didn't really blame him for trying to avoid the stress of a diagnosis so controversial in so many ways. “But I'm not the infectious disease expert,” she repeated. “I did the biopsy. The frozen section was positive for Kaposi sarcoma, not really a sarcoma, as you know, but a hallmark for AIDS. And the pneumocystis stain was positive, another AIDS-defining finding.”

Kellerman just shook his head. “I'd like to transfer the patient to your care.”

“Duncan, I'll follow the patient for surgical complications, you know that. But this is a medical disease with multiple infectious organisms, not my bailiwick. The patient certainly won't tolerate another surgical procedure. Not for a long time.” Never, Laura guessed. “Dr. Jones at the CDC said to feel free to call her if you want advice.”

When Laura returned to the O.R., Mr. Kelly had been prepped. A wide incision would expose his lungs, allowing her to remove the hyperinflated, useless portions so that the healthier remaining tissue could perform properly. The cheerful seventy-year-old was one of her favorite patients. Short curly gray hair with hazel eyes that sparkled despite his constant stuggle for breath. She knew his equally affable wife would be in the waiting room, pacing, praying.

Lung reduction surgery was Laura's specialty, and she was a principal investigator in a clinical trial of the procedure coordinated by Washington University in St. Louis. Patients with severe respiratory distress secondary to emphysema in the upper lobes of the
lung responded best. She couldn't offer a cure, but she hoped to deliver a better quality of life for the elderly gentleman; less shortness of breath, a more active lifestyle so he could enjoy his grandchildren.

Mr. Kelly's surgery went well, and Laura let the gangly male med student close the large midline chest incision. The procedure had taken two and a half hours, giving Laura just enough time to regroup before starting her five o'clock case.

A new team, the second shift, had Tom Mancini, the beryllium toxicity factory worker, ready. Michelle's on-call day had ended, but she asked whether she could scrub in, too, and Laura agreed.

“This case should go quickly,” Laura said as soon as the patient had been anesthetized. “We just have to grab a biopsy of that lesion over there.” She nodded at the x-ray tacked to the light box. “Right upper lobe. Shouldn't be hard to find. Speed is important here. The lungs are compromised by the toxicity.”

Laura let Michelle make the intercostal incision, and once the lung was exposed, pointed out the cratered nodule. “One centimeter diameter,” she said.

“Is the tumor part due to the beryllium damage?” Michelle asked.

“Yes. Inhalational exposure. I'm seeing a lot more of these cases, mostly from the Bradenton/Sarasota area.”

“And,” Michelle concluded, “lung cancer's related.”

So Michelle had read up on this. Very good. Smart, as well as technically competent.

“Do we need a frozen section?” asked Michelle.

“No, we can wait on the path report. If it's carcinoma, he's not a candidate for a surgical cure. Too bad, he's a nice man, active in the community. And only fifty-four.”

This time, Laura asked the junior resident to close the incision with the staple device as Michelle supervised.

The surgical teaching staff made rounds every day at six thirty p.m. All attending physicians and house staff who were not in the operating room or responding to an emergency gathered at the nursing
station before proceeding room to room to discuss patients' status. Patients who were stable were passed by with a word or two, but patients with complications were discussed, a group consensus developed, and the house staff left to implement treatment decisions. Laura made clinical rounds a high priority. She easily could get so mired in the administrative minutiae of running the department, that she feared losing touch with what mattered most: the patients and the students.

When Laura joined the rounding physicians they were just approaching Matthew Mercer's room. She decided to intervene. “This patient is in strict isolation,” Laura told the students and doctors. “No need for all of you to gown up. Why don't you move on, and Michelle, you come with me.”

Laura grabbed a gown, capped her hair for the umpteenth time that day, put on the booties, a mask, and gloves. She pointed to the chart hanging on the wall outside the room. “Use gloves when handling the chart,” she told Michelle. “Check the blood gases, CBC, kidney, liver, and electrolytes. I'll check the surgical site.”

The patient was sedated. The ventilation settings had been decreased, Laura noted with satisfaction. The incision looked clean and dry. She checked the intravenous antibiotics: trimethoprim-sulfamethoxazole, methicillin, vancomycin—a reasonable cocktail. She wondered whether Dr. Kellerman had decided to take her advice and call Stacy at the CDC for advice. She doubted it. His pride would get in the way.

“I was reading about AIDS,” Michelle said. “That's what Mr. Mercer has, right?”

Laura nodded. “Yes. Although I don't know how we are going to handle patient confidentiality issues. That's why I didn't review him with the rest of the group.”

“Would this be the first AIDS case in Tampa?” Michelle asked.

“Maybe, but since the diagnosis is shrouded in confidentiality issues, how would we know? I can understand trying to protect patients from the stigma of an AIDS diagnosis, but I think the treatment team has a right to know. Anyway, I'm leaving that up to internal medicine and the administration. AIDS or not, we have
him in strict isolation. That's about all we can do to protect ourselves and the other patients.”

“But what about the nursing staff?” Michelle asked. “They're the ones who come into close contact with the body fluids. Are they careful enough?”

“I hope Dr. Kellerman decides to inform them,” Laura said. “Now let's go check on the families.”

After rounds, Laura talked to her patients' families. Her message to Kelly's wife: upbeat and positive. Her feedback to Marcini's wife and two sons: guarded and tentative.

“What about Mr. Mercer?” Michelle asked as they left the Mancini family.

“I should check whether his father made it to Tampa.”

“I'm going home to get some sleep,” Michelle sighed. “I'm on call the entire Thanksgiving weekend. I traded for Christmas off so I can go to Toledo to meet my boyfriend's family.”

“Toledo? Really, I'm not sure whether that's a good trade-off. You run along, I'm going home to my kids.”

Laura forgot all about Matthew Mercer's father arriving from Bethesda.

M
ONDAY
, N
OVEMBER
25

Seven fifteen p.m. Victor hoped he wasn't too late to catch Dr. Nelson. Matthew was listed in Intensive Care, but housed in a separate room, off to the side of the ICU main entrance. You couldn't miss the sign on his door: I
NFECTION
C
ONTROL
. D
O NOT ENTER
. In smaller type: V
ISITORS, REPORT TO THE NURSING STATION
.

At the station, the desk clerk looked up from a stack of lab reports.

“I'm here to see Matthew Mercer and I'd like to speak to his doctor. Could you page Dr. Laura Nelson, please?”

“Visitors are restricted to relatives. Are you a relative of Mr. Mercer?” The female clerk reached into her files. “Mercer, Matthew.” She chose a chart. “Let me see who's listed.”

“Yes, I am a relative,” Victor said. “I'm his father. I'm his only relative, so it's urgent that I be here for him.”
I am the only person in the entire world that loves this boy. Nobody's going to stand in my way
.

“I don't see a father listed, but—” The clerk hesitated with the chart in her hand. Before she could decide what to do, an orderly pushed a gurney up in front of the nursing station between the desk and Victor.

“Excuse me,” Victor said, starting to work his way around the impediment, but the patient on the gurney, apparently sedated, still managed to preempt administrative attention.

“Just a minute, sir,” the clerk spoke to Victor but looked past him at the orderly. “We're really busy here. I have to see to this new patient. What procedure?”

“Five days post discharge for hip replacement,” the orderly answered. “Admitting diagnosis: pulmonary embolus. Erratic ECG. No beds in the coronary care unit, so here we are.”

“Ma'am?” Victor tried to divert the clerk's attention.

“You have to wait, sir, until I get this patient admitted.” She accepted the newcomer's chart and shuffled pages.

Victor turned, walked the few steps to Matthew's door. From a supply of gowns, masks and paper booties and head caps neatly stacked at the entrance to the room, he grabbed the protective garments and wrestled the gown over his heavy cashmere jacket. If someone came in, they'd expect him to follow protocol. He stepped inside. He thought he was prepared, but when he saw Matthew, tubes coming from everywhere, unconscious, hooked up to a ventilator, Victor's heart plunged, tears stinging his eyes. Victor did not breathe until he saw the steady pattern on the ECG monitor.

Victor wondered whether the medical staff here had come up with the AIDS diagnosis. That sign on the door suggested that they had. They'd have to tell Matthew, and when they did, Victor needed to be right there with his son. Victor himself had intellectually, but not emotionally, accepted that Matthew would not live more than a couple of years. But Victor wanted to be a part of every remaining day of his life, to create some common history. He needed to get Matthew home—and soon. His son certainly could not die hooked up to machines in a hospital nine hundred miles from D.C.

M
ONDAY
, N
OVEMBER
25

When Laura walked through the door into her spacious kitchen, Marcy was putting meatloaf, Brussels sprouts, and sliced beefsteak tomatoes on the table. That salad at lunch was a long time ago and she was starved, but she also felt contaminated. Just how infectious was that HIV virus?

“Marcy, I'll explain later, but I have to jump in the shower.” Laura set down her briefcase. “Do we have any antimicrobial soap?”

“Just hurry, Laura, I'll put the meat back in the oven and keep the vegetables warm. All we have is that brown stuff you keep in the medicine cabinet.”

“Betadine.” The stuff she used pre-op for incision sites. “Yuck.”

In ten minutes Laura was back, scrubbed, her hair wet and pulled back at the nape of her neck. She called the kids while Marcy put the food back on the table.

“Hey, Ma, I almost hit the cycle today. Thrown out at second, tried to slide, but didn't make it.” Patrick never failed to give her a play-by-play for any game she missed. Of that she was glad. With three sons, she'd made a point of learning the basics of their various sports. All three played all three guy sports, but each had his favorite. Mike, football. Kevin, basketball. And her baby, Patrick, baseball.