After forty-five minutes of waiting, Springer’s receptionist finally announced to Pia that the doctor could see her now. Pia quickly entered his office. Springer was at his desk facing into the small room. There were no other chairs; it was Springer’s way of keeping meetings short.
“Dr. Springer, I’m sorry to bother you again, and I know I annoyed you the last time we met. I apologize for all that. But I’m a medical student, and if I can’t learn from my experiences, then I’m a pretty poor excuse for one. And I apologize for questioning-”
“Yes, yes,” Springer said, cutting Pia off midstream. Her apologies sounded rehearsed and there was nothing resembling contrition in her eyes. Worst of all, his schedule was completely full with residents, at that moment, awaiting his arrival in the emergency room. He cleared his throat. “From our last chat I suspect you believe you know better than some of the foremost authorities in the land what has taken place here. Well, I want to disabuse you of that notion. Also I’d like to say that I wouldn’t have even taken the time to see you this morning were it not for the fact that you discovered the early signs of peritonitis in Dr. Rothman. Dr. De Silva told me about a medical student who she assumed was on rotation catching rebound tenderness in Dr. Rothman’s abdomen, which had not presented itself previously. We’ll overlook the fact that this medical student was not, in fact, on rotation and had essentially broken into the ward and was wholly unauthorized to approach the patients. Of course, I later learned that this medical student was yourself.”
It took Pia a couple of seconds to realize that Springer was paying her a slight compliment, even if it was cloaked in a sardonic reprimand. Pia took it as an opening. “I fully admit it was, and perhaps I shouldn’t have been there,” she said. “But it was an important discovery with important consequences. The man was clearly getting worse, which makes one wonder why the original antibiotic was chosen.”
“Please,” Springer said, his face empurpling. “This is where we left off last time. I just indicated that we were grateful for your help, and now you’re back with this nonsense. I can’t win. Again, there is nothing to indicate that chloramphenicol wasn’t doing the best job under the circumstances. And, as we have said about fifty times, we were informed by the sensitivity studies carried out by Dr. Rothman himself that it was the correct choice of antibiotic. We are working under the assumption that Dr. Rothman’s work in the study was as thorough and accurate as was customary.”
Pia couldn’t believe what she was hearing. Was Springer attempting to shift some of the responsibility onto Rothman? In this case it seemed especially crass to even suggest blaming the victim. “So how come, considering those sensitivity studies, neither Dr. Rothman nor Dr. Yamamoto showed any sign of response to the chosen antibiotic?”
Springer closed his eyes for a moment. “The answer to your question is simple. The virulence of the involved strain of salmonella overwhelmed both the antibiotic and the patients’ defenses. Remember, antibiotics, contrary to myth, do not cure. It is the patient’s immune system that cures. Obviously with Rothman and Yamamoto, their immune systems were completely overwhelmed. Simple as that.”
Pia started to respond, but Springer cut her off. “Listen, we’ve been over this issue. And let me add that a department head at this hospital does not have this kind of conversation with a medical student. A department head does not have this kind of conversation at all-there are protocols to be observed, there are panels that are convened if there are questions about the diagnosis or treatment. It’s not clear in this case that there are any questions. Jesus, why am I justifying myself to you? This is not how we conduct business around here.”
Pia wasn’t picking up on Springer’s rising sense of outrage. She had him in the room and she wanted answers. “Why weren’t Rothman and Yamamoto being monitored more closely?”
“They were being monitored extremely closely. Each had his own nurse.”
“Closely? How did it happen that a medical student had to pick up on the signs of developing peritonitis?”
“That was a fluke. It would have been picked up very quickly. Trust me. Now, is there anything else I can help you with, any other hospital policy you might want to critique for me?”
Springer’s sarcasm was lost on Pia.
“This case confuses me,” Pia continued. “In fact, it’s one of the worst cases of salmonella or typhoid that I’ve ever come across.”
“In your vastly broad experience,” Springer said.
“In my experience, yes.”
“Well, what are you alluding to? I’m sure you’re alluding to something. So enlighten me, please.”
“One of the first things they told us when we got here was about diagnosis. ‘When you hear galloping hoofbeats, you should think of horses, not zebras.’ ”
“Yes, of course, it’s the oldest saw in medicine. What about it?”
“Should we be looking for zebras here, Dr. Springer?”
“We are not looking for anything here, Ms. Grazdani. But I am dying to know what it is that you are looking for. So enlighten me again.”
“Okay. Is it possible that this case represents some exotic form of an antibody/antigen reaction the body can have, like a Shwartzman reaction? In which case would it not have made sense to use Decadron or some similar anti-inflammatory agent, something potent, to try to head it off at the pass?”
“If that is your great revelation, well, I’m sorry to say it’s not much of one. Because we used Decadron in the evening when it became clear that the two researchers were approaching extremis. Perhaps you should review the patients’ charts before making accusations like that.”
“Of course. If I had been given access to the charts I wouldn’t have made the mistake. But I’m not making accusations, I just want to get to the truth, Dr. Springer.”
“We all do, Ms. Grazdani.”
Springer was suddenly overcome with fatigue. Talking with Pia Grazdani was frustrating, and he had more people he was going to have to deal with that afternoon who were going to be even more of a burden. There would be the inevitable press and the patients’ families. It was not going to be a good day, since ultimately, it was the patients he cared about.
“Do you think perhaps there could have been yet another bacteria involved besides salmonella, a bacteria or a virus that was being covered or camouflaged by the salmonella? And maybe it was this bacteria that was totally resistant to chloramphenicol and was the real killer?”
There was silence while Springer tried to control his anger. This was simply too much. His eyes drilled into Pia’s while she maintained her composure, waiting for an answer while looking down at her feet. Finally Springer exploded with bottled-up emotion.
“I cannot, for the life of me, imagine a more ridiculous scenario. We made the diagnosis by fulfilling Koch’s hypothesis. The illness was caused by salmonella, whose presence we ascertained in multiple ways, but most convincingly from blood culture. We classified the strain in multiple ways as well, particularly by DNA analysis. The offending organism was, without an ounce of doubt, the alpha strain of salmonella typhi that Rothman himself had had grown in space with the cooperation of NASA. There was no other pathogen, for Christ’s sake. The blood cultures only grew out the salmonella. Nothing else! Nothing at all!”
Undaunted, Pia changed the subject on a dime. “What about the hair loss? Does serious salmonella infection cause hair loss?”
Springer was having difficulty controlling himself, yet the woman seemed completely calm. “The stress of almost any severe illness, particularly one presenting with high fever, can cause hair loss. Anyway, what hair loss are you talking about?”
“I saw hair loss with Rothman before I discovered the rebound tenderness. The resident suggested it could be attributed to the chloramphenicol.”