The fifth vial

CHAPTER 8

Yaounde was just four degrees north of the equator. Joe Anson had never handled the heat and humidity of Cameroon as well as those who were born there, but this day, with monsoon season just a couple of weeks away, was the worst he could remember. The air-conditioning units in the hospital were fighting a losing battle? the odors of illness were intensified throughout the building? flies were everywhere? and worst of all, the air was just about too heavy for him to breathe.

If there was a bright spot in the oppressive day, it was the girl, Marielle, who had responded remarkably to her clandestine treatment with Sarah-9, and was now sitting up in a chair by her bed, taking fluids and nourishment. The drug was an absolute miracle, just as he had known from the beginning it would be. Another day, perhaps, and the Whitestone Center for African Health van would bring her back to her mother, along with enough rice and other staples to improve the health and well-being of the village until the monsoons hit. After that, the cycle of malnutrition and illness would begin anew.

"Okay, dear one," Anson said, placing his stethoscope on the girl's back, "breathe in, breathe out…You are doing so well. So well. Maybe tomorrow you will go home."

The child turned and threw her arms around Anson's neck. "I love you, Dr. Joe," she said. "Love, love, love, love, love."

"And I love you, too, dear peanut."

The few words took more out of Anson than he would ever care to admit to anyone. He handed Marielle a picture book and inched away from her bedside to the small office he shared with whichever doctors were on call. What in the hell was going to happen to him? What should he do? After thirty seconds, with his air hunger mounting, he used the emergency two-way radio he always carried to summon help.

"This is Claudine, Dr. Anson," the nurse said. "Where are you?"

"Doctor's office…in the hospital."

"You need oxygen?"

"Yes.

"One minute."

It was half that when Claudine raced in pulling a green 650-liter tank of the precious gas, dropped into a frame on wheels. She was a tall woman nearing fifty, with a regal bearing, caring eyes, and a smooth, richly dark complexion. She had been at the hospital almost since its inception.

"You are working the day shift?" Anson managed as she set his mask in place and started the oxygen flow at maximum.

"Just breathe," she said. "I…um…one of the other nurses got sick. I am working for her."

Anson missed her deeply troubled expression. He withdrew a cortisone inhaler from the top drawer and took two deep breaths from it, followed by two puffs from a bronchodilator.

"It is good to see you," he said.

"You are feeling better?"

"The humidity makes it hard."

"The humidity is only going to get worse until the rains start."

"Then it will be worse still. A hundred percent humidity. I do not know how I will ever deal with that."

Again, a shadow crossed the nurse's face.

"You are going to be all right," she said with more than casual determination.

"Of course I am, Claudine."

"You are scheduled for your Wednesday lunch with Dr. St. Pierre. Should I cancel that?"

"No, no. I do not cancel things. You know that."

Anson, once no more reliable than the wind, had become a creature of absolute discipline and unwavering habit. On Wednesdays at noon — every Wednesday — he met with St. Pierre in the small hospital dining area, where he ate conch chowder and a green salad, drank a bottle of Guinness Cameroun, brewed in Yaounde, and finished his meal off with a scoop of chocolate ice cream. It was there they informally discussed the business affairs of the hospital, clinic, and laboratory, as well as his Sarah-9 research and, over recent years, his health.

"Excuse me for saying so, Doctor," Claudine said, "but your breathing is as labored as it has been for some time."

"It is…unpredictable."

"And there is no other treatment I can get for you?"

"I…am…on so much…medication I…am jittery…most of the…time."

"Please, just relax and breathe. Perhaps I should get Dr. St. Pierre, or a respirator."

Anson motioned her to stay calm and wait. The nurse backed off to one side of the room, but her dark eyes, moist with caring and concern, never left him. Unseen by Anson, she reached into the pocket of her uniform and nervously fingered the vial of clear liquid that was there.

Exactly one-point-four cc's — no more, no less.

That was the instruction.

Exactly one-point-four…

Lunch was scheduled for noon, but it was a quarter after before Anson had enough breath to set the oxygen aside and make his way to the dining area. The room was empty save for St. Pierre, who was seated at one of the

three small tables, eating a tuna sandwich, drinking a tall iced tea, and going over some ledgers. She wore khaki shorts and a white tee that accented her alluring breasts. For a few moments, Anson was actually diverted from his respiratory difficulty. Over the years, he had often felt their relationship was about to move beyond a close friendship, but that had yet to happen. He settled in at the table, and moments later the cook reverently set his meal in front of him, a reminder that there was no one in the hospital or lab at the center whose life had not in some way been touched by the man.

"I'll never know," he said to St. Pierre in English, pausing once for air, "how you manage to look so fresh in the face of this humidity."

"I suspect you would look fresher if you were breathing at something better than an oxygen saturation of eighty percent."

"I have managed to put in a full day's work."

"I fear that won't last much longer."

"Who can say: Lungs adjust."

"Not with pulmonary fibrosis they don't, Joseph, and you know that as well as I do."

Anson picked at his salad and, as was his habit, took a lengthy pull straight from the bottle of his Guinness Cameroun. Elizabeth was right, he was thinking. She was always right when it came to his health. Still -

"It just isn't the time for me to submit to a transplant. The monsoons are almost upon us. Our work in the lab is going so well. I simply have too much to do."

"You are risking death every day from sudden heart failure or even a stroke." She reached over and placed her hand on top of his. Her expression left no doubt that her concern for him was personal as well as professional. "You have done so much for so many, Joseph. I don't want anything more to happen to you. Your breathing is getting worse, and it is destined to get even worse still. If matters deteriorate much more, any operation will become far more risky."

"Perhaps."

"The recovery from surgery won't be nearly as lengthy as you think. The doctors with whom I have been working are some of the greatest transplant surgeons in the world. They are standing by to ensure that you get the best care possible."

Anson drained his bottle, hoping for at least a little fortitude in the battle to convince Elizabeth that the medical indications for a transplant were not overwhelming, and the timing was poor.

"I've had several good days in a row," he tried.

"I beg you to get honest with yourself. Just because you haven't stopped in the middle of the day for therapy on a respirator doesn't mean you've had a good day. Look at you now. You are an intellectual, a scholar, yet you don't say half the things that are on your mind because you don't have enough breath to get the words out." Again she took his hand in hers. "Joseph, listen to me, please. The doctors at Whitestone have learned of a donor — a twelve out of twelve donor, Joseph — a perfect tissue match for you. It's what we've been searching the world for. You will be on virtually no anti-rejection medication. That means no debility or side effects. You will be back here at work before you even know it."

Anson stared across at her. This was the first time a donor had actually been located, let alone one who was a virtually perfect tissue match. Elizabeth and the others with whom she had been consulting had just increased the ante in this high-stakes game.

"How long have you had people looking for someone?" "Ever since we tissue-typed you and realized that your profile was unusual and rare."

Anson slumped back, shaking his head. "Where is this match?" he asked.

"India. Amritsar, India. It's in Punjab State, north and west of Delhi. A man lies on machines in the hospital there. He is brain-dead from a massive cerebral hemorrhage. His hospital wants to move forward with the harvesting of his organs, but we have begged them to wait."

Anson stood and walked across the room. The short distance strained his breathing, but, he rationalized to himself, the humidity was intense.

"I can't do it," he said finally. "I just can't. There's work to do here and Sarah to notify and…and…"

"Please, Joseph," St. Pierre said firmly. "Please stop! If this is something you're not ready to do then that's the way it's going to be. Why don't you go on back to your apartment and rest for an hour until afternoon clinic. I'll cover for you here."

"O'okay," Anson said, his tone almost a baby's. "I'm glad you're not angry with me."

"I'm worried for you, Joseph, and I'm worried for our Sarah-nine project, but I am hardly angry. Let me get the security guard to accompany you to your room. Would you like a wheelchair?"

"No!" Anson snapped. As he turned away, a sudden wave of weakness and profound fatigue swept over him. "On second thought, maybe a wheelchair would be best," he capitulated.

By the time the guard entered the dining area and helped Anson into a wheelchair, his fatigue had intensified, and he was barely able to take in any air at all. He strained to breathe, but it was as if his mind had decided it could no longer be involved in such an effort. He tried to speak, to call for help, but no words emerged.

The room was whirling as the guard wheeled the chair out the doorway and onto the path to the living quarters. Just a few feet into the journey, Anson realized his breathing had stopped altogether. The scene around him dimmed, then grew black. Helpless and rapidly losing consciousness, he toppled forward out of the chair, landing face-first on the gravel.

The guard, a stocky man with massive arms, scooped Anson up as if he were a rag doll and raced back into the hospital crying for help. In seconds, the physician's limp form was supine on a stretcher in the critical care room, and Claudine had readied the well-equipped crash cart. St. Pierre, a cool head in even the most dire medical emergencies, ordered a cardiac monitor, urinary catheter, and IV, then positioned Anson's head chin up, and began inflating his lungs with a breathing bag and mask. One of the medical residents from Yaounde offered to take over for her, but St. Pierre declined.

"No matter how proficient you are, Daniel," she said, "I will never trust your technique in situations such as this as much as I trust my own. Without this man, we are all lost. Check his femoral artery for a pulse. Claudine, prepare for me to intubate. A seven-point-five tube. Be certain to check the balloon on it before giving it to me."

There was a momentary, silent spark between the two women, unseen by anyone else in the room.

"He still has a pulse," the resident said. "Faint at one-twenty." "Help get the monitor running and see if you can get a blood pressure.

St. Pierre continued breathing effectively for Anson, whose color had marginally improved, although his level of consciousness had not. Claudine inflated the balloon used to seal the breathing tube in place inside the trachea and found it to have no leaks. Then, still as composed as if she were selecting fruit at the market, St. Pierre crouched at the head of the stretcher, had the resident hold Anson's head steady in the chin-up position, set a lighted laryngoscope blade against her colleague's tongue, and in just seconds, slid the tube between the delicate half-moons of his vocal cords. A syringeful of air inflated the balloon and sealed the tube in place.

St. Pierre then replaced the mask on the breathing bag with an adapter that hooked to the tube, and breathed for Anson until the tube could be taped in place and attached to a mechanical respirator. With six people working so closely and intensely, the heat and humidity in the small room was staggering. Only St. Pierre showed no external signs of being affected, although once she removed her glasses and wiped them on the hem of her shirt.

For fifteen minutes a tense silence held sway. There was no change in Anson's appearance, but his vital signs steadily improved. Then, with obvious effort, Joe Anson opened his eyes.

One by one, St. Pierre thanked her assistants and the nurses, and asked each to leave the room. Then she bent over the stretcher and positioned her face just a few inches from his.

"Easy does it, Joseph," she said when they were at last alone. "The heat and humidity were too much for you. You just had a complete respiratory arrest. Do you understand? Don't even nod if you do. Just squeeze my hand. Good. I know that tube is uncomfortable. I'll give you some sedation in just a few minutes. As long as the tube is in place, the danger of disaster is greatly lessened.

"Joseph, please, please listen to me. If this had happened in your apartment, we never would have gotten to you in time. We need you, Joseph. need you. Sarah-nine needs you. The world needs you. We can't have this happen again. Please, please consent to the transplant."

Minutely at first, then with greater force, he squeezed her hand.

"Oh, Joseph," she said, kissing him on the forehead, then on the cheek, "thank you, thank you. We're going to move quickly. Do you understand? Whitestone has a jet to fly you to India. It's waiting in Capetown right now. I will be with you all the way. We'll keep you sc dated and on the ventilator for the whole trip. Understand? Good. Please don't be frightened. This is what is needed. Soon all your troubles will be over and you will be back here making all of mankind better. I ask you one last time, do you understand? All right, Joseph, I will make the call. Soon we will be on the way to Yaounde Airport to meet our jet."

St. Pierre mobilized the team who would be caring for Anson while she was off arranging the ambulance ride to Yaounde Airport and the subsequent flight to Amritsar International. When Claudine moved in to take over the nursing, St. Pierre shook her head and motioned the woman outside.

"You almost killed him," St. Pierre snapped before Claudine could get out a word.

The nurse's eyes glossed over at the rebuke. Elizabeth St. Pierre was a person — a Yaounde-born woman- whom she had respected for many years. Had she not thought so much of her, she would have never agreed to add the mixture of tranquilizers and respiratory depressants to Dr. Anson's beer.

"I did nothing wrong," she said. "You told me to add one-point-four cc's to the bottle, and that is precisely what I did."

St. Pierre was at once fire and ice.

"Nonsense," she said. "All I wanted to do was force him into more difficulty so he would opt to go ahead with a transplant before it was too late, and while we had a perfect donor. I formulated that preparation based on his body mass and oxygen levels. If you had given the proper amount, he would never have stopped breathing."

"But it is extremely hot and humid today and — "

"Just imagine if that had happened five minutes later in his quarters. If he was unable to call for help, then he would be dead right now, and we would have lost one of the greatest men who ever lived. Clearly you misread the dose. Admit it."

"Dr. St. Pierre, I cannot admit to something I did not — "

"In that case, I want you packed and out of here by two. I'll have one of the guards drive you back to Yaounde. If you wish a positive recommendation from me, let there be no talk of what went on here today."

Without waiting for a reply, St. Pierre whirled, stalked to her office, and placed a long-distance call. Again, the man who called himself Laertes answered.

"All right," she said in English. "Set the team in motion. If this tissue match is all you say, A should be renewed and working for us for as long as is necessary. We have accomplished so much."

"Agreed."

"Has the donor been certified brain-dead?"

"Do you care, Aspasia?"

"No," St. Pierre said without hesitation. "No, I don't."