“Sounds a breeze,” said Pereira.
If anyone else had said this there would almost certainly have been laughter but people were unsure of Pereira. There were only a few uncertain smiles.
“There’s no reason why it shouldn’t be,” said Neef. “Any questions?”
“I’d like to ask Dr Pereira what exactly his virus does,” said one of the theatre nurses. There was a murmur of assent.
Pereira stopped picking his teeth with his thumbnail and looked lazily about him before scratching his head. “Basically, the virus does nothing,” he said. “We’re just using it to transport a new gene into the patient’s tumour cells. The gene is called the thymidine kinase gene, the TDK gene for short. Once it’s inside the cells it will start producing thymidine kinase and it just so happens that any cell producing thymidine kinase will be killed by the drug, Gancyclovir. In a week’s time we’ll give the patient Gancyclovir and kill the tumour. Simple huh?”
“Sounds a breeze,” said the nurse. There was general laughter.
“Our third patient today will be Thomas Downy and his case will be handled by Mr Beavis and the neurosurgical team in the main theatre. Thomas has an inoperable tumour of the cerebellum. Injecting the virus into the tumour will almost certainly not be a breeze. Video and ultrasound are of course, out of the question. The progress of the needle will be monitored by CT scan at staggered intervals. The cerebellum, as many of you will know, is a bit of a minefield. Any damage to the normal cells around there and the patient’s equilibrium and balancing function may be totally destroyed. Are there any questions?”
“What’s to stop Dr Pereira’s virus getting into the patient’s bloodstream and putting this kinase thing into all his cells. Surely there’s a danger of making all his cells vulnerable to Gancyclovir?” asked one of the radiology department’s team.
“Good point,” said Pereira. “Firstly the virus is actually disabled. It can’t replicate itself so there’s no question of spiralling viral infection. Secondly we have engineered the kinase gene to suit the tissue it’s being injected into. That’s why there are several variations of the virus being used today. For instance, the version we’ll be using for the hepatoma kid has an alpha fetoprotein promoter sequence in front of the kinase gene. It can only be turned on by liver cells.”
“Isn’t science wonderful,” said one of the nurses.
“That I think, is what we’re about to find out,” said Neef. “Any more questions?”
There were none.
Rebecca Daley’s body looked very small and fragile as Neef prepared to begin the procedure which would end with eight millilitres of Pereira’s virus suspension being injected into the heart of her tumour. Pereira had asked to be present at all the injections. Neef explained what he was doing for his benefit.
“We’ll just rub a bit more jelly on her abdomen to make sure that we have a really good contact for the ultra-sound probe,” he said. He smeared the conductive gel over the exposed area of Rebecca’s stomach and then applied the head of the probe, moving it ton and fro several times until he was satisfied with what he saw on the screen monitor in front of him. “There we are,” he said. “Can you make out the liver?”
“It all looks a complete blur to me,” replied Pereira. “Sorry.”
“I suppose we’re used to it.” said Neef. He stretched out one arm towards the screen and pointed. “That’s the liver there,” he said. “And that...” He manoeuvred the probe a little to get a better picture, “is Rebecca’s tumour.”
Pereira leaned closer the screen to get a better view. “Now I see,” he said. “I guess you use this gear a lot these days?”
“We certainly do,” replied Neef. “In many ways it’s revolutionised medicine. It’s just so good to be able to see inside your patients without the need for invasive techniques.”
Neef made a mental calculation of the angles involved in introducing the needle that was to carry the virus. He said to Pereira, “I’m positioning the probe so that the needle will cross its path and show up on the screen. That way we can follow its progress.”
There was a moment’s silence while Neef pushed the needle through the wall of Rebecca’s abdomen and started to feed it slowly inside.
“I can see it!” exclaimed Pereira as a solid white line appeared on screen.
Neef continued to propel the needle on its journey towards the tumour, watching the screen all the time instead of the patient. “Almost there,” he said as the tip of the needle reached the outer edge of the tumour. “And now we’re about to go into it.”
Based on the volume of the tumour calculated from Rebecca’s CT and MRI scans, Neef knew that he had to advance the needle one centimetre further to be at the heart of the tumour. He did this by watching the lumen of the needle which had graduations etched along it. “We’re there,” he announced.
“And now you pull the trigger,” said Pereira.
Neef injected the virus and the operation was over. He withdrew the needle slowly and let out a sigh as he pulled it out. “Our first patient,” he said. “Good luck, Rebecca.”
There was a one and a half hour gap before the next operation was due to begin. Pereira decided to take himself off for a walk and get some fresh air. Neef wondered if he was feeling queasy. If Pereira was having problems with a simple needle op he was going to be in real trouble by the time the afternoon came. Neef asked in the duty room if there had been any word from Kate Morse. Staff Nurse Collins shook her head and said, “Sister’s not on duty till two.”
“Her husband was taken ill last night,” explained Neef. “I thought she might have phoned to say how he was.”
“Fraid not,” replied the nurse. “But Mr Louradis was trying to get in touch. Did the switchboard not tell you?”
Neef shook his head and the nurse rolled her eyes skywards. “Maybe you should call him.”
Neef returned to his office and called Mark Louradis. He was hoping that there wasn’t going to be any problem with the surgical team due to operate on Martin Liddle.
“Mark? It’s Michael Neef. No problem I hope?”
“None at all, Michael. I just thought I would tell you that I plan to carry out the ERCP on Martin Liddle myself, this morning.”
Neef was slightly taken aback. “I’m sure we’re very honoured. Isn’t it a bit routine for a surgeon of your standing?”
“I just thought I’d like to be part of a little piece of history in the making at St George’s. Our first Gene Therapy trial and all that. You don’t mind do you?”
“No, of course not,” replied Neef, still a bit puzzled. “I hope you won’t object if Dr Pereira and I observe?”
“Not at all.”
Neef put the phone down. Mark Louradis had actually sounded as if he was in a good mood. Not often that happened, he mused. Neef checked his watch and saw that he had plenty of time. He called the emergency admission ward at University College Hospital.
“Staff Nurse Mellor. Can I help you?”
“Good Morning, Staff. It’s Dr Neef at St George’s. You had an emergency admission last night. I was wondering how he was this morning.”
“We had two last night, Doctor. Which one are you interested in?”
“Charles Morse. He’s our Chief Path Technician.”
“Mr Morse had a rather uncomfortable night, I’m afraid. He’s not well at all.”
“Has there been any word from the lab yet?”
“Perhaps you’d better speak to Dr Clelland, sir.”
“Rules is rules,” muttered Neef under his breath as he waited. He did not have to wait long.
“Dr Neef?”
“Good Morning, Doctor. I was responsible for having Charles Morse admitted to you last night. I was wondering if you’d had any lab results yet?”
“Not yet, Doctor. Although there were several atypical features, he’s been provisionally diagnosed as Klebsiella pneumonia because of the severity. He’s been put on ampicillin.”
“I suppose it’s too soon to say how he’s responding?” asked Neef.
“We’ve certainly had no encouraging response as yet,” agreed Clelland. “He’s still very ill but as you say, it’s early days.”
“Thank you Doctor.”
Neef put down the phone and reflected on the unpleasant sense of foreboding that had come over him. Maybe he was just hyper-sensitive to the word pneumonia these days but Clelland’s additional qualification of, “atypical” had only heightened his unease. He thought for a moment about the GP who’d called Charlie’s condition, flu and then called Kate Morse’s home number.
“Kate? I hear Charlie’s not so good.”
“Hello, Mike. Good of you to call. He’s really ill. In fact, I think if you hadn’t come out and called the ambulance when you did, he mightn’t have made it through the night. He had to have oxygen in the ambulance. He’s still on it this morning.”
“The ID unit at University College think it’s Klebsiella pneumonia. That would certainly explain why it’s so severe. The ampicillin should get it under control though. He should start getting better soon.”
“God, I hope so, Mike. It gave me a real scare.”
“I’ll bet.”
“I’m on at two. I’ll see you then.”
“Look, Kate, if you don’t feel up to it today, we’ll manage.”
“I’ll be there,” said Kate. “Sitting around worrying doesn’t help anyone, least of all Charlie.”
“As you wish,” said Neef. “I probably won’t see you until after Thomas Downy’s op. We’re going to theatre at two thirty.”
“That had completely slipped my mind,” said Kate. “I hope it goes well for Thomas. He’s such a nice kid.”
Pereira returned from his walk and Neef asked him if he still wanted to attend the next operation.
“You bet,” replied Pereira.
Neef wasn’t convinced but he shrugged his shoulders and suggested they started making their way down to theatre. Mark Louradis was already in scrub when they got there. Neef introduced him to Pereira. “Mr Louradis is our chief surgeon here at St George’s. He is going to inject your virus into Martin Liddle.”
“It’s nice to have the best,” said Pereira, lathering his hairy arms.
Louradis looked sideways at Pereira as if searching for signs of sarcasm but didn’t find any there. Pereira had obviously meant the comment to be taken at face value. How like Louradis to have doubted it, thought Neef. Despite a faultless reputation as a surgeon, Louradis suffered greatly from some unfathomable Mediterranean inferiority complex. Neef sometimes wished he had a fiver for every time he had seen Louradis’ features darken with suspicion over something everyone else present would regard as innocent.
“What a colour!” whispered Pereira to Neef as he saw Martin Liddle’s yellow skin hue.
“That’s the tumour,” replied Neef. “Pancreatic tumours are notorious for being advanced by the time they’re diagnosed. The bile duct gets screwed up as the tumour spreads.”
“This isn’t ultrasound, right?” asked Pereira, nodding at the monitor positioned to the side of the table.
“No, it’s a real video picture. There’s a small camera positioned just to the side of the end of the endoscope.”
Louradis inserted the endoscopy tube and everyone watched its progress through Martin Liddle’s alimentary canal.
“Now we come to the tricky bit,” whispered Neef to Pereira. “He’s reached the duodenum.”
Louradis coaxed the control levers at the head of the tube until he had negotiated an awkward turn and was satisfied with the picture on the monitor. “Almost there, Dr Pereira,” he said. “About here do you think?”
Neef sensed Pereira’s discomfort at the question. He had obviously not been expecting to be asked for his opinion.
“What d’you think, Mike?” Pereira asked.
Neef smiled behind his mask. “Maybe another half inch,” he said.
“Here?”
“Fine.”
Louradis injected the virus and started the process of extracting the tube.
“I need a cigarette,” said Pereira with feeling as he and Neef left the theatre together. “That’s it till two thirty, right?”
“That’s right,” said Neef. “Two down, one to go.”
After changing out of gown and gloves, Pereira disappeared outside for his cigarette and Neef walked back to the unit alone. As he crossed the courtyard past groups of chatting nurses a vehicle parked on the far side caught his attention. It had a press sticker in the windscreen. Two men with notebooks at the ready were standing nearby; they were talking to a man with a camera bag slung over his shoulder. “What’s that all about?” he wondered with an uneasy feeling.
When he got back to his office he called the hospital press officer, John Marshall. “You are remembering our agreement about no publicity for the Gene Therapy trial aren’t you?” he said.
From the first faltering syllable of Marshall’s reply, Neef knew there was something wrong. He closed his eyes in anticipation of hearing something unpleasant.
“It didn’t come from this office, Michael, I promise. But the press got it from somewhere. Mr Louradis is giving an interview about the Martin Liddle case at this very moment.”
“Oh shit,” said Neef. He put down the phone. So this was why Louradis had been keen to carry out such a routine procedure himself. He wanted media attention. He must have set the whole thing up for himself. The man bitterly resented all the press coverage the surgical teams at University College had been getting. He must have seen this as his chance to grab some of the limelight for himself.
Neef’s first thought was to have it out with Louradis and give free rein to the tide of adjectives that were springing to mind but he began to see that what was done was done. It seemed likely they were now going to have to conduct the trial under press scrutiny as University College had done the year before. Nothing was going to change that. He decided not to say anything to Louradis. In the event, Louradis phoned him some twenty minutes later.
“Michael, I’m calling to assure you that I had nothing to do with the press being here this morning. I was a surprised as everyone else.”
“Of course.”
“There were a couple of reporters waiting for me when we’d finished with Martin Liddle this morning. I don’t know how they possibly got wind of it but I felt I had to say something. You know how it is.”
“Quite.”
“I know you didn’t want the press to know about the trial until you knew how it was shaping up but I’m sorry, there it is, there was nothing I could do without being rude. I played it down as much as I could. No hard feelings I hope?”
“Of course not.”
“Good. I look forward to hearing how our young friend progresses.”
“I’ll see that you’re kept informed.”
Neef heard the line go dead and tried out some of his adjectives anyway. Who else would have called the press?