Free Sensing Light by Mark A. Jacobson Page B

clear.”
    â€œYou sure it’s not meningitis? What about cryptococcal meningitis? That’s a GRID-related infection, and the patients can’t mount an inflammatoryresponse when the fungus invades their brain. So, typically, we don’t see cells in the spinal fluid.”
    Dana flushed and left to find a telephone. While she dialed the laboratory, Kevin explained the test she was requesting to Gail.
    â€œIndia ink stain. Very low-tech assay. A fourth grader could do it. The lab will put a drop of Miller’s spinal fluid on a slide, then add a drop of India ink. Cryptococcus has a capsule that can’t absorb the ink. If the bug is there, they’ll see white dots on a black background. Which reminds me, Dana, when you tapped Miller, what was his opening pressure?”
    â€œSorry,” said Dana, now mortified, “We were in a rush to get samples to the lab. I forgot to measure the pressure.”
    â€œ I was watching the pressure.” Gail interjected. “When the intern got the needle in, spinal fluid rose up the manometer so fast it would have spilled over the top if he hadn’t opened the valve to fill specimen tubes in time.”
    â€œGood observation skills, Gail.” Kevin said. “That’s exactly what we need to know. So Miller does have elevated intracranial pressure. If the India ink is positive, he’ll need repeated spinal taps, every twelve hours, to lower the pressure on his brain. Done a tap before, Gail?”
    â€œNo,” she replied timidly.
    â€œThis is your chance. If you just saw a lumbar puncture, then you’re ready to do one.”
    Gail beamed.
    The phone rang. Kevin picked it up and listened for a moment.
    â€œIt’s Cryptococcus,” he announced.
    Dana hurried out, Gail in tow, to write orders for an antifungal medication and gather equipment for another spinal tap.

III
    K EVIN RETURNED TO M ILLER ’ S room and was surprised to find Gwen at the bedside making notes on a clipboard.
    â€œHey, how come you’re here?”
    â€œI just started a pulmonary elective. It’s the fellow’s day off, so I’m pre-rounding before the attending comes in. Herb paged me and said I should see Miller. But he doesn’t have any respiratory issues. I don’t get why we’re consulting. What’s up?”
    Kevin couldn’t enlighten her, and it troubled him that Herb had already heard about the case. He was certain Dana wouldn’t have asked for a pulmonary consult, which meant someone higher up in the hospital chain of command must have contacted Herb. He deflected her question.
    â€œWhat do you think is going on with him?”
    â€œHe has GRID, that’s for sure. I’m guessing some kind of opportunistic infection, too.”
    â€œYou’re right. It’s cryptococcal meningitis. How do you know for sure he has GRID?”
    Gwen bent Miller’s left ear forward, revealing a small purplish nodule.
    â€œAnd there’s more,” she added, rolling the patient on his side and pointing at a tiny, similar lesion on Miller’s back, hidden in a skin fold.
    â€œWow! Good pick-up.”
    â€œYou’re a good teacher.”
    â€œMaybe, but you seem to be better at putting knowledge into practice than me.”
    â€œThat’s not true. Doing a thorough skin exam is a spinal cord reflex for me from all those years in the Haight Street clinic hunting for signs of secondary syphilis.”
    â€œYeah, right,” he said dryly. “I’m sure no higher cortical function is involved.”
    Unable to dodge the compliment, she grinned.
    Trifecta, he thought, happy with himself for provoking her amusement, pride, and affection, all with one remark.
    When Gwen began her residency, Kevin was still in his fellowship, toiling in Flagler’s laboratory to make sense out of how the mouse immune system responded to bacterial infection. During her first rotation at City Hospital,