by Robin Cook
Dr. Keitzman looked away from Charles’s challenging eyes to Cathryn’s frightened face. She had paused in her notetaking, gaping at Dr. Keitzman. He knew the meeting was going badly. He glanced at Dr. Wiley for support, but Dr. Wiley had his head down, watching his thumbnail play against his other fingers. Trying to avoid Charles’s stare, Keitzman said in a low voice, “The five-year survival is not impressive in acute myeloblastic leukemia, but it’s not impossible.”
“Now you’re getting closer to the truth,” said Charles, jumping to his feet and leaning over Dr. Keitzman’s desk. “But to be more exact, the median survival of acute myeloblastic leukemia if a remission is obtained is only one to two years. And, in Michelle’s case, with circulating leukemic cells, her chances of a remission are a lot less than eighty percent. Wouldn’t you agree, Dr. Keitzman?”
Taking his glasses off, Dr. Keitzman tried to think of how best to word his response. “There’s some truth in what you say, but it is not a constructive way to view the disease. There are lots of variables.”
Charles abruptly walked to the window, watching the dirty snow flutter past. “Why don’t you tell Mrs. Martel what the survival time of the nonresponder is . . . the patients who don’t have a remission.”
“I’m not sure what good this . . .” began Dr. Keitzman.
Charles whirled around. “What good? You dare to ask? I’ll tell you what good it is. The worst thing about disease is the uncertainty. Humans are capable of adapting to anything as long as they know. It’s the hopeless floundering that drives people crazy.”
Charles stormed back to Dr. Keitzman’s desk as he spoke. Eyeing Cathryn’s pad, he grabbed it and threw it into the wastebasket. “We don’t need notes on this gathering! It’s not a goddamn lecture. Besides, I know all too well about leukemia.” Turning back to Dr. Keitzman, Charles’s face was flushed. “Come on, Keitzman, tell us about the survival time of nonresponders.”
Keitzman moved back in his chair, his hands gripping the edge of the desk as if he were prepared for flight. “It’s not good,” he said finally.
“That’s not good enough,” snapped Charles. “Be more specific.”
“All right!” said Dr. Keitzman. “Weeks, months at the most.”
Charles didn’t answer. Having successfully backed Dr. Keitzman into a corner, he was suddenly adrift. Slowly he sank back down into his chair.
Keitzman’s face recovered from a series of sustained twitches as he exchanged sympathetic glances with Dr. Wiley. Turning to Cathryn, he resumed his recommendations. “Now, as I was saying. It is best to try to think of leukemia as a nonfatal disease and to take each day as it comes.”
“That’s like telling a man on death row not to think about death,” mumbled Charles.
“Dr. Martel,” said Dr. Keitzman sharply, “as a physician I would expect your response to the crisis to be significantly different.”
“It’s easy to respond differently,” said Charles, “when it’s not a member of your own family. Unfortunately I’ve been through this before.”
“I think we should discuss therapy,” offered Dr. Wiley, speaking for the first time.
“I agree,” said Dr. Keitzman. “We must start treatment as soon as possible. In fact, I’d like to start today, immediately after all the baseline studies are done. But of course, we are going to need consent to treat because of the nature of the drugs.”
“With the chance of a remission so slight, are you sure it’s worth subjecting Michelle to the side effects?” Charles was speaking more calmly now, but he had a terrible vision of Elizabeth during those last months, the violent nausea, the loss of hair . . . He closed his eyes.
“Yes, I do,” said Dr. Keitzman firmly. “I think it is well established that we have made significant advances in treating childhood leukemia.”
“That’s absolutely true,” confirmed Dr. Wiley.
“There have been advances,” agreed Charles, “but unfortunately in types of leukemia other than Michelle’s.”
Cathryn’s eyes darted from Charles, to Keitzman, to Wiley. She expected and wanted unanimity on which she could build her hope. Instead she could feel nothing but dissension and animosity.
“Well,” said Dr. Keitzman, “I believe in aggressively treating all cases, whatever the chances are for remission. Every patient deserves a chance at life, whatever the cost. Every day, every month, is precious.”
“Even if the patient would rather end her suffering,” said Charles, recalling Elizabeth’s last days. “When the chances of a remission—let alone a cure—are less than twenty percent, I don’t know if it’s worth subjecting a child to the additional pain.”
Dr. Keitzman stood up abruptly, pushing back his chair. “We obviously view the value of life very differently. I believe chemotherapy to be a truly remarkable weapon against cancer. But you are entitled to your opinion. However, it seems evident that you would prefer to find another oncologist or handle your daughter’s therapy yourself. Good luck!”
“No!” said Cathryn, leaping to her feet, terrified at the prospect of being abandoned by Dr. Keitzman, who Dr. Wiley had said was the best. “Dr. Keitzman, we need you. Michelle needs you.”
“I don’t think your husband shares your view, Mrs. Martel,” said Dr. Keitzman.
“He does,” said Cathryn. “He’s just distraught. Please, Dr. Keitzman.” Turning to Charles, Cathryn put a hand on his neck. “Charles, please! We can’t fight this alone. You said this morning you weren’t a pediatrician. We need Dr. Keitzman and Dr. Wiley.”
“I think you should cooperate,” urged Dr. Wiley.
Charles sagged under the weight of his brooding impotence. He knew he could not care for Michelle even if he were convinced the current approach for her particular disease to be wrong. He had nothing to offer and his mind was overloaded, an emotional jumble.
“Charles, please?” Cathryn pleaded.
“Michelle is a sick little girl,” said Dr. Wiley.
“All right,” said Charles softly, once again forced to surrender.
Cathryn looked at Dr. Keitzman. “There! He said all right.”
“Dr. Martel,” asked Dr. Keitzman. “Do you want me to serve as the oncologist on this case?”
With a sigh which suggested breathing to be a great effort, Charles reluctantly nodded his head.
Dr. Keitzman sat down and rearranged some papers on his desk. “All right,” he said at length. “Our protocol for myeloblastic leukemia involves these drugs: Daunorubicin, Thioguanine, and Cytarabine. After our workup we’ll start immediately with 60 mg/m2 of Daunorubicin given IV by rapid infusion.”
As Dr. Keitzman outlined the treatment schedule, Charles’s mind tortured him by recalling the potential side effects of the Daunorubicin. Michelle’s fever was probably caused by an infection due to her body’s depressed ability to fight bacteria. The Daunorubicin would make that worse. And besides making her essentially defenseless for a host of bacteria and fungi, the drug would also devastate her digestive system and possibly her heart . . . besides that . . . her hair . . . God!
“I want to see Michelle,” he said suddenly, leaping to his feet, trying to stifle his thoughts. Immediately he became aware that he had interrupted Dr. Keitzman in mid-sentence. Everyone was staring at him as if he had done something outrageous.
“Charles, I think you should listen,” said Dr. Wiley, reaching up and grasping Charles’s arm. It had been a reflexive gesture and only after he’d made contact did Dr. Wiley question its advisability. But Charles didn’t react. In fact his arm felt limp and after the slightest tug, he sat back down.
“As I was saying,” continued Dr. Keitzman, “I believe it is important to tailor the psychological approach to the patient. I tend to work by age: under five; school age; and adolescents. Under five it’s simple; constant and loving supportive therapy. Problems start in the school-age group where the fear of separation from parents and the pain of hospital procedures are the major concerns of the child.”
Charles squirmed in his seat. He didn’t want to try to think of the problem from Michelle’s point of view; it was too painful.
Dr. Keitzman’s teeth flashed as his face momentarily contorted, then he continued, “With the school-age child, the patient is told no more than he specifically asks to know. The psychological support is focused on relieving the child’s anxieties about separation.”
“I think Michelle is going to feel the separation aspect a lot,” said Cathryn, struggling to follow Dr. Keitzman’s explanation, wanting to cooperate to please the man.
“With adolescents,” said Dr. Keitzman without acknowledging Cathryn, “treatment approaches that of an adult. Psychological support is geared to eliminate confusion and uncertainty without destroying denial if that is part of the patient’s defense mechanism. In Michelle’s situation, unfortunately, the problem falls between the school age and the adolescent. I’m not sure what is the best way to handle it. Perhaps you people as parents might have an opinion.”
“Are you talking about whether Michelle should be told she has leukemia?” asked Cathryn.
“That’s part of it,” agreed Dr. Keitzman.
Cathryn looked at Charles, but he had his eyes closed again. Dr. Wiley returned her gaze with a sympathetic expression that made Cathryn feel a modicum of reassurance.
“Well,” said Dr. Keitzman, “it is an issue that demands thought. No decision has to be made now. For the time being, Michelle can be told that we are trying to figure out what’s wrong with her. Before we go, does Michelle have any siblings?”
“Yes,” said Cathryn. “Two brothers.”
“Good,” said Dr. Keitzman. “They should be typed to see if they match Michelle’s HLA and ABO loci. We’re probably going to need platelets, granulocytes, and maybe even marrow, so I hope one of them matches.”
Cathryn looked at Charles for support but his eyes were still closed. She had no idea what Dr. Keitzman was talking about but she assumed Charles did. But Charles seemed to be having more trouble than she was with the news.
On the way up in the elevator, Charles fought to control himself. He’d never before experienced such painfully conflicting emotions. On the one hand he could not wait to see his daughter, to hold her and protect her; on the other he dreaded seeing her because he was going to have to come to terms with her diagnosis. And in that sense he knew too much. She would see it in his face.
The elevator stopped. The doors opened. Ahead stretched a pale blue hall with pictures of animals affixed like decals directly on the paint. It was busy with pajama-clad children of a variety of ages, nurses, parents, even hospital maintenance men grouped about a stepladder fixing the lights.
Dr. Wiley led them down the hall, skirting the ladder and passing the busy nurses’ station. The charge nurse, seeing Dr. Wiley from behind the chart racks, scurried out and caught up with them. Charles glanced down at the floor and watched his feet. It was as if he were looking at someone else. Cathryn was beside him with her arm thrust under his.
Michelle had a single room, painted the same shade of pastel blue as the hallway. On the left wall beside the door to the lavatory was a large, dancing hippopotamus. At the end of the room was a shaded window. To the right was a closet, a bureau, a night table, and a standard hospital bed. At the head of the bed was a stainless steel pole supporting a small plastic bag as well as an IV bottle. The plastic tubing snaked down and entered Michelle’s arm. She turned from looking out the window when she heard the group enter.
“Hello, peanuts,” said Dr. Wiley brightly. “Look who I brought to see you.”
At the first glimpse of his daughter, Charles’s dread of seeing her vanished in a wave of affection and concern. He rushed up to her and scooped her head in his arms, pressing her face against his. She responded by throwing her free arm around his neck and squeezing.
Cathryn stepped around the bed to the opposite side. She caught Charles’s eye and saw that he was struggling to hold back tears. After a few minutes, he reluctantly released his hold, lowering Michelle’s head to the pillow, and smoothing out her rich, dark hair to form a fan about her pale face. Michelle reached out for Cathryn’s hand and grasped it tightly.
“How are you?” asked Charles. He was afraid that his precarious emotional state was apparent to Michelle.
“I feel fine now,” said Michelle, obviously overjoyed to see her parents. But then her face clouded and turning to Charles, she asked: “Is it true, Daddy?”
Charles’s heart leaped in his chest. She knows, he thought with alarm. He glanced at Dr. Keitzman and tried to remember what he had said about the proper psychological approach.
“Is what true?” asked Dr. Wiley casually, coming to the foot of the bed.
“Daddy?” pleaded Michelle. “Is it true I have to stay overnight?”
Charles blinked, at first unwilling to believe that Michelle wasn’t asking him to confirm the diagnosis. Then when he was sure she didn’t know she had leukemia, he smiled with relief. “Just for a few nights,” he said.
“But I don’t want to miss school,” said Michelle.
“Don’t you worry about school,” said Charles with a nervous laugh. He eyed Cathryn for a moment who also laughed in the same hollow fashion. “It’s important that you stay here for some tests so that we can find out what’s causing your fever.”
“I don’t want any more tests,” said Michelle, her eyes widening in fright. She’d had enough pain.
Charles was struck by how tiny her body was in the hospital bed. Her narrow arms looked incredibly frail as they poked out of the sleeves of the hospital gown. Her neck, which had always seemed substantial, now looked about the size of his forearm; she had the appearance of a delicate and vulnerable bird. Charles knew that somewhere in the heart of her bone marrow was a group of her own cells waging war against her body. And there was nothing he could do to help her—absolutely nothing.
“Dr. Wiley and Dr. Keitzman will only do the tests they absolutely need,” said Cathryn, stroking Michelle’s hair. “You’re going to have to be a big girl.”
Cathryn’s comment awakened a sense of protectiveness in Charles. He recognized he couldn’t do anything for Michelle, but at least he could protect her from unnecessary trauma. He knew too well that patients with rare diseases were often subjected to all sorts of physical harassment at the whim of the attending physician. With his right hand, Charles twisted the soft plastic bottle so he could see the label. Platelets. With his hand still holding the bottle, he turned to Dr. Wiley.
“We felt she needed platelets immediately,” said Dr. Wiley. “Hers were only about twenty thousand.”
Charles nodded.
“Well, I’ve got to be going,” said Dr. Keitzman. Grasping one of Michelle’s feet through the covers he said, “I’ll be seeing you later, Miss Martel. Also there will be a few other doctors coming in to talk to you sometime today. We’ll be giving you some medicine in that tube, so keep your arm nice and still.”
Charles peered at the plastic tube: Daunorubicin! A fresh wave of fear washed over him, accompanied by a new urge to reach down and snatch his beloved daughter from the clutches of the hospital. An irrational thought passed through his mind: maybe the whole nightmare would disappear if he got Michelle away from all these people.
“I’m available anytime at all if you’d like to speak to me,” said Dr. Keitzman as he moved to the door.
Cathryn acknowledged the offer with a smile and a nod. She noticed that Charles didn’t look up from Michelle. Instead he sat on the edge of the bed and whispered something in her ear. Cathryn hoped his silence would not further antagonize the oncologist.
“I’ll be right outside,” said Dr. Wiley, following Dr. Keitzman. The charge nurse who hadn’t spoken left, too.
In the hall Dr. Keitzman slowed his steps, giving Dr. Wiley a chance to catch up. Together they walked toward the nurses’ station.
“I think Charles Martel is going to make this a very difficult case,” said Dr.
Keitzman.
“I’m afraid you’re right,” agreed Dr. Wiley.
“If it weren’t for that poor sick child, I’d tell Martel to stuff it,” said Dr. Keitzman. “Could you believe that bullshit about withholding chemotherapy? God! You’d think that someone in his position would know about the advances we’ve made with chemotherapy, especially in lymphocytic leukemia and Hodgkin’s.”
“He knows,” said Dr. Wiley. “He’s just angry. It’s understandable, particularly when you know he’s been through all this when his wife died.”
“I still resent his behavior. He is a physician.”
“But he’s in pure research,” said Dr. Wiley. “He’s been away from clinical medicine for almost ten years. It’s a good argument for researchers to keep one foot in clinical medicine to keep their sense of perspective alive. After all, taking care of people is what it’s all about.”
They reached the nurses’ station, and both men leaned on the counter surveying the busy scene about them with unseeing eyes.
“Charles’s anger did scare me for a moment,” admitted Dr. Wiley. “I thought he’d totally lost control.”
“He wasn’t much better in my office,” said Dr. Keitzman, shaking his head. “I’ve dealt with anger before, as I’m sure you have, but not like this. People get angry at fate, not the diagnosing physicians.”
The two men watched an OR orderly skillfully navigate a gurney carrying a recent post-op down the corridor from the patient elevator. For a moment they didn’t talk. The gurney carrying the child from recovery disappeared into one of the rooms, and several nurses hurried after it.
“Are you thinking about what I am?” asked Dr. Keitzman.
“Probably. I’m wondering just how stable Dr. Charles Martel is.”
“Then we’re thinking the same thing,” said Dr. Keitzman. “Those sudden mood shifts in my office.”
Dr. Wiley nodded. “Even given the circumstances, his reaction seemed inappropriate. But he’s always been an odd duck. Lives someplace in the middle of nowhere in New Hampshire. He claimed it was his first wife’s idea but after she died, he didn’t move. And now he’s got this wife living up there, too. I don’t know. To each his own, I guess.”
