The Magic Bullet

by Harry Stein

  “Yes?”

  “Could you hold your arm out straight?” She demonstrated with her own.

  It is the simplest possible test for hepatic encephalopathy. When a patient is suffering the condition, the hand will jerk back and forth spasmodically.

  Which is precisely what Mrs. Dietz’s now began to do.

  Sabrina looked to Logan and their eyes momentarily locked. There was no need for words.

  “Can I put my arm down?”

  “Yes, of course.” Sabrina managed a smile as she stroked her forehead. “See, nothing to it.”

  “You’re a very kind girl, do you know that? Very loving.”

  “Thank you. From you, I consider this a great compliment.”

  Dietz opened her gray eyes a little wider. “I’m going to die now.”

  For an instant, Sabrina thought to protest.

  But, no, Mrs. Dietz wasn’t looking for reassurance. It was a declaration.

  Though it sounds like myth, many doctors who’ve done serious time in hospitals believe it: when a patient tells you they’re dying, even in apparent contradiction of the facts, they usually are.

  Neither of the doctors doubted now it was true.

  As she drifted off to sleep, Sabrina remained perched on the side of the bed, watching the beautiful old face.

  She touched Logan’s hand. “You should get Phil.”

  He was there a few minutes later when she fell into a hepatic coma; and still there early that evening when she peacefully died.

  The initial autopsy report came in two days later. As he read through it, Logan physically shuddered.

  A congested and grossly distended liver. Fulminent hepatic necrosis. Holy shit! It was almost identical to the one on the damn rabbits!

  The speed of the improvement startled her. Three days after she started radiation therapy, the pain in her back had begun to subside; within a week, she no longer felt it at all.

  “I’d forgotten what it was like not being constantly aware of it,” she delightedly told her husband that night. “I feel like the Tin Man in The Wizard of Oz—like someone took an oil can to me and made all the stiffness disappear.”

  Her husband, the President, took her in his arms. “That’s so wonderful, darling. Maybe the worst is over.”

  “I hope so. They say so much of it is attitude. Well I’m going to test that theory—because no one’s going to top my attitude!”

  Gregory Stillman knew not to be fooled, of course. They’d killed only a single, localized tumor—just a symptom, not the disease itself. Now it was a crap shoot. The distinctive cancer cells, born in the breast, could resurface almost anywhere, anytime: in thirty years, thirty months, or thirty days.

  And this last was by far the most likely. By every indication, this was an exceptionally aggressive tumor.

  Still, for the time being, there was no reason to disabuse the patient of her optimism—especially this patient. “Obviously, things are looking pretty good right now,” Stillman told her when the ten days of radiation were over. “The treatment’s done everything I hoped it would and more.”

  “And now?”

  “I’m going to want to keep a close eye on you, of course. There’s still disease there.”

  “Isn’t that what we should be doing now, rooting out what remains of the disease?”

  “It’s not that simple.” He opened his briefcase and withdrew a book—a copy of his own Basic Principles of Breast Malignancy. “Read this, I’d be pleased to discuss any questions you have then.”

  She looked at him, incredulous. If he hadn’t just pulled off what she regarded as a minor miracle, she’d have been tempted to fire him on the spot.

  “I would suggest an examination every two weeks,” he continued. “But, please, call me if you experience unusual physical symptoms of any kind.”

  The first three exams were uneventful. When she arrived for the fourth, she once again reported nothing unusual. But it was impossible not to notice her cough.

  “How long have you had that?” asked Stillman.

  “Just a few days. I’ve always gotten a lot of colds.”

  But there were no other cold symptoms evident. The cough was dry and rasping.

  This was not necessarily cause for concern. Coughs are wildly nonspecific, they can be caused by a thousand things, nine hundred and ninety-eight of which are meaningless. And, in fact, when he took a chest X ray, it was clean.

  Five days later, he reached her at the White House. “Just checking on that cough.”

  Before she could respond, he heard it. “It’s no big deal,” she insisted. “Aside from that, I’m feeling strong as a horse.”

  “How you’re feeling otherwise doesn’t interest me. I’d like you to come in tomorrow.”

  “No!” Tomorrow truly was impossible. She had meetings all day and, with the Irish prime minister in town, a formal dinner scheduled for the evening. But more than that, she resented his peremptory manner. “It will just have to wait until next week. And frankly, Doctor, if we’re going to continue, I’d appreciate a bit more courtesy.”

  That was the right button to push; like most bullies, he responded well to threats. “I’m sorry, Mrs. Rivers,” he instantly backed off, “I didn’t mean it as it sounded. My only concern is your health.”

  “Believe me, Doctor, it concerns me also. But surely this can wait a few more days. Till next week.”

  “Of course.”

  The cough was still there the following week, perhaps even a bit stronger. But she resisted his suggestion of another X ray. “Look, I just had one last week. I know that’s not healthy.”

  He smiled benignly, his mind brimming with contempt: This fucking moron’s just gotten dosed with three thousand rads and now she’s worrying about a twelth of a rad more! “Mrs. Rivers,” he said, in his best, concerned manner, “I really think this is pretty important. Knowing how you feel, I certainly wouldn’t suggest it otherwise.”

  The new X ray showed it clearly: a streaky density, like a cirrus cloud, in the left lung. Studying it in his office while she waited in an adjoining room, he assumed the worst. The tumor was growing within the walls of the lymph vessels inside the lung. Radiation had taken them as far as it could. If this proved out, he’d have to begin a course of chemotherapy—and soon.

  “Mrs. Rivers, I’m going to suggest you have a bronchoscopy. Just as a precautionary measure.”

  “What’s that?”

  “Well …” There was no way to make it sound anything other than gruesome, snaking a tube down the trachea and up into the lungs to take a look—but he tried. “I really think it’s something that must be done.”

  “I’d like to discuss this with Dr. Burke. I value his opinion.”

  “Absolutely. Of course.” He was coming to truly dislike this woman. He was the expert, Burke was a nothing! “If you can possibly arrange it, I’d like to schedule it for the day after tomorrow.”

  “All right,” she suddenly relented, pain in her eyes, “since you seem to feel it can’t wait.”

  This was a very sick woman. He knew it—and now she knew it too.

  For the time being, at least, he suspected she wouldn’t be giving him much trouble.

  For the first few days after Hannah Dietz’s death, Logan found reason for hope, if not optimism. Several of his colleagues expressed dismay at the shocking turn of events; wanting to know what he thought had gone wrong and, more to the point, what it would do to a protocol that had seemed so promising.

  “I only know what they tell me,” he stiff-upper-lipped it. “As far as I can tell, we’re still viable. Patients are still coming in to be dosed. And we still have three success stories on our hands.”

  But, in fact, he was honest enough to recognize that things had begun to change almost before Hannah was cold. His very first act, after spending a quarter hour trying to comfort a sobbing Phil, had been to call Shein’s office. Logan needed some bucking up himself. He didn’t expect sympathy from this quar
ter, but hoped for some realistic counsel.

  Typically, Shein was already on top of things: he’d gotten a blow-by-blow account of Hannah Dietz’s last hours from the head nurse on duty.

  “Sorry,” he told Logan. “Tough luck.”

  But his voice was so flat, he might have been a stranger.

  “Look,” said Logan, “I’d really like to get together—all of us—to talk about the impact this might have on the protocol.”

  “Yeah, yeah. Of course.”

  “Good. Thank you. Is there a good time tomorrow?”

  “I don’t know.” He hesitated. “Why don’t you call the office?”

  After he hung up, it was Shein’s detachment that lingered. Logan would have been far more reassured by a barrage of put-downs.

  When Logan reached him the next day, Shein no longer saw any reason for such a meeting. “Look,” he said, at least sounding like himself. “What the hell am I gonna tell you? Nothing to do now but tough it out.”

  “I was just wondering if, from a political perspective, there’s anything we might do to—”

  “Yeah, bring her back to life.” He laughed mirthlessly. “Just, whatever you do, don’t use a helicopter again. You know how much that cost us? Six grand!”

  Logan had no idea how to respond to this. Under the circumstances, six thousand—half the price of a third-rate car—seemed like pocket change.

  But of course it was really something else he was hearing. It wasn’t the money that irked Shein—it was that he’d let himself be persuaded to put through the request to the director’s office. And that was Logan’s doing.

  “Look,” said Logan, “things were moving pretty fast. I thought we should get her down here as fast as possible.”

  “Yeah, well, I guess you were wrong.” He suddenly coughed. “And look now, I’m comin’ down with a damn cold. Good-bye, Logan, I got no time for you this morning.”

  Only with Sabrina was there relief from the sense of impending disaster. That night, in bed, they held each other tight for two hours without even a thought of making love. She told him about the summers she’d spent as a child in Lugano, and her long-ago best friend Marissa, and her first wild crush on the pop star Joe Dassin. He talked about his undergraduate days at Princeton and, coming cleaner than he ever had before, the assorted peculiarities of his family.

  “I love these stories,” she said.

  “Hearing them’s a lot more fun than living them,” he assured her. “We’re dealing here with lunatics.”

  She snuggled even closer. “Soon it will be light. We should get some sleep.”

  “Sabrina …”

  “Yes.”

  He’d been avoiding the subject all night. “Has anyone said anything to you? About Mrs. Dietz?”

  It was possible no one had. As the least combative member of the Compound J team, Sabrina was generally spared the hostility that came Logan’s way as a matter of course.

  She paused before answering. “Allen Atlas.”

  “Oh, Christ. What?”

  “He was happy at the news. Making jokes. He said to me, ‘So, this is one of your success stories?’ ”

  “I love these guys. They don’t mind being known as vicious bastards as long as they’re not hypocrites!”

  “In Italian we have an expression, ‘lupo affamato.’ A hungry wolf.”

  In the dark, Logan nodded grimly. “It’s almost the same in English—‘licking his chops.’ ”

  Three days later, just past noon, Logan got the call from a Dr. Edward Reed of Holy Name Hospital in Dover, Delaware. Sharon Williams had just been admitted to his care.

  “I understand she’s part of a protocol you’re running there.”

  “Yes, that’s right,” said Logan, in his best noncommittal voice.

  Sharon Williams! Incomplete as the supporting evidence remained, Logan considered her response against tumor in the bone the protocol’s most startling achievement yet!

  “What seems to be the problem?”

  “Her husband brought her in just a little while ago. I’m afraid she’s decompensating.”

  “Could you be more specific?”

  “Apparently, she was at home when she began complaining about not feeling well. By the time she got here she was already becoming encephalopathic. We’ve got her in the intensive care unit.”

  Oh, Christ. Another liver failure!

  “I don’t suppose there’s any chance you could put her in an ambulance and get her over here?” From Dover, the trip would be little more than an hour—with no expenses that had to be okayed.

  “I don’t think that’s a good idea. This woman is really too unstable to be moved.”

  “No, you’re probably right,” he paused. “I hope you won’t mind if I come to you.”

  Holy Name Hospital featured little of the super-high-tech equipment that by now Logan had come to take for granted, but he quickly noted the place was modern and efficiently run. By community hospital standards, a superior facility.

  To facilitate observation, Mrs. Williams’s bed was in a room enclosed on three sides by clear glass. A monitor above her registered an EKG reading of 160 and showed her blood pressure at eighty-five over fifty. At her side heaved a ventilator, helping to keep her lungs going. A Swan-Ganz catheter had been threaded through her subclavian vein, through the heart and the pulmonary artery directly into the lung, where it was recording pulmonary capillary pressure.

  Literally within seconds, Logan knew all he needed to know. Sharon Williams was dying.

  “Dr. Logan?” He turned to face a smallish young man with white-blond hair and a face so young, he might have been a teenager. “Ed Reed.”

  They shook hands.

  “It’s painful to see,” said Logan softly. “I saw her less than a week ago.…”

  “We did some blood work on her. Would you like to see the results?”

  “Tell me.”

  “It’s not pretty. Her hepatic transaminases”—enzymes measuring liver function—“are completely out of sight.”

  “Do you have her on fentanyl?” The drug in question, a highly potent anesthetic, is often used with patients who are obliged to spend prolonged periods immobile.

  “There doesn’t seem much point, she’s not aware anyway.”

  “No.” Logan sighed. “Look, thanks for putting up with me. I know it’s not easy having a stranger hanging around.”

  The other smiled broadly. “My pleasure, really. I’m a big fan of you people at the ACF.”

  If only you knew, kid, if only you knew. “Thanks. Do you maybe have a library here, somewhere I can kill some time?”

  “You’re going to wait it out?”

  “I’d like to.”

  Reed pointed down a hallway. “Take the stairs down and then a left through the waiting room. It’s not much after what you’re used to.”

  “Actually, I’ve been so busy lately, I wouldn’t mind just catching up with the basic journals.”

  He was following Reed’s directions, heading through the waiting room, when he spotted a large black man, sitting beside a girl of seven or eight. Or, more precisely, they simultaneously spotted one another. It took Logan a moment for the face to register: Sharon Williams’s husband. They’d met only once before, at the ACF, the day his wife came in for her first treatment.

  He stopped and turned. But already Simon Williams was on his feet, coming his way.

  “Mr. Williams,” said Logan, extending his hand. “Dan Logan, from the American Cancer Foundation.” Up close, he saw the strain Williams was under in his eyes.

  “I know who you are,” he said softly. Slowly, with seeming reluctance, he shook the doctor’s hand.

  “I got here as soon as I heard about Sharon.”

  “Yes.”

  “She’s a strong person. We’re all hoping for the best.”

  He was sorry as soon as the words were out of his mouth. There are people who want to be bullshitted, but this man already knew the truth. He
fixed Logan with a hard stare.

  “I have just one question.”

  “Yes.”

  “I read that consent form of yours. It didn’t say anything about something like this.”

  “Mr. Williams, I’m sorry. We truly had no way of knowing.”

  “See that little girl over there?” He indicated his daughter. “Why don’t you tell that to her? Or to her three-year-old sister?”

  To this, Logan made no reply. It was an uncharitable thought, but given Logan’s state of mind, it arose all the same: Would this guy be complaining if, as it had seemed such a short time before, the drug’s effects had been beneficial? Yes, he understood the man’s distress, even his anger. But doctors are also human—and medicine is imperfect.

  “I’m deeply, deeply sorry you and your family have to go through this,” he said blandly, just wanting to get the hell out of there. “No one should have to. I only hope you understand that we’ve done the very best we know how.…”

  He spent the next several hours in the library—actually, no more than a normal patient room outfitted with shelves and a couple of chairs as a reading room—catching up on the New England Journal of Medicine and the Annals of Modern Medicine. But he read distractedly, frequently lapsing into troubled daydreaming. What he needed to know would never turn up in any journal. How could a drug that showed such tantalizing promise simultaneously be so brutally destructive? And why did the deadly side effects appear to be so pronounced in the very patients it at first seemed most to benefit?

  It was early evening when Logan heard the footsteps in the deserted hall and Reed appeared in the doorway.

  “She’s gone,” he said. “Just a few minutes ago.”

  Logan rose to his feet. “Well … thanks for letting me know.”

  “There was nothing we could do. She never had a chance.”

  “I know that.” He glanced at his watch. “I guess I should be heading home.”

  “Hey, look. If you’re up for it, maybe we could grab some dinner.”

  Caught off guard by the sudden shift in the young doctor’s tone, Logan looked at him quizzically. Reed was smiling. “Maybe it’s not the best time,” he added in explanation, “but I thought maybe you could give me some tips on how I could hook up with the ACF.”