“Don’t say or even hint at that. Your optimism is the one constant in my universe.”
Debbie resigned with the birth of the first of her three kids. She knew she’d return to teaching someday, but for now, her children were priority one. The family settled in Lafayette, five miles from the Caldecott Tunnel that separated the east bay from Contra Costa County.
While taking a shower, Debbie felt something in her right breast. Her breasts were lumpy for sure. Dr. Roth had told her that it was fibrocystic disease and it made examining her breasts difficult. She continued to feel her breast, hoping it would go away; it didn’t.
In full panic mode, Debbie Wallace was waiting at my office the next morning. She looked at me expectantly. “It’s a lump, Arnie.”
Her breasts were cystic and fibrous making manual examination and mammography problematic. Her breasts felt universally lumpy to me, but once I thought about cancer, I needed to follow through. Not doing so would be like smelling smoke, and failing to check it out. Delay and it might be too late.
She returned to my office the day after the mammogram.
I smiled and held up the radiologist’s report. “Good news, it was negative.”
“What do you mean, negative? I feel something, how could it be negative?”
I picked up two mammograms. “Come with me, Debbie.” I placed the two films side by side on my x-ray view box. “Yours is the one on the right. What do you see?”
“I see all that white streaky irregular stuff on my mammogram. What’s that?”
“Mammograms show tissue density. The denser the tissue, the more the x-rays are absorbed, creating the variations in black and white that make up the image. Fat hardly absorbs the beam at all, so it shows up as black. Breast tissue, particularly the thick breast tissue of a young woman like you, shows up on an x-ray as shades of light gray or white. The white on your films reflect fibrocystic disease. Tumors being especially solid also show up as dense whiteness.”
“If tumors are white, and my breasts show all this white stuff, how can you see the tumor?”
“That’s exactly our problem. Small tumors can hide within the white and we wouldn’t see them until they were quite large. The whiteness we see here,” I pointed to her x-ray, “means that what you’re feeling is likely to be fibrocystic disease and not cancer. Here’s the report.”
Debbie read the report carefully. When her eyes reached the bottom, she looked up at me. “What’s this starred note on the bottom of the report?”
“It’s a disclaimer. They’re an unfortunate fact of life in modern medicine. It means that no test is 100 percent accurate. It’s a way for radiologists to cover their asses to protect themselves should cancer show itself later. In the world of rampant malpractice judgments, trial lawyers make disclaimers necessary.”
“Excuse me, Dr. Roth, but none of that means a damn thing to me. Just tell me I’m okay.”
“I wish I could, Debbie, and the odds are overwhelmingly in your favor. If we take one hundred women with lumps in their breasts, do all our imaging techniques, mammograms, ultrasounds, and MRIs, and we get negative reports, 1 to 3 percent of these women will still have cancer.”
“One to three percent sounds pretty high when you’re sitting in my position.”
“I agree, but we’re stuck, especially in patients like you Debbie with cystic, fibrous breasts. Keep checking your breasts. Once a week is enough. We’ll repeat the mammograms as often as needed. I’ll order a biopsy if we see something suspicious.”
“I don’t like all those x-rays. Are they safe?”
“Mammograms are a special type of low dose x-ray. When combined with special high-resolution film, we get spectacular images. In experiments, it takes x-ray doses hundreds to thousands higher before we see a statistical increase in cancer.”
“I’ll keep checking, Doctor, but that’s a hell of a way to live.”
“I know, but try not to obsess about it. One warning: if you’re constantly examining your breasts, you can aggravate the inflammation and a lump can persist or enlarge.”
Two months later, Debbie returned. “I tried to ignore it at first thinking it was my imagination, but it’s still there, I feel it. It’s larger. I know it.”
A quick examination told me Debbie was right.
This time, the mammogram showed a small mass, suggestive of a tumor. When I said the words she feared the most, “We need to do a biopsy,” Debbie’s eyes glazed over and she slumped in her chair. I managed to catch her before she hit the ground.
Matt saw Debbie’s fear—abject fear. She was frantic, but frozen in place. Their lives were no longer under their control. They sought safe haven—there wasn’t one.
Matt, an optimist by nature, felt helpless, as he was unable to control his own fears gathering momentum and speeding to a brick wall finish line, toward the worst possible scenario.
“We’re going to make it through this, no matter what it takes,” he said with the conviction he didn’t feel.
Debbie reached for his face and stroked it gently with her hand. “I love you, Matt. I’ll always love you.” She placed her head on his shoulder and wept.
Chapter Eight
I began ICU rounds on this eighth day of Samantha Goldstein’s coma by confronting Richard and Marion, her parents. Their superficial impassive greetings couldn’t mask their desperation.
After so many days, I marveled how they maintained hope, although having children of my own, I understood.
I entered the isolation room, masked and tying the green hospital gown behind my back. “Good morning.”
Today, like every day, we met in Samantha’s room. Gowns and masks hid their body language, but their eyes shone with unrelenting hope that only parents can have for their children. It was desperation, not simply born out of desire, but built on their belief that there was no way they could lose their daughter—they couldn’t—they wouldn’t, outlive their little girl.
I encouraged Marion to help the nurses when they bathed Samantha and changed her bedclothes. I had misgivings because the physical act of moving Samantha’s extremities told Marion that her daughter wasn’t merely asleep. Arranging Samantha’s lax extremities was like moving a puppet.
I watched as Marion stopped in midstream when she lifted Samantha’s lifeless arm. It shocked her, I could tell. She paused a moment, stared at the arm, her daughter, and continued the bed bath.
She knows, I thought.
Samantha looked asleep, a princess with her warm blond center-parted hair neatly combed and splayed over the white pillow. The clear plastic tube that we’d passed through her nose and into the windpipe, the trachea, was connected to the ventilator that whirred and clicked rhythmically as it breathed life into her.
I raised my hand to forestall their questions until I examined Samantha, knowing in advance that change in her condition was unlikely. “Give me a moment, and then we’ll talk.”
I shook Samantha gently—no response. I shook her more vigorously—no response. I placed my body between Samantha and her parents so they wouldn’t see that I applied my knuckles to her chest, a potent and painful stimulus to see if she’d respond—she didn’t. My neurological examination showed an array of abnormal reflexes, all indicating severe brain damage.
We walked into the anteroom to talk.
I shook my head slowly, but before I uttered a word, Marion trembled and moaned her deep visceral devastation.
I sat beside her. “I’m so sorry.”
Richard stood erect, his lips held tight.
“I don’t know what else to say. I’m a father. I have two daughters. I see tragedy and death as part of my life, yet I still don’t know how parents ever survive the loss of a child.”
Richard’s tears ran down his cheeks. “The thought of losing Samantha is more than I can bear.” He looked at the floor. “We had plans. No matter her age or the distance between us, I’d always be there for her. I’ll never walk her down the aisle or be the grandfat
her to her children. She has so much to give; so much to experience, so much talent. How can her life end this way?”
Marion reached out to her husband, caressed his neck, trying to ease his pain.
Richard slowly lifted his head and stared at me. “What are you going to do?”
I recognized this as a desperate father’s question, and a challenge, too.
Each family dealt with tragedy in its own way, some withdrew in quiet desperation, while others abandoned the cultural restraints that kept their emotions in check. I remember…
My chief resident smirked. “It’s your turn.”
“My turn for what?”
“Their daughter just died. You need to tell them.”
“Find someone else. I’m not up to it.”
He stared at me. I felt nauseated. I didn’t know whether this was a dump, palming off an unpleasant job on an underling, or was he offering me the opportunity to learn something. Whatever his intention, I found myself unprepared for what happened. How bad could it be, I’d thought at the time, after all, they knew their daughter was dying.
The moment I entered the waiting room, my carefully planned script crumbled as I met her parents’ eyes.
Her mother stood. “What is it, Dr. Roth?”
I stared at my feet. “I’m so sorry.”
“Sorry...Sorry for what?”
I grasped her hands and whispered, “She’s gone. It was peaceful. She didn’t suffer.”
She pushed my hands away as if they carried an electric current and faced her husband, “What is he talking about?”
From the back of the room came a communal moan. “No, Dear God…Jesus…Lord.” A few at first, followed by mountainous waves of grief that increased in height until they crested, and crashed into the room that exploded into the screaming, shouting, and wailing whirlpool. Whatever sense of control I had, vanished in an instant, as I stood there, a mute among the disconsolate. I knew that there had to be words to ease their pain, but each hollow platitude stuck in my throat…
That experience with patients and their loved ones taught me much about death and tragedy. Mostly, they showed me how to listen to what families said, to really listen, so I understood immediately Richard’s choice of words: what are you going to do?
I could resent the question and the implication that the decision was mine, but I chose not to avoid the responsibility. After all, I was their physician, their advisor, and I admit it, their friend.
The question suggested no easy answer for me or for them. I couldn’t think of a way to be truthful to the situation, yet withhold the words that I knew would sound cold and callous. The cruelty of this truth would overwhelm any spoonful of sugar.
“I’m going to order another EEG to measure her brain wave activity. If it’s like the last one, showing no signs of higher brain function, we will face a difficult decision.”
Richard tightened his lips. “You’re suggesting we stop treating Samantha, and turn off her respirator.”
“Yes.”
The icy clouds of reality chilled the room. Silence replaced their aggressive denials. For weeks, fear sustained them while denial provided comfort. Now they understood.
Richard embraced his wife, their heads side-by-side. My eyes filled in empathy for their tragedy.
After rounds, I returned to the office. Workmen blocked my private entrance. That forced me to use the front door and walk through the packed waiting room. Dozens of eyes followed my every step.
I’d have to deal with their problems soon enough. I didn’t need an appetizer.
“Hey, Doc. What’s up?”
“Good morning, Dr. Roth.”
“Great to see you, Doc.”
I nodded, waved, and made my way back to the office as quickly as possible.
As usual, they’d over-scheduled me this morning. Most patients looked okay, while others were clearly in the right place as they coughed and hacked, sharing their bacteria and viruses with the rest of the waiting room. I often hesitated with my hand on the examining room’s doorknob when I heard coughing and sneezing within. Why would anyone choose to join Typhoid Mary in her den? This was an occupational hazard. It surprised me that more doctors and nurses didn’t share their patients’ infectious diseases. Maybe this was my unwritten contract with the fates for doing this job. I picked up the chart from its holder on the door.
Annie Franklin was a twenty-two-year-old graduate student at UC Berkeley, and the moment I entered the room she assailed me. “Dr. Roth, you must do something.”
“Good morning, Annie, it’s nice to see you, too.”
“I’m sorry, but this cold’s making me crazy. I’m supposed to be the maid of honor tomorrow. I can’t walk down the aisle sniffling and sneezing with mucous dripping from my nose. I don’t think the bride will find my condition fitting for her elegant wedding.”
“That’s a charming visual image, Annie. Let’s see what’s going on.”
Her throat was red and the nasal mucosa looked inflamed, but her lungs were clear. “I’d say you have an upper respiratory viral illness, Annie, better known as the common cold.”
Annie smirked. “Thanks, Doc, but my $120,000 education already told me that. What can you do? I’m such a mess. I can’t ruin this for my best friend. Whip out your prescription pad and write for a strong antibiotic.”
“Here’s the news, we can’t treat the common cold, and, for sure, antibiotics won’t help. I’ll give you nose drops and a strong, long-lasting antihistamine. You’ll still feel lousy until this thing runs its course, but hopefully your nose won’t drip.”
I wrote two prescriptions. “Call me if the symptoms persist or if that cough worsens, and by the way, watch your alcohol consumption. Alcohol and antihistamine can lead you to embarrass yourself in other ways.”
“Thanks, Doc, but I was hoping for a cure.”
“Go to medical school or become a research virologist, Annie. A Nobel Prize looms ahead for you.”
By the end of the busy day, I felt unusually tired and achy. Even my three p.m. dose of energy, a large cup of cappuccino, failed to perk me up. I also had a headache and a scratchy throat—so much for my unwritten contract with the fates.
Chapter Nine
As Henry Fischer sat at his enormous desk ignoring the spectacular view of the San Francisco Bay, he thought, how could a life so full of promise turn to shit?
His business and his marriage to Ruth were in trouble. He was a man of big appetites, too accustomed to, and too expectant of, the approval and the envy of others. Their sex life diminished dramatically after the birth of their first child. Before, they’d made love three or more times a week. He’d delighted in Ruth’s desire for him and her uninhibited sexuality. Now, they rarely made love and, by her seeming indifference, Ruth convinced him she did it only from a sense of duty. What a turn-off! What happened to her?
Henry had his physical and emotional needs, after all. He was an attractive, affluent man, and he’d had no difficulty finding willing and enthusiastic partners. At first, he sought the company of high-class professionals who were good at their work and allowed Henry to avoid the messy emotional attachments that could complicate his life.
His current affair with Monica Kelly, his director of sales, may have been a mistake. After nine months, their relationship had become anything but detached. They worked closely together, and over time, their casual flirtations progressed from joking references about sex to reality. Monica, thirty-two and recently divorced from a local obstetrician, had no children. Her career was her life and she, too, hadn’t been looking for entanglements, especially with her boss.
Henry smiled as Monica entered his private office. “You’re a sight for sore eyes…just what the old man needs.”
“What old man?” she asked, pulling his face to her lips, kissing him passionately, and caressing him between his legs. “That sure doesn’t feel like anything an old man would be packing.”
“You’re too much, Monica. With
you around, I never feel old.”
Her tongue slid across moistened berry-red lips. “I can’t wait for this weekend. We’re still on, aren’t we?”
“It’s becoming a strain creating plausible excuses for being away. If Ruth’s suspicious, I don’t see it. Maybe she doesn’t give a damn. The Denver meeting of the National Community Pharmacists’ Association gives us reason to be away together. I can’t wait to sleep with you for four whole nights.”
She smiled. “I don’t know about the sleep part.”
Henry returned to his chair. “Any good news from your front?”
“When don’t I bring good news? I’ve picked up three new accounts, and have substantial orders from another six. How’s that?”
“You’re the best, baby, but we’re getting squeezed by the hospital associations, the HMO’s, and especially from Medicaid. I don’t know how they think we can stay in business with their drug reimbursement formulas. Our recent expansion adding five new pharmacies, and purchasing United Drugs, have put us into a bind.”
“How serious is it?”
“It’s serious enough. If we can’t do something to increase revenues, we’ll be in big trouble. Another computer glitch from Medi-Cal, and we’ll have to borrow to pay our bills.”
Monica shook her head. “This is a first-rate business. If you can’t make it, I don’t see how any pharmacy can.”
“It’s not rocket science. The prices of drugs are rising, and health insurers are under tremendous pressure to cut costs. We may be the first casualty.”
The clock struck eight as Henry returned home that evening. Ruth sat at the dinner table correcting class homework.
“Your dinner is in the oven. It may be a little dry by now. If you’d let me know you were going to be late, I’d have waited for you.”
“Thanks, Ruth. I’m not hungry.” He paused for a moment and reconsidered his answer. “Okay, I’ll take a few bites.”
Ruth studied him as he picked at his dry chicken and shrunken vegetables. “Is everything okay? You’ve been unusually quiet lately.”
The Sixth Sense (Brier Hospital Series Book 3) Page 4
