It’s a mistake for family, friends, or even a physician, to tell a patient like Connie Rinaldi how lucky she was. Luck was a matter of perspective, and she wouldn’t wish such good fortune on her worst enemy. People loved her and were happy that she survived, but none of them was a thirty-seven-year-old single, childless woman with severe advanced chronic bronchitis. None of them would be connected by a tether to an oxygen generator, or to a shoulder sling carrying a portable oxygen tank, her permanent appendage.
Connie sat on Jim McDonald’s examining table. She loved Jim, they’d been through so much together, but at times, his boundless optimism pissed her off.
He smiled as she entered the room. “How’s it going, Connie?”
“Do you want the truth?”
“No, I want you to lie,” Jim said, pulling up his rolling stool to sit with her. “Don’t you think I understand what you’ve been through…what you’re going through?”
“I’m sick of the whole damn thing. I’m a prisoner…a lifer, without the chance of parole. Everyone says, I’m depressed, but I say you can’t use that term when my life’s a living hell. Feeling anything other than depression’s not possible. I can’t live this way, Jim. I won’t live this way.”
“What do you want me to do, Connie?”
Tears streamed down her puffy cheeks. “I want you to give my life back to me.”
“You’re on the list for a combined heart and lung transplant at UC San Francisco and at Stanford.”
“Please, Doc, with twenty or thirty heart/lung transplants per year for the whole country, I’m not betting on those odds.”
“I know, but you’re a good candidate. You’re young and otherwise healthy, and you’re right here near two world-class transplant centers. That makes a difference.”
“What would you do?”
“I’m not you, and I don’t know if anyone could answer that question in the abstract. I don’t know if I have your courage and strength to get through what you have. Few people do.”
Beverly Ramirez was enjoying her big four zero birthday party. Her Richmond home’s backyard had a dozen folding tables set and joyously decorated. Red, green, and yellow balloons attached to chairs, branches, and the redwood fence, floated in the breeze. Food overflowed everywhere. Both sides of the family had come to celebrate as kids of all ages played in every available open space, but mostly found reason to streak screaming through the crowds of relatives. The bright midday sun shining from clear blue skies made a perfect party setting.
By four in the afternoon, the families had enough and were trying to corral their children to leave.
Tino Ruiz and Beverly sat under a large oak tree.
“I’m so glad you could come, Tino. We don’t see enough of you.”
“I enjoyed the party, but I can’t believe you’re forty.”
“You can’t believe it. What about you?” She paused and grasped Tino’s hand. “How’s it going with school and work?”
“School is much easier than I thought. My grades are good and I’m planning to transfer to UC Berkeley next year.”
“Wonderful. How’s work?”
“Work is work. It’s all pretty routine, and I think that Henry and Brian have finally learned to trust at least one Border Bandit. They don’t even check their back pockets anymore. How are things at Dr. Roth’s office?”
“Pretty much the same. Arnie’s back in the groove.” Beverly hesitated a moment, and then her face darkened. “Debbie Wallace’s cancer recurrence devastated us. I think I told you about her.”
“Yes, I remember her. She’s the young mother with breast cancer. I also know her because Horizon has provided her chemotherapy drugs. What happened?”
“Debbie’s had the worst luck; surgeries, radiation, and chemotherapy, and just when we felt that she was through with the cancer, it recurred and spread to her brain. Everyone’s upset. All the expert opinions said that her odds were more than 90 percent for success. I guess that some unfortunates need to make up the 10 percent group. She was doing well. The last few cycles with Taxol were easy for her, with fewer side-effects.”
Taxol? Tino’s thoughts raced through a disturbing sequence of events: an unanticipated recurrence, fewer side-effects, Brian Shands’ furtiveness in the clean room, the drug labels from Mexico, and Horizon Drug’s sudden reversal of fortune. His mind resisted the logic of these observations, and a conclusion so evil that it made his gang’s worst activities seem like petty theft.
“What’s going to happen to her?”
“Arnie will discuss Debbie’s case with Dr. Becker from UC San Francisco. We don’t know what will happen; more surgery, more chemotherapy, or an alternative form of chemotherapy more appropriate to a woman with advanced breast cancer.” She paused and then continued, “This is the toughest part of medicine for me, Tino. I love these people and I have to stand by watching as they fail treatment, get complications, and die. It makes me sick.”
I haven’t worked so hard to become a part of this, Tino thought. That poor woman, her kids, and everyone’s efforts…for what? He stared at Beverly and thought, where did I put Reggie Brand’s card.
I dialed Stanley Bank’s office at UC San Francisco. “Stan, it’s Arnie Roth.”
“Arnie, how are you doing? I heard you had a rough time of it.”
“I’m doing well, a lot better than Debbie Wallace.”
“My God, not another recurrence?”
“Worse, she has a frontal lobe tumor. The only upside is that it’s an isolated metastasis. We haven’t biopsied it yet, but the odds are overwhelming that it’s her breast cancer.”
“I agree, and it surprises me. The nature of her malignancy and the combined chemotherapy should have dealt with the tumor, but we all know that treatment isn’t 100 percent effective. I need to see her ASAP. We can probably approach the brain with the Gamma Knife and maybe she’s a candidate for Herceptin, her tumor was Her2 positive, wasn’t it?”
“Yes it was.”
Herceptin was a medication that contains specific antibodies that block a protein at the tumor cell surface called Her2. It existed in about 25 percent of women with breast cancer. Since it targeted the cancer cells, it was effective in advanced breast cancer and had few side effects.
The Gamma Knife program began at UC in 1991. It’s a form of radiosurgery where they aim multiple beams of radiation at a specific site, in Debbie’s case, her brain tumor.
“We’re having unbelievable results with the Gamma Knife, especially since we automated the process with our computers,” Becker said. “With all that Debbie’s been through, the high expectations and the disappointments, making her understand that her chances are still good won’t be easy. While she’s lost another battle, the war is far from over.”
“Be careful with the war metaphors, Stan. Debbie and Matt are smart and determined, but this disease can overwhelm the strongest. Lay it out for them. Tell them the odds, and as I do, emphasize the therapeutic value of an optimistic viewpoint.”
“I’ll keep you posted, Arnie. After the radiation, we’ll begin the first round of Herceptin and outline the protocol for you when she returns to your office.”
“I don’t know how you do it, Stan. It kills me each time we get a recurrence.”
“Cancer is tough business. If I broke down every time a patient died or had a recurrence, I couldn’t do my job. I’d love to cure them all, but either way, I’m here to help. It’s the best I can do and it’s enough for me… it has to be.”
Near the end of today’s busy afternoon, Beverly came into my office carrying a chart. “Sal Bruno’s back, Arnie. What are you going to do with him?”
“I don’t know.”
My practice was busy enough without Sal Bruno’s intrusion into my schedule. The news about Debbie Wallace and my devastation over Beatrice Hodges left little sympathy for the likes of Sal Bruno.
Bruno was a teamster in his late twenties. He paced my examining room ranting, “What do you mean,
no more Vicodin? I’m in pain. What part of pain don’t you understand?”
“I’ve filled that prescription for the last time, Sal. I’ll give you anti-inflammatory agents and I’ll work with the pain control clinic to help you, but you’ll get no more dope from me.”
Sal was a large man, hardened by the job—Kojak on steroids. His shiny baldhead and snake and spider tattoos on both arms, sent a message of intimidation, a tool of his trade that he used well. He approached me red-faced, our noses separated by inches. I could smell a citrus scent on his breath, an aroma I recognized. I scanned my increasing inventory of aroma/memory associations and recalled opening an old bottle of Percodan I’d used years ago after a root canal. It had the same distinctive aroma.
“I’m tired of this shit,” he yelled. “You didn’t mind all the workmen’s comp. bucks you took since my injury, did you? I need the Vicodin…I’m in pain.”
I wiped the small droplets of spittle off my face and stared back at him. My usual reaction to stress was a sense of the world slowing as my mind remained calm and in control.
“You’re hiding something from me, Sal.”
“I don’t know what you’re talking about.”
The ammonia-like stench confirmed his lies.
I opened Sal’s chart to the summary of his prescriptions. “I gave you forty Vicodan two weeks ago. If you were in so much pain, you should have been out last week. What happened to make things worse?”
“You’re the doctor. You tell me. All I know is that I’m in pain and you’re giving me shit.”
“Yes, Sal, I am giving you a hard time. First, you overused the Vicodan, and second, you’re on something else and lying about it.”
“You son-of-a-bitch,” he shouted as he closed the little gap between us, his face beet red, his fists clenched.
I stepped forward to meet him. “Percodan. You’re on Percodan. What’s the matter, couldn’t you buy or steal more?”
“You’ve got one hell of a nerve accusing me. You don’t know what you’re talking about.”
“I’d like to help you, Sal, but play it your own way.”
He remained silent.
I stood. “We’re wasting our time, Sal. Call me when you’re ready.”
Sal backed onto the chair and sat with his head down. “How did you know?”
“It doesn’t matter, does it? You’re too deep into this. You can’t handle it by yourself.”
Sal looked up. His eyes welled. “I’d do whatever you say, Doc.”
I picked up the intercom. “Beverly, get me Santa Rosa Rehab. I have a referral.”
Chapter Forty-Two
After admitting Beatrice Hodges to Brier Hospital, I began intravenous fluids and medication to control her vomiting.
Irv sat by her side holding her hand.
“Can I stay with her, Doc?”
“Of course, Irv. I’ll ask the nurses to bring a cot into Bea’s room.”
“She looks awful,” Irv said, as we stood in the hallway.
“I agree. I’m hoping the chemotherapy caused her dehydration and malnutrition.”
“What else could it be?”
Patients often asked questions when they knew or suspected the answers. It was a plea, a hope that their worst fears were unfounded, and that I would come up with another explanation.
“Let’s see how she responds to treatment.”
Soon it became obvious. My hope that her decline was the consequence of chemotherapy and its side effects had been based on wishful thinking.
By the third day, Beatrice looked 100 percent better. She’d gained eight pounds with correction of dehydration and control of vomiting.
I held Bea’s hand. “You look much better this morning. How are you feeling?”
“I’m back from the dead, Dr. Roth, thanks to you. I’ve never been so sick or felt so hopeless or so alone.” She looked at Irving, who sat at her side. She caressed his scruffy unshaven face, and smiled. “Look at him. Clean him up, before you send him back to me.”
“Are you eating?”
“My appetite isn’t worth a damn. The smell of food sets my stomach off every time.”
“Maybe it’s the hospital food. You can order anything you want or you can have Irv bring in your favorites.”
“I don’t think it would help. I’m not hungry.”
I examined her carefully. The abdominal fluid, absent on admission due to dehydration, had returned. If that wasn’t ominous enough, my stomach twisted when for the first time I could feel her liver. It was firm, enlarged, and irregular, and I knew immediately what the abdominal CAT scan would reveal—a cancer-filled liver.
“I’m ordering a CAT scan of your belly for this morning, Bea. Your liver is a little enlarged.”
Irv rose and stared at me. “What does that mean?”
“I won’t say anything until I’m sure.”
Although I was confident in what the scan would show, I paled when the radiologist flipped the films onto his viewing box. Normal liver substance had a uniform texture, while Bea’s showed a dozen or more irregular round densities, the classical picture of cancer’s spread to the liver.
“I’m so sorry, Arnie,” said the radiologist without explanation.
I discharged Beatrice that afternoon, but met with the Hodges the next day in the office.
“No…No!” Irv cried. “It can’t be true. There must be another explanation.”
“I’m sorry. The cancer has spread to her liver.”
“What can we do? We’ve got to do something.”
Bea reached over to her husband and grasped his hands in hers. “It’s okay, baby. It’s my time.”
Irv lowered his head to their joined hands and sobbed.
Bea looked at me and took a deep breath. “What next, Dr. Roth? I’m frightened of death for sure, but what scares me is the pain and the burden I’ll place on Irv.”
“Don’t worry about me, baby. You’ve never been a burden and you never will.”
“You’ve heard of hospice?”
Irv’s jaw tightened. “She’s not going to any nursing home to die. I’ll never let that happen.”
“Hospice is not a place, Irv, it’s a philosophy. It’s the best way to care for people in the last stages of their lives. I’m sure we can provide that care in your own home.”
“You must find something else. Experimental drugs or treatments,” Irv begged. “We can’t walk away and let her die.”
“I shouldn’t put myself or my wife into your situation, but it helps me to help you. I’ve looked over all the possibilities and discussed them with experts at the university, and I can’t find one experimental protocol I’d try for my wife if she was in Bea’s situation. They’ll only make her miserable and won’t help. Hospice will offer her humane and compassionate care. They’ll keep her alert, pain-free and she’ll live what remains of her life with dignity, surrounded by her loved ones.”
Bea tightened her grip on Irving’s hands. “It’s what I want, Irv. Help me through it. Please help me.”
It amazed me that once patients knew they had a fatal illness, the disease surged into ascendency. I knew it was irrational, even mystical. People went for long periods with fatal diseases, but once we made the diagnosis, they died quickly as they physically and emotionally submitted to the inevitable.
So it was with Beatrice Hodges. Three weeks later, with Irv and the family at her bedside, Bea slipped into a coma and never regained consciousness.
Bea’s three daughters dressed in black. Irv Hodges wore his charcoal-gray suit. On this warm and bright day at Rose Hill Cemetery in nearby Lafayette, the family sat under a large elm tree. Family mourners filled the front rows. They’d been pleasantly surprised at the large number of vehicles following the black Lincoln hearse through the iron gate at the cemetery’s entrance.
The ornate oak casket sat on a platform before the open grave. Each daughter contributed to a moving graveside eulogy, while Irv sat in silence.
K
athy, Arthur’s oldest daughter pleaded with her father. “Please Dad, say something for Mom. I know it’s hard for you, so do it for us, for the family.”
Irv refused to meet his daughter’s eyes. He was mortified that he’d let this happen and embarrassed to be alive. Finally, he looked at them. “There’s nothing I can say.”
After the ceremony, they lowered the coffin. The minister handed Irv the shiny stainless steel shovel, but he refused this as well.
When it was all over, Kathy grasped Irv’s left hand, suggesting that it was time to go. She looked into his dispassionate face and saw a single tear streaking from each eye, running over his wrinkled cheeks. In his right hand, a thin gold chain wrapped itself around twice with a gold locket in the center of his palm.
Losing Bea was more than Irv could tolerate. Emotionally, his world ended with the love of his life’s death. He became depressed, refusing my offers of support and the exhortations of his family. He ate, slept, did his chores and shopping, but the heart of the man died when Bea took her last breath.
Chapter Forty-Three
I was up most of the night. The ER at Brier Hospital had called at midnight and I went in to admit a patient with pneumonia.
When the coarse buzzing of my alarm clock awakened me at 6:30, I’d only slept two hours. My head ached and my mouth felt like leather. Although awake, my mind remained in park, and then shifted into overdrive as my nose detected maple sausage, fried eggs, coffee, wheat toast, and fresh orange juice. With my mouth watering, I felt energized and leapt out of bed to confront the day ahead.
Lois sat at one end of the kitchen table. On the other, sat two bowls with the soggy remnants of an unidentifiable cereal. The girls had managed to splatter milk and orange juice on the shiny oak table. I heard the door slam as my daughters headed for the Lincoln Navigator at the curb.
“What time did you get in, Arnie?”
“Around 4:30. I admitted Pam Davis with another flare of bronchitis. I knew it was coming and put her on antibiotics, but I acted too late.”
“How did you know?”
The Sixth Sense (Brier Hospital Series Book 3) Page 19
