by Sanjay Gupta
Bill McManus heard it within minutes of arriving at the hospital, from one of his residents. He groaned, remembering his impassioned defense to Sydney of this man’s right to remain artistic and unmedicated. Then he pulled out his cell phone and called the paging operator.
“Would you page Dr. Sydney Saxena for me?”
CHAPTER 41
S
o far, Park’s recovery from surgery was flawless. He had no infection, and his subsequent MRI looked good. His platelets and white blood counts were both good, and Hooten had not missed any of the tumor. Nothing you could see, anyway. Sung knew better than to rejoice in being NED—no evidence of disease—or to consider the clean MRI as the basis of a positive prognosis. A glioblastoma multiforme was the nastiest of nasty malignant tumors. Park of all people knew how a GBM could come roaring back without warning and kill him in a matter of weeks.
Since he’d started his radiation treatment, Park had gotten into the habit of taking his older daughter to the bus stop in the morning. Somehow, beating his colleagues to the hospital no longer seemed as important.
“Daddy, are you going to be bald?” Emily asked him suddenly. Park was surprised by the question.
“Why do you ask, Emily?”
“My friend Kaylee. She says when you have cancer you get bald.”
Park wondered for a moment how this friend had acquired such cancer literacy.
“Is that so?”
“Well, are you?”
Park still had almost all his hair despite the operation. Hooten liked to perform a “shaveless” surgery. Hooten first washed Park’s hair for six minutes with a Hibiclens scrub. He then used a comb to part the hair away from the incision site and then sterilized the area with betadine solution. Before Park’s operation, the surgical tech had shaved a thin arc along the line of the incision. Unless you looked closely, you couldn’t tell Park had undergone surgery. The hair around the wound camouflaged the scar. Hooten, and now many others, believed that patients who retained their hair recovered more quickly, because they didn’t look sick. Aside from his somewhat gaunt appearance, you would never guess Park had undergone major brain surgery.
Standing at the bus stop, Park looked at his daughter. She awaited his answer. Her expression was both excited and concerned.
“Hair does not matter,” Park said. “It’s what’s under the hair that matters.”
“Oh, Daddy,” Emily said. “Does it hurt when you get bald? I don’t want them to hurt you.” She hugged her father. Park wrapped his arms around his daughter. He worried that she’d be too distracted by his cancer to learn anything at school.
“Do not worry about me, Emily,” he said, adding, “It doesn’t hurt to have your hair fall out. Just ask your uncle Lee.”
Emily put her hands on her hips and cocked her head. Park laughed. Emily now saw that her father was joking and she laughed, too. Uncle Lee was Pat’s sister’s husband, a giant of a man with a monk-like fringe of hair.
Park had two more weeks of radiation. Then he would start taking a chemotherapy pill for the first four days of the month, which seemed a little more civilized than the traditional IV drip. Truth was, this regimen would do a lot more than leave him hairless as a newborn. The chemicals would certainly kill healthy cells as well as the cancerous ones, sickening and weakening him in the process. And he was concerned about what the powerful chemicals might do to his thinking and memory.
One of the chemotherapy’s documented side effects was impairing cognitive abilities. In fact, Park was at least as worried about problems with his thinking and memory as he was about the chemotherapy’s success or failure. Park’s mind was his greatest asset. He didn’t have looks, or charisma, or even much wit, he thought. Most of the time he was too literal-minded to even understand the jokes his colleagues or daughters told him. His greatest assets were a vast depth of medical knowledge and dogged determination. The determination might help, Park thought. The medical knowledge only informed him of the slim odds he possessed for beating this cancer for long. If Park could choose between the chemo succeeding and leaving him fuzzy-thinking and the chemo failing and leaving his mind sharp for his remaining months, he would opt for the failure. Of course, that wasn’t the choice. His choice was chemo or no chemo, and Park would go ahead with chemotherapy. Choosing otherwise was suicidal.
Park had a patient once who was worried about the chemotherapy damaging his short-term memory, so the man had started studying memorizing techniques and then memorizing anything and everything, from names in the phone book to cards in a deck. You could shuffle all fifty-two cards, show them to him once, and he would recite them back in order. He emerged from chemotherapy with a stronger memory, thanks to his mnemonic techniques.
In many ways, modern medicine seemed a puzzling mix of harming and helping patients. Patients needed to be cut open to operate. Patients needed to be poisoned to go after the cancer cells. With radiation, Park was choosing to have colleagues aim potentially deadly beams of energy at his body. Not just any part of his body, but his brain. Someday in the future, Park was certain, radiation, chemotherapy, even brain surgery, would be looked upon as some sort of barbarism. Fifty years from now, or maybe a hundred, doctors would look back on modern medicine the way he looked back on bleeding patients as a way to release bad humors, a common practice in the eighteenth century.
Even treatments that weren’t so old were crude and wrongheaded. One of his brain cancer patients had been subjected weekly to high doses of X-rays as an infant in the 1940s in an attempt to restore hearing to her left ear. As a result, she was left completely deaf and blind. Almost weekly, it seemed, large studies and new research would raise doubts about long-held beliefs and common medical practices. The efficacy of angioplasty, radical mastectomy, arthroscopic knee surgery, prostate PSA tests and surgery…the list went on and on. Medicine seemed to lurch two steps back for every three it moved forward. Even with the scientific method, Park realized that what doctors knew—really knew—was small, and the limits to medical knowledge were vast. Sometimes, Park had to admit, the best thing doctors could do was get out of the way and allow the body’s own natural healing abilities to take over.
As a patient with a brain tumor, of course, that was out of the question. Park would seek out every weapon in modern medicine’s arsenal, including chemotherapy.
As a student of medical history, Park knew that the first chemotherapy agent employed against cancer had been mustard gas, in the 1940s. Doctors tried it against advanced lymphomas after discovering during World War I that mustard gas victims had low white blood cell counts. Even today, Park knew, doctors counted nitrogen mustards—related to the lethal chemical from the War to End All Wars—among their weapons against Hodgkin’s disease and lymphatic cancers.
Three weeks or so into his chemo, Park would lose his hair, as his daughter Emily predicted. As he stood now at the bus stop, he wondered how his three children would react. Would they think him funny looking? Terrifying? Would they call him an alien? Would they see him any differently at all when he was balder than his brother-in-law? Outwardly, he’d be transformed. But inside, what would he look like? When the MRI reconstructed a three-dimensional picture of his brain, what would it show? That was what counted.
The bus arrived. Emily stepped high to get on the bus, pulling her small body up. She turned and gave him a quick wave and a smile before finding a seat next to another girl.
As Park walked back toward his house, his mind drifted to his vocabulary tape: “Mnemonics: the process or technique of improving or developing the memory. Morose: gloomy or ill-humored. Morph: to transform.”
Park walked into the house, unhurried. Pat had been watching him through the window, and greeted him expectantly. “I am sorry,” Sung suddenly said to his wife. “In case I don’t get a chance to tell you later, I am sorry for leaving you.”
CHAPTER 42
T
y awoke remembering little of the dream. All he remembered was his br
other and sister standing next to him. Smiling at him. He couldn’t remember where they were, or if they were anywhere in particular. Their smiles, though, exuded love. Ty woke with an incredible sense of relief and calm. It was as though he had emerged from a fever. It was the quiet after the storm. He knew the moment he awoke that Ty Wilson the surgeon was back. Ty felt a joy surging in him. He was back.
Ty was not one to believe in the interpretation of dreams. He knew there were dozens of books that translated dream imagery. He’d even heard of people who kept diaries of their dreams, so they could better act on them in their waking hours. Ty didn’t buy it. Still, there was no denying that this morning he felt free from the paralyzing doubt. This emotional dream had somehow liberated him from his demons, and he didn’t want to talk himself out of the sense of freedom he felt at that moment.
Ty rose and made a fresh fruit smoothie thinking about the dream. His brother and sister were the reasons he’d become a neurosurgeon. He wanted to develop the skills to vanquish death where others could not. Their deaths had pushed him, propelled him to become a top neurosurgeon, but he was only human. He was fallible. The pure love flowing from his brother and sister in his dream told him he had not violated his silent vows to them. All he could do was his best, and that was better than most. Ty laughed at the ridiculousness of it all. A dream had set him free. He was back.
Ty couldn’t wait to get back to the OR. This was his calling, his purpose. The Okinawans called this sense of purpose ikigai. Before he went back to the hospital, though, Ty had one stop to make.
Ty knocked on the door of Allison McDaniel’s apartment an hour later. She answered right away. She was wearing a stylish red coat and holding a cup of coffee. She was surprised to see him.
“Dr. Wilson. You look different.”
“Ty, please. Call me Ty. Are you heading out?”
“Yeah, job interview.”
“May I walk with you?”
“Sure.” They started down the stairs.
“Allison, I’m not sure how to say this, so I’ll just go ahead. I get the sense that you’re a remarkable person. A generous and warmhearted person. I’d like to take you to dinner. To get to know you better.”
They reached the landing. Allison stopped. She looked hard at Ty as though she was trying to divine his motive.
“This isn’t about Quinn?”
“No. It’s about you.”
Allison thought for a moment. She took a deep breath.
“Okay. Why not?” she said finally. She smiled. Ty didn’t return the smile. There was something else he wanted to say. Something else he needed to say.
“Allison, I can’t undo what happened. I wish I could. But I realize now I’ve got to move forward. It’s all I can do. If I don’t I sink. All I can do is be the best doctor I can be—and the best person I can be.”
They reached Allison’s car. She retrieved the key from her purse.
“I understand.” She unlocked the car and then stopped. “You didn’t say when.” Ty looked confused. He thought she was asking when he planned to be the best doctor, the best person he could be. “When you want to have dinner?” Allison added.
“Oh, how about Friday night? Seven o’clock?”
“All right.”
“Great. I’ll see you then.”
Allison got in her car and backed up. Ty watched her go. She gave him a little wave and then pulled away. If it was redemption Ty Wilson had been looking for, he hadn’t found it. Now, though, he realized that it wasn’t the point. Redemption only worked, he thought, if you believed in a perfect world, where good and evil were always in a state of perfect balance. It was naive, and he had finally realized it. In his dream, his brother and sister had figured it out, and they were trying to tell him. Sometimes bad things just happen to good people. “How the good people react,” Ty said out loud, “that is what really counts.”
McManus sat across from Sydney at a small Japanese restaurant. Their pagers rested between them. They had a deal: Whoever’s went off first paid for dinner. Getting Sydney to agree to dinner was no easy task. McManus had found her after a lecture at the med school.
“I don’t waste my time on wiseass, know-it-all doctors,” Sydney said. She was still smarting from McManus questioning her judgment in the case of the ear-loving artist Malchus.
“Ouch” was all McManus could answer, and the genuine hurt in his voice made Sydney reconsider. Maybe she was being a little too harsh. A little.
“All right,” she added. “I’ll go out to dinner with you if you repeat after me: Crazy people need medication.”
“Crazy people need medication.”
“I should never have doubted Dr. Sydney Saxena, and I will never doubt her judgment again,” Sydney added.
“Now you’re going too far!” he exclaimed, but he said it with a smile on his face. “How about this? I realize that doubting the judgment of Dr. Sydney Saxena comes with potentially grave mental and physical consequences.”
“Extremely grave consequences!” Sydney laughed.
And with that, she had relented. He had picked the restaurant, a small place in Chelsea that served yakitori—Japanese-style meat and vegetable skewers.
They ordered and then McManus excused himself for a moment. When he returned, Sydney’s pager was buzzing.
“I guess I know who’s buying dinner!” McManus said. Sydney looked at the number on the pager. She frowned. It was unfamiliar. She pulled out her cell phone.
“If it’s an emergency, I’m sure they’ll page again,” McManus said. Sydney ignored him and punched the number into her phone. A jaunty Latin beat emanated from McManus’s pocket.
“I should have known!”
“Must be some sort of coincidence,” McManus said, barely suppressing a grin.
“Now I know what sort of pathology I’m dealing with here.”
McManus looked at his pager and saw the same unfamiliar number.
Driving to clinic, Ty felt the elation of someone healthy after a long illness. He was energized. He couldn’t wait to see new patients. Pulling into the physicians’ parking area he spotted a nurse getting out of her car. It was Monique Tran. He was immediately transported back to Room 14 on October 23. She had been there on the day Quinn McDaniel died. He took in a deep breath, and waited for all the feelings to come flooding back. But nothing happened. Thinking of the boy did not cause a relapse of doubt.
Instead, Ty thought it strange Monique was parking there because nurses had their own parking three levels up in the garage. Then he saw a resident emerge from the car, Dr. Sanford Williams. The young doctor placed an arm around the shorter nurse. Ty now noticed the bulge in her pink scrub shirt. She was pregnant. It all clicked into place in his mind. Ty continued up the ramp to the next level. He thought about the awe and excitement that must come from bringing new life into the world. Right then, Ty’s pager went off. He looked at it, and pure panic crossed his face.
CHAPTER 43
I
nside the hospital, Marjorie Gonsalves was lying in a bed for observation. Her husband brought her around midnight, confused and near collapse. She had seen her doctor the day before complaining of abdominal pain and was now reporting the addition of pain in her chest. Also, she said she felt dizzy when she stood up. The resident considered gastritis, aortitis, and cirrhosis of the liver. But none seemed a good fit.
The forty-year-old woman said she didn’t drink and used nonsteroidal anti-inflammatories only sparingly. Alcohol and prolonged use of NSAIDs were two common ways people could end up with inflammation in their stomach lining. Nor had she had surgery or a severe infection or an auto-immune disorder or chronic bile reflux, which were other possible causes of gastritis. The resident decided to hold off for the time being on an upper gastrointestinal endoscopy.
As for aortitis, an inflammation of the aorta, her chest pain and confusion when she arrived at Chelsea General certainly fit the bill of Phase III aortitis. Her history did not. She had not su
ffered from a trauma or infection. The woman had been happily married for twenty years and bristled when the medical student taking her history asked about gonorrhea, syphilis, or herpes. Nor did she have any history of TB or hepatitis. Also, the resident took the blood pressure on each arm. A difference would point to vascular obstruction. There was none.
Gonsalves had a lifelong history of allergies and asthma, but neither of these seemed to be a likely source of her troubles.
Stumped by the case and swamped by other admissions, the resident turned his attention elsewhere.
Marjorie Gonsalves’s temperature had been normal when she was admitted at midnight, but it began to spike. At eight the following morning, it was 101. By afternoon, it was over 103.
Worse still, Gonsalves’s list of symptoms began growing. The pain spread, and she began itching. Her eyes became puffy.
The resident finishing his shift thought it must be something to do with the patient’s allergies. The resident who arrived that evening, Dr. Eduardo Torres, decided to order a differential. When this blood test came back an hour later, it showed Gonsalves’s white blood cell count spiking along with her temperature, primarily because of eosinophils. These white blood cells, which stained orange-red, were possibly a sign of a viral infection. But what virus? Herpes and hepatitis had been ruled out.
Villanueva was leaving the cafeteria when Torres stopped him to see if he had any thoughts about what could be ailing Mrs. Gonsalves. Villanueva, for once, was stumped. He was experiencing some stomach pain himself and made a mental note to lighten up on the hot sauce with his grits. He told Torres to seek out Dr. Um-So.
“Guy’s a friggin’ encyclopedia,” Villanueva said.
When Um-So, aka Kauffman, arrived at Mrs. Gonsalves’s bedside, her voice was down to a barely audible croak. Outside her room, Torres explained why he had ruled out Cushing’s disease and a host of other possibilities. He asked if Kauffman had ever seen an allergic reaction present these types of symptoms. Um-So said nothing. He looked through the door at Gonsalves. She stared up at the ceiling, arms crossed on her chest like a corpse. Kauffman stared for a long time, then he approached the bed and knelt close to her ear.
