by Robin Cook
“Sean Murphy,” the clerk said.
“CRAP!” SEAN said as his beeper went off. He was certain that Janet had long since disappeared, but just to be sure, he opened the door carefully and scanned the area. He didn’t see her, so he pushed through. He had to use the phone out in the nurses’ station since Peter was hogging the one in the back room, trying to get last-minute lab reports.
Before Sean called anybody, he approached Carla Valentine, the head nurse. “You guys looking for me?” he asked expectantly. He was hoping they were because then the page would involve some easily performed scut work. What Sean feared was that the page was coming from either admitting or the ER.
“You’re all clear for the moment,” Carla said.
Sean then dialed the operator and got the bad news. It was the ER with an admission.
Knowing the sooner he got the history and physical done, the better off he’d be, Sean bid farewell to Peter, who was still on the phone, and went downstairs.
Under normal circumstances Sean liked the ER and its constant sense of excitement and urgency. But on the afternoon of his last day on his medicine rotation, he didn’t want another case. The typical Harvard medical student’s workup took hours and filled between four and ten pages of tightly written notes.
“It’s an interesting case,” George said when Sean arrived. George was on hold on the phone with radiology.
“That’s what you always say,” Sean said.
“Truly,” George said. “Have you ever seen papilledema?”
Sean shook his head.
“Grab an ophthalmoscope and look at the guy’s nerve heads in both eyes. They’ll look like miniature mountains. It means the intracranial pressure is elevated.” George slid the ER clipboard along the countertop toward Sean.
“What’s he got?” Sean asked.
“My guess is a brain tumor,” George said. “He had a seizure at work.”
At that moment someone came on the phone line from radiology, and George’s attention was directed at scheduling an emergency CAT scan.
Sean took the ophthalmoscope and went in to see Mr. Martin. Sean was far from adept at using the instrument, but after persistence on his part and patience on Louis’s part, he was able to catch fleeting glimpses of the mounded nerve heads.
Doing a medical student history and physical was a laborious task under the best of circumstances, and doing it in the emergency room and then up in X-ray while waiting for a CAT scan made it ten times more difficult. Sean persisted, asking as many questions as he could think of, especially about the current illness. What Sean learned that no one else had was that Louis Martin had had some transient headache, fever, and nausea and vomiting about a week after his prostate surgery in early January. Sean had stumbled onto this information just before Louis began his enhanced CAT scan. The technician had to order Sean out of the CAT scanner room and into the control room moments before the study commenced.
Besides the technician running the CAT scanner, there were a number of other people in the control room including Dr. Clarence Handlin, Louis Martin’s internist, George Carver, the medical resident, and Harry O’Brian, the on-call neurology resident. They were all grouped around the CRT screen, waiting for the first “cuts” to appear.
Sean pulled George aside and told him about the earlier headache, fever, and nausea.
“A good pickup,” George said while he pulled pensively at the skin at the edge of his jaw. He was obviously trying to relate these earlier symptoms to the current problem. “The fever is the curious part,” he said. “Did he say it was a high fever?”
“Moderate,” Sean said. “102 to 103. He said it was like having a cold or mild flu. Whatever it was, it went away completely.”
“It might be related,” George said. “At any rate this guy is a ‘sickle.’ The preliminary CAT scan showed two tumors. Remember Helen Cabot upstairs?”
“How can I forget?” Sean said. “She’s still my patient.”
“This guy’s tumors look very similar to hers,” George said.
The group of doctors around the CRT screen began talking excitedly. The first cuts were coming out. Sean and George stepped behind them and peered over their shoulders.
“Here they are again,” Harry said, pointing with the tip of his percussion hammer. “They’re definitely tumors. No doubt at all. And here’s another small one.”
Sean strained to see.
“Most likely metastases,” Harry said. “Multiple tumors like this have to come from someplace else. Was his prostate benign?”
“Completely,” Dr. Handlin said. “He’s been in good health all his life.”
“Smoke?” Harry asked.
“No,” Sean said. The people in front moved to give Sean a better view of the CRT screen.
“We’ll have to do a full metastatic workup,” Harry said.
Sean bent over close to the CRT screen. The areas of reduced uptake were apparent even to his inexperienced eye. But what really caught his attention was how much they resembled Helen Cabot’s tumors, as George had said. And like hers, they were all in the cerebrum. That had been a point of particular interest with Helen Cabot, since medulloblastomas generally occurred in the cerebellum, not the cerebrum.
“I know statistically you have to think of a metastasis from lung, colon, or prostate,” George said. “But what are the chances we’re seeing a tumor similar to Helen Cabot’s? In other words, multifocal primary brain cancer like medulloblastoma.”
Harry shook his head. “Remember, when you hear hoof-beats you should think of horses, not zebras. Helen Cabot’s case is unique even though there have been a couple of similar cases recently reported around the country. Nonetheless, I’ll be willing to wager anyone that we’re looking at metastatic tumors here.”
“What service do you think he should be on?” George asked.
“Six of one, half dozen of another,” Harry said. “If he’s on neurology, we’ll need an internal medicine consult for the metastatic workup. If he’s on internal medicine, he’ll need the neuro consult.”
“Since we took Cabot,” George suggested, “why don’t you guys take him. You interact better with neurosurgery anyway.”
“Fine by me,” Harry said.
Sean groaned inwardly. All his work doing the history and physical was for naught. Since the patient would be admitted to neurology, the medical student on neurology would get credit for it. But at least that meant Sean was free.
Sean motioned to George that he’d see him later on rounds, then slipped out of the CAT scan room. Although he was behind on his off-service notes, Sean took the time for a visit. Having been thinking and talking about Helen Cabot, he wanted to see her. Getting off the elevator on the seventh floor, he walked directly down to room 708 and knocked on the half-open door.
Despite her shaved head and a series of blue marker stains on her scalp, Helen Cabot still managed to look attractive. Her features were delicate, emphasizing her large, bright green eyes. Her skin had the translucent perfection of a model. Yet she was pale, and there was little doubt she was ill. Still, her face lit up when she saw Sean.
“My favorite doctor,” she said.
“Doctor-to-be,” Sean corrected her. He didn’t enjoy the charade of playing doctor like many medical students. Ever since he graduated from high school he’d felt like an imposter, play-acting first at the role of a Harvard undergraduate, then an MIT fellow, and now a Harvard medical student.
“Have you heard the good news?” Helen asked. She sat up despite her weakness from the many seizures she’d been having.
“Tell me,” Sean said.
“I’ve been accepted into the Forbes Cancer Center protocol,” Helen said.
“Fantastic!” Sean said. “Now I can tell you I’m heading there myself. I’ve been afraid to mention it until I heard you were going too.”
“What a marvelous coincidence!” Helen said. “Now I’ll have a friend there. I suppose you know that with my particular ty
pe of tumor they’ve had a one hundred percent remission.”
“I know.” Sean said. “Their results are unbelievable. But it’s no coincidence we’ll be down there together. It was your case that made me aware of the Forbes. As I’ve mentioned to you, my research involves the molecular basis of cancer. So discovering a clinic where they are having hundred-percent success treating a specific cancer is extraordinarily exciting for me. I’m amazed I hadn’t read about it in the medical literature. Anyway, I want to go down there and find out exactly what they’re doing.”
“Their treatment is still experimental,” Helen said. “My father emphasized that to me. We think the reason they’ve avoided publishing their results is that they first want to be absolutely sure of their claims. But whether they’ve published or not, I can’t wait to get there and start treatment. It’s the first ray of hope since this nightmare started.”
“When are you going?” Sean asked.
“Sometime next week,” Helen said. “And you?”
“I’ll be on the road the crack of dawn on Sunday. I should be there early Tuesday morning. I’ll be waiting for you.” Sean reached out and gripped Helen’s shoulder.
Helen smiled, placing her hand over Sean’s.
AFTER COMPLETING report, Janet returned to the seventh floor to look for Sean. Once again the nurses said he’d been there only moments earlier but apparently had disappeared. They suggested paging him, but Janet wanted to catch him off guard. Since it was now after four she thought the best place to find him would be Dr. Clifford Walsh’s lab. Dr. Walsh was Sean’s Ph.D. advisor.
To get there, Janet had to leave the hospital, brace herself against the winter wind, walk partway down Longfellow Avenue, cross the medical school quadrangle, and climb to the third floor. Even before she opened the door to the lab, she knew she’d guessed correctly. She recognized Sean’s figure through the frosted glass. It was mostly the way he moved that was so familiar. He had surprising grace for such a stocky, muscular frame. There was no wasted motion. He went about his tasks quickly and efficiently.
Entering the room, Janet closed the door behind her and hesitated. For a moment she enjoyed watching Sean. Besides Sean there were three other people busily working. A radio played classical music. There was no conversation.
It was a rather dated and cluttered lab with soapstone-topped benches. The newest equipment were the computers and a series of desk-sized analyzers. Sean had described the subject of his Ph.D. thesis on several occasions, but Janet still wasn’t a hundred percent certain she understood it all. He was searching for specialized genes called oncogenes that had the capability of encouraging a cell to become cancerous. Sean had explained that the origins of oncogenes seemed to be from normal “cellular control” genes that certain types of viruses called retroviruses had a tendency to capture in order to stimulate viral production in future host cells.
Janet had nodded at appropriate times during these explanations but had always found herself more interested by Sean’s enthusiasm than the subject matter. She also realized that she needed to do some more basic reading in the area of molecular genetics if she was to understand Sean’s particular area of research. Sean had a tendency to assume that she had more knowledge than she had, in a field where advances came at a dizzying pace.
As Janet watched Sean from just inside the door, appreciating the V that his broad shoulders and narrow waist formed, she became curious about what he was currently doing. In sharp contrast to many other visits she’d made over the last two months, he wasn’t preparing one of the analyzers to run. Instead he seemed to be putting objects away and cleaning up.
After watching for several minutes, expecting him to notice her, Janet stepped forward and stood right next to him. At five-six Janet was relatively tall, and since Sean was only five-nine, they could just about look each other in the eye, especially when Janet wore heels.
“What may I ask are you doing?” Janet said suddenly.
Sean jumped. His level of concentration had been so great he’d not sensed her presence.
“Just cleaning up,” he said guiltily.
Janet leaned forward and looked into his startlingly blue eyes. He returned her stare for a moment, then looked away.
“Cleaning up?” Janet asked. Her eyes swept around the now pristine lab bench. “That’s a surprise.” Janet redirected her eyes at his face. “What’s going on here? This is the most immaculate your work area has ever been. Is there something you haven’t told me?”
“No,” Sean said. Then he paused before adding, “Well, yes, there is. I’m taking a two-month research elective.”
“Where?”
“Miami, Florida.”
“You weren’t going to tell me?”
“Of course I was. I planned on telling you tomorrow night.”
“When are you leaving?”
“Sunday.”
Janet’s eyes angrily roamed the room. Absently, her fingers drummed on the countertop. She questioned to herself what she’d done to deserve this kind of treatment. Looking back at Sean, she said: “You were going to wait until the night before to tell me this?”
“It just came up this week. It wasn’t certain until two days ago. I wanted to wait until the right moment.”
“Considering our relationship, the right moment would have been when it came up. Miami? Why now?”
“Remember that patient I told you about? The woman with medulloblastoma.”
“Helen Cabot? The attractive coed?”
“That’s the one,” Sean said. “When I read about her tumor, I discovered…” He paused.
“Discovered what?” Janet demanded.
“It wasn’t from my reading,” Sean corrected himself. “One of her attendings said that her father had heard about a treatment that is apparently achieving one hundred percent remission. The protocol is only administered at the Forbes Cancer Center in Miami.”
“So you decided to go. Just like that.”
“Not exactly,” Sean said. “I spoke to Dr. Walsh, who happens to know the director, a man named Randolph Mason. A number of years ago they worked together at the NIH. Dr. Walsh told him about me, and got me invited.”
“This is the wrong time for this,” Janet said. “You know I’ve been disturbed about us.”
Sean shrugged. “I’m sorry. But I have the time now, and this is potentially consequential. My research involves the molecular basis of cancer. If they are experiencing a hundred-percent remission rate for a specific tumor, it has to have implications for all cancers.”
Janet felt weak. Her emotions were raw. Sean’s leaving for two months at this time seemed the worst possible situation as far as her psyche was concerned. Yet his reasons were noble. He wasn’t going to the Club Med or something. How could she get angry or try to deny him. She felt totally confused.
“There is the telephone,” Sean said. “I’m not going to the moon. It’s only a couple of months. And you understand that this could be very important.”
“More important than our relationship?” Janet blurted out. “More important than the rest of our lives.” Almost immediately Janet felt foolish. Such comments sounded so juvenile.
“Now let’s not get into an argument comparing apples and oranges,” Sean said.
Janet sighed deeply, fighting back tears. “Let’s talk about it later,” she managed. “This is hardly the place for an emotional confrontation.”
“I can’t tonight,” Sean said. “It’s Friday and…”
“And you have to go to that stupid bar,” Janet snapped. She saw some of the other people in the room turn to stare at them.
“Janet, keep your voice down!” Sean said. “We’ll get together Saturday night as planned. We can talk then.”
“Knowing how upset this leaving would make me, I cannot understand why you can’t give up drinking with your trashy buddies for one night.”
“Careful, Janet,” Sean warned. “My friends are important to me. They’re my roots.”
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For a moment their eyes met with palpable hostility. Then Janet turned and strode from the lab.
Self-consciously, Sean glanced at his colleagues. Most avoided his gaze. Dr. Clifford Walsh did not. He was a big man with a full beard. He wore a long white coat with the sleeves rolled up to the elbows.
“Turmoil does not help creativity,” he said. “I hope your leaving on this sour note does not influence your behavior down in Miami.”
“Not a chance,” Sean said.
“Remember, I’ve gone out on a limb for you,” Dr. Walsh said. “I assured Dr. Mason you’d be an asset to his organization. He liked the idea that you’ve had a lot of experience with monoclonal antibodies.”
“That’s what you told him?” Sean questioned with dismay.
“I could tell from our conversation that he’d be interested in that,” Dr. Walsh explained. “Don’t get your dander up.”
“But that was what I did three years ago at MIT,” Sean said. “Protein chemistry and I have parted ways.”
“I know you’re interested in oncogenes now,” Dr. Walsh said, “but you wanted the job and I did what I thought was best to get you invited. When you are there, you can explain you’d rather work in molecular genetics. Knowing you as I do, I’m not worried about you making your feelings known. Just try to be tactful.”
“I’ve read some of the work of me chief investigator,” Sean said. “It’s perfect for me. Her background is in retroviruses and oncogenes.”
“That’s Dr. Deborah Levy,” Dr. Walsh said. “Maybe you can get to work with her. But whether you do or not, just be grateful you’ve been invited at this late date.”
“I just don’t want to get all the way down there and get stuck with busywork.”
“Promise me you won’t cause trouble,” Dr. Walsh said.
“Me?” Sean asked with eyebrows arched. “You know me better than that.”
“I know you too well,” Dr. Walsh said. “That’s the problem. Your brashness can be disturbing, to put it mildly, but at least thank the Lord for your intelligence.”
