Fever (11 page)

“I think you'll agree it's rather conclusive,” said Dr. Wiley gently.

With a crash, Charles leaped to his feet, knocking his stool over backwards. An uncontrollable anger, anger pent up from the exasperating morning and now fired by Michelle's illness, blinded him. “Why?” he screamed at Dr. Wiley, as if the pediatrician were part of an encircling conspiracy. He grabbed a fistful of the man's shirt and shook him violently.

Cathryn leaped between the two men, throwing her arms around her husband. “Charles, stop!” she shouted, terrified of alienating the one person she knew they needed to help them. “It's not Dr. Wiley's fault. If anyone's to blame, it's us.”

As if waking from a dream, Charles embarrassingly let go of Dr. Wiley's shirt, leaving the surprised pediatrician's bow tie at an acute angle. He bent down and righted the stool, then stood back up, covering his face with his hands.

“Blame is not the issue,” said Dr. Wiley, fumbling nervously with his tie. “Caring for the child is the issue.”

“Where is Michelle?” asked Charles. Cathryn did not let go of his arm.

“She's already been admitted to the hospital,” said Dr. Wiley. “She's on Anderson 6, a floor with a wonderful group of nurses.”

“I want to see her,” said Charles, his voice weak.

“I'm sure you do,” said Dr. Wiley. “But I think we have to discuss her care first. Listen, Charles.” Dr. Wiley reached out a comforting hand, but thought better of it. Charles's fury had unnerved him. Instead he put his hands in his pockets. “We have here at Pediatric one of the world's authorities on
childhood leukemia, Dr. Stephen Keitzman, and with Cathryn's permission I've already contacted him. Michelle is a very sick little girl, and the sooner a pediatric oncologist is on the case the better. He agreed to meet with us as soon as you arrived. I think we should talk to him, then see Michelle.”

At first Cathryn wasn't sure about Dr. Stephen Keitzman. Outwardly he was the opposite of Dr. Wiley. He was a small, young-looking man with a large head and thick dark, curly hair. He wore rimless glasses on a skinny nose whose pores were boldly evident. His manner was abrupt, his gestures nervous, and he had a peculiar tic that he displayed during pauses in his speech. All at once he'd curl his upper lip in a sneer that momentarily bared his capped teeth and flared his nostrils. It lasted only an instant but it had a disquieting effect on people who were meeting him for the first time. But he was sure of himself and spoke with an authority that made Cathryn feel confidence in the man.

Certain that she would forget what was being told to them, she pulled out a small notebook and ballpoint pen. It confused her that Charles didn't seem to be listening. Instead he was staring out the window, seemingly watching the traffic inching along Longwood Avenue. The northeast wind had brought arctic air into Boston and the mixture of light rain and snow had turned to a heavy snow. Cathryn was relieved that Charles was there to take control because she felt incapable. Yet he was acting strangely: angry one minute, detached the next.

“In other words,” summed up Dr. Keitzman, “the diagnosis of acute myeloblastic leukemia is established beyond any doubt.”

Swinging his head around, Charles surveyed the room. He knew that he had a precarious hold on his emotions, and it made it difficult to concentrate on what Keitzman had to say. Angrily he felt he'd spent the whole morning watching people undermine his security, dislocate his life, destroy his family, rob him of his newly found happiness. Rationally he knew there was a big difference between Morrison and Ibanez on the one hand and Wiley and Keitzman on the other, but at the
moment they all triggered the same unreasoning fury. Charles had great difficulty believing that Michelle had leukemia, particularly the worst possible type, the most deadly kind. He had already been through that kind of disaster; it was someone else's turn.

Listening half-heartedly, Charles examined Dr. Stephen Keitzman, who had assumed that typical condescending air of the physician in charge, doling out bits and pieces of information as if he were lecturing. Obviously Keitzman had experienced this scene many times before and his stock phrases like “I'm sorry to say” had an overused, insincere ring. Charles had the uncomfortable feeling that the man was enjoying himself, not in the same manner he'd enjoy a movie or a good meal, but in a more subtle, self-satisfied way: he was the center of attention in a crisis. This attitude abraded Charles's already frayed emotions, especially since he was more than familiar with the general material Dr. Keitzman was covering. Charles forced himself to remain silent while his mind's eye conjured up kaleidoscopic images of Michelle as she grew up.

“In order to allay the inevitable sense of guilt,” continued Keitzman as he bared his upper teeth in one of his nervous grimaces, “I want to emphasize that the cause and date of onset of leukemia like Michelle's is unknown. Parents should not try to blame specific events for initiating the disease. The goal will be to treat the condition and bring about a remission. I'm pleased to be able to report that we have very favorable results with acute myeloblastic leukemia; something we didn't have ten years ago. Now we are able to engineer a remission in about eighty percent of cases.”

“That's wonderful,” said Charles, speaking for the first time. “But unlike the five-year cures you've been achieving with other forms of leukemia, can you tell us how long the remission lasts in Michelle's form of the disease.” It was as if Charles had to goad Keitzman into revealing the worst news at once.

Keitzman pushed back his glasses and cleared his throat. “Dr. Martel, I am aware you know more about your daughter's
disease than other parents I deal with. But since your field is not specifically childhood leukemia, I don't have any idea what you know and what you don't know. Therefore, I felt it best to have this discussion as if you knew nothing. And even if you are already familiar with these facts, perhaps they are helpful to Mrs. Martel.”

“Why don't you answer my question?” said Charles.

“I think it is a more fruitful approach if we concentrate on obtaining a remission,” said Dr. Keitzman. His nervous tic became more frequent. “My experience has shown that with the advances in chemotherapy, leukemia should be approached on a day-to-day basis. We have seen some spectacular remissions.”

“Except in Michelle's type,” snarled Charles. “Come on, tell us what the probability is of a five-year survival with acute myeloblastic leukemia.”

Dr. Keitzman looked away from Charles's challenging eyes to Cathryn's frightened face. She had paused in her notetaking, gaping at Dr. Keitzman. He knew the meeting was going badly. He glanced at Dr. Wiley for support, but Dr. Wiley had his head down, watching his thumbnail play against his other fingers. Trying to avoid Charles's stare, Keitzman said in a low voice, “The five-year survival is not impressive in acute myeloblastic leukemia, but it's not impossible.”

“Now you're getting closer to the truth,” said Charles, jumping to his feet and leaning over Dr. Keitzman's desk. “But to be more exact, the median survival of acute myeloblastic leukemia if a remission is obtained is only one to two years. And, in Michelle's case, with circulating leukemic cells, her chances of a remission are a lot less than eighty percent. Wouldn't you agree, Dr. Keitzman?”

Taking his glasses off, Dr. Keitzman tried to think of how best to word his response. “There's some truth in what you say, but it is not a constructive way to view the disease. There are lots of variables.”

Charles abruptly walked to the window, watching the dirty snow flutter past. “Why don't you tell Mrs. Martel what the
survival time of the nonresponder is . . . the patients who don't have a remission.”

“I'm not sure what good this . . .” began Dr. Keitzman.

Charles whirled around. “What good? You dare to ask? I'll tell you what good it is. The worst thing about disease is the uncertainty. Humans are capable of adapting to anything as long as they know. It's the hopeless floundering that drives people crazy.”

Charles stormed back to Dr. Keitzman's desk as he spoke. Eyeing Cathryn's pad, he grabbed it and threw it into the wastebasket. “We don't need notes on this gathering! It's not a goddamn lecture. Besides, I know all too well about leukemia.” Turning back to Dr. Keitzman, Charles's face was flushed. “Come on, Keitzman, tell us about the survival time of nonresponders.”

Keitzman moved back in his chair, his hands gripping the edge of the desk as if he were prepared for flight. “It's not good,” he said finally.

“That's not good enough,” snapped Charles. “Be more specific.”

“All right!” said Dr. Keitzman. “Weeks, months at the most.”

Charles didn't answer. Having successfully backed Dr. Keitzman into a corner, he was suddenly adrift. Slowly he sank back down into his chair.

Keitzman's face recovered from a series of sustained twitches as he exchanged sympathetic glances with Dr. Wiley. Turning to Cathryn, he resumed his recommendations. “Now, as I was saying. It is best to try to think of leukemia as a nonfatal disease and to take each day as it comes.”

“That's like telling a man on death row not to think about death,” mumbled Charles.

“Dr. Martel,” said Dr. Keitzman sharply, “as a physician I would expect your response to the crisis to be significantly different.”

“It's easy to respond differently,” said Charles, “when it's
not a member of your own family. Unfortunately I've been through this before.”

“I think we should discuss therapy,” offered Dr. Wiley, speaking for the first time.

“I agree,” said Dr. Keitzman. “We must start treatment as soon as possible. In fact, I'd like to start today, immediately after all the baseline studies are done. But of course, we are going to need consent to treat because of the nature of the drugs.”

“With the chance of a remission so slight, are you sure it's worth subjecting Michelle to the side effects?” Charles was speaking more calmly now, but he had a terrible vision of Elizabeth during those last months, the violent nausea, the loss of hair . . . He closed his eyes.

“Yes, I do,” said Dr. Keitzman firmly. “I think it is well established that we have made significant advances in treating childhood leukemia.”

“That's absolutely true,” confirmed Dr. Wiley.

“There have been advances,” agreed Charles, “but unfortunately in types of leukemia other than Michelle's.”

Cathryn's eyes darted from Charles, to Keitzman, to Wiley. She expected and wanted unanimity on which she could build her hope. Instead she could feel nothing but dissension and animosity.

“Well,” said Dr. Keitzman, “I believe in aggressively treating all cases, whatever the chances are for remission. Every patient deserves a chance at life, whatever the cost. Every day, every month, is precious.”

“Even if the patient would rather end her suffering,” said Charles, recalling Elizabeth's last days. “When the chances of a remission—let alone a cure—are less than twenty percent, I don't know if it's worth subjecting a child to the additional pain.”

Dr. Keitzman stood up abruptly, pushing back his chair. “We obviously view the value of life very differently. I believe chemotherapy to be a truly remarkable weapon against cancer. But you are entitled to your opinion. However, it seems
evident that you would prefer to find another oncologist or handle your daughter's therapy yourself. Good luck!”

“No!” said Cathryn, leaping to her feet, terrified at the prospect of being abandoned by Dr. Keitzman, who Dr. Wiley had said was the best. “Dr. Keitzman, we need you. Michelle needs you.”

“I don't think your husband shares your view, Mrs. Martel,” said Dr. Keitzman.

“He does,” said Cathryn. “He's just distraught. Please, Dr. Keitzman.” Turning to Charles, Cathryn put a hand on his neck. “Charles, please! We can't fight this alone. You said this morning you weren't a pediatrician. We need Dr. Keitzman and Dr. Wiley.”

“I think you should cooperate,” urged Dr. Wiley.

Charles sagged under the weight of his brooding impotence. He knew he could not care for Michelle even if he were convinced the current approach for her particular disease to be wrong. He had nothing to offer and his mind was overloaded, an emotional jumble.

“Charles, please?” Cathryn pleaded.

“Michelle is a sick little girl,” said Dr. Wiley.

“All right,” said Charles softly, once again forced to surrender.

Cathryn looked at Dr. Keitzman. “There! He said all right.”

“Dr. Martel,” asked Dr. Keitzman. “Do you want me to serve as the oncologist on this case?”

With a sigh which suggested breathing to be a great effort, Charles reluctantly nodded his head.

Dr. Keitzman sat down and rearranged some papers on his desk. “All right,” he said at length. “Our protocol for myeloblastic leukemia involves these drugs: Daunorubicin, Thioguanine, and Cytarabine. After our workup we'll start immediately with 60 mg/m2 of Daunorubicin given IV by rapid infusion.”

As Dr. Keitzman outlined the treatment schedule, Charles's mind tortured him by recalling the potential side effects of the Daunorubicin. Michelle's fever was probably caused by an
infection due to her body's depressed ability to fight bacteria. The Daunorubicin would make that worse. And besides making her essentially defenseless for a host of bacteria and fungi, the drug would also devastate her digestive system and possibly her heart . . . besides that . . . her hair . . . God!