Sensing Light (7 page)

II

D
ANA
P
EARLSTEIN, A PETITE
junior resident, pushed a somnolent man on a gurney toward the only unoccupied bed in City Hospital's intensive care unit. Dana had two months of experience leading a medicine team and was twenty-six hours into her on-call shift. Her impeccable make-up remained intact, but her confidence, appropriately tenuous at this point in her training, was waning, especially with her last admission. She'd heard rumors the patient had a lot of clout in local politics, and he was gravely ill.

Once Dana saw Kevin enter the ICU, her hunched-up shoulders relaxed. Kevin looked at the toothpaste-advertisement smile she gave him, the thin man asleep on the gurney, the familiar intravenous solutions, portable cardiac monitor, and oxygen tank, then back to Dana's smile. He calmed down.

As Dana was handing admission orders to an ICU clerk, Kevin grabbed her stethoscope and took over wheeling the patient to his room. He signaled Dana that he would return in a moment. Kevin noticed a scaly rash on the man's forehead, a severe type of dandruff common in Gay-Related Immune Deficiency, and the hollow shape of his temples, a sign of muscle wasting. The man didn't react to Kevin's calling out his name.

“Mr. Miller,” Kevin said shaking him gently, “Are you OK?”

“I don't know,” the patient mumbled.

Further questioning revealed he was disoriented to place and time. Kevin listened to his heart and lungs, felt his abdomen, flexed his neck, and used a tongue blade and penlight to look inside his mouth. In addition to the patient's confusion, there was another abnormality. A white layer, like thinly spread cottage cheese, covered the roof of his mouth.

Kevin sat down at the ICU conference table with Dana and her medical student, and she launched into her case presentation—an account of Mr. Miller's symptoms and history, her physical exam findings, the laboratory
and x-ray results, and finally her formulation of a differential diagnosis and plan of action.

“Mr. Miller is a forty-two year old white male with no prior hospitalizations or chronic diseases. He works as an assistant to the mayor of San Francisco and lives alone in the Marina.”

Dana arched her eyes in feigned surprise. City Hospital patients rarely came from this upscale neighborhood.

According to a friend who discovered Mr. Miller yesterday on the kitchen floor of his apartment, he had been well until a week ago when he began complaining of fatigue and headache. Then he stopped coming to the office or answering his phone. Per the friend, Miller was gay. He didn't use drugs or frequent bathhouses.

Dana's physical exam findings were identical to Kevin's. The blood test results were unremarkable except for anemia and an extremely low lymphocyte count. Dana's intern had done a spinal tap which showed no white blood cells to suggest meningitis or red blood cells to suggest a brain hemorrhage.

Kevin was pleased by Dana's presentation—fluent, precise, thorough yet succinct enough to communicate in less than five minutes all the elements he required in deciding what to do next. She had clearly mastered one important skill for leading an inpatient medicine team. She could sift through massive amounts of information, discard the dross, and communicate the essential data in the minimum time necessary without sounding manic.

“I think the white stuff in his mouth is thrush,” Dana concluded. “That and his low lymphocyte count fit with GRID.”

“What's thrush? What's GRID?” asked the student, a frumpy young woman who wore thick-lens glasses.

“Thrush is like athlete's foot but in the mouth,” said Dana. “It's a superficial fungal infection caused by Candida. And GRID is Gay-Related Immune Deficiency.”

Turning to Kevin, she added, “Here's the expert.”

“That's OK,” he said deferentially. “Let's hear you explain it.”

Dana eagerly accepted the challenge. She talked about the clusters of gay men in New York, Los Angeles, and San Francisco recently diagnosed with a rare form of skin cancer, Kaposi's sarcoma, or Pneumocystis pneumonia.
All had been previously healthy. Since Pneumocystis only caused disease in people with profoundly impaired immune systems, the syndrome had been named Gay-Related Immune Deficiency. A preliminary investigation by the Centers for Disease Control identified two common denominators among GRID patients—past gonorrhea and syphilis infections and a lifetime history of hundreds of sexual partners.

Dana looked to Kevin. He nodded with approval.

“Kevin has seen, what, ten Pneumocystis cases here?”

He nodded, less enthusiastically.

“And in his clinic he's seeing lots of gay men who have enlarged lymph nodes and thrush. A couple of them have gone on to develop Kaposi's or Pneumocystis.”

“Have you biopsied their lymph nodes?” asked the student.

Noting the name on her ID badge, he answered, “Good question, Gail. We did, at first. But the results have been negative—no underlying infection or malignancy.”

Dana chimed in, “Kevin just gave grand rounds. Didn't you say the number of new patients coming to City Hospital with the pre-GRID lymph node syndrome has doubled in the last four months?”

He nodded somberly.

Gail frowned as she considered the implications of that fact.

Returning to the case at hand, Kevin said, “The low lymphocyte count is a good pick-up, Dana. And that's definitely thrush in his mouth. So he's got pre-GRID, if not GRID itself. But why's he confused and barely arousable? What's wrong with his brain?”

“He could be septic. He has a temperature of a hundred and two. Blood cultures are cooking. I already started him on broad-spectrum antibiotics.”

“That's good. No downside to covering him for sepsis. But why would he have bacteria in his blood?”

“I don't know. His spinal fluid showed no cells, so it's not meningitis. The chest x-ray and brain scan are clear.”

“You sure it's not meningitis? What about cryptococcal meningitis? That's a GRID-related infection, and the patients can't mount an inflammatory
response when the fungus invades their brain. So, typically, we
don't
see cells in the spinal fluid.”

Dana flushed and left to find a telephone. While she dialed the laboratory, Kevin explained the test she was requesting to Gail.

“India ink stain. Very low-tech assay. A fourth grader could do it. The lab will put a drop of Miller's spinal fluid on a slide, then add a drop of India ink. Cryptococcus has a capsule that can't absorb the ink. If the bug is there, they'll see white dots on a black background. Which reminds me, Dana, when you tapped Miller, what was his opening pressure?”

“Sorry,” said Dana, now mortified, “We were in a rush to get samples to the lab. I forgot to measure the pressure.”

“
I
was watching the pressure.” Gail interjected. “When the intern got the needle in, spinal fluid rose up the manometer so fast it would have spilled over the top if he hadn't opened the valve to fill specimen tubes in time.”

“Good observation skills, Gail.” Kevin said. “That's exactly what we need to know. So Miller
does
have elevated intracranial pressure. If the India ink is positive, he'll need repeated spinal taps, every twelve hours, to lower the pressure on his brain. Done a tap before, Gail?”

“No,” she replied timidly.

“This is your chance. If you just saw a lumbar puncture, then you're ready to do one.”

Gail beamed.

The phone rang. Kevin picked it up and listened for a moment.

“It's Cryptococcus,” he announced.

Dana hurried out, Gail in tow, to write orders for an antifungal medication and gather equipment for another spinal tap.

III

K
EVIN RETURNED TO
M
ILLER
'
S
room and was surprised to find Gwen at the bedside making notes on a clipboard.

“Hey, how come you're here?”

“I just started a pulmonary elective. It's the fellow's day off, so I'm pre-rounding before the attending comes in. Herb paged me and said I should see Miller. But he doesn't have any respiratory issues. I don't get why we're consulting. What's up?”

Kevin couldn't enlighten her, and it troubled him that Herb had already heard about the case. He was certain Dana wouldn't have asked for a pulmonary consult, which meant someone higher up in the hospital chain of command must have contacted Herb. He deflected her question.

“What do you think is going on with him?”

“He has GRID, that's for sure. I'm guessing some kind of opportunistic infection, too.”

“You're right. It's cryptococcal meningitis. How do you know for sure he has GRID?”

Gwen bent Miller's left ear forward, revealing a small purplish nodule.

“And there's more,” she added, rolling the patient on his side and pointing at a tiny, similar lesion on Miller's back, hidden in a skin fold.

“Wow! Good pick-up.”

“You're a good teacher.”

“Maybe, but you seem to be better at putting knowledge into practice than me.”

“That's not true. Doing a thorough skin exam is a spinal cord reflex for me from all those years in the Haight Street clinic hunting for signs of secondary syphilis.”

“Yeah, right,” he said dryly. “I'm sure no higher cortical function is involved.”

Unable to dodge the compliment, she grinned.

Trifecta, he thought, happy with himself for provoking her amusement, pride, and affection, all with one remark.

When Gwen began her residency, Kevin was still in his fellowship, toiling in Flagler's laboratory to make sense out of how the mouse immune system responded to bacterial infection. During her first rotation at City Hospital, he was glad to show her the ropes on the medical wards. It was an excuse to escape from what was becoming tedium. Once he appreciated how at ease she was with herself and others, he sought opportunities to be with her, hoping it might rub off on him. She took the next step, suggesting they double-date. Their respective boyfriends, Marco and Rick, found each other kindred spirits and poked gentle fun at the two more reserved doctors. The evening was a wild success.

“How are things at home?” asked Gwen.

“OK. Better, actually. You?”

“Good enough.”

“Good enough?”

“Maybe they could be better. I shouldn't complain. So what happened with you two? You'd been fighting a lot.”

“I don't know…”

She waited.

“OK,” he confessed. “We decided to get some relationship advice from friends, an older gay couple who've been together for years. Now we're working at not letting conflicts stew. They call it ‘immediate decompression of tension.'”

“Kevin, that sounds like New Age psychobabble. I can't picture you and Marco constantly talking about your feelings.”

“Hardly. Come on, you know what I mean. Don't you?”

“Not really. Have you guys figured out how to avoid getting annoyed with each other?”

“No, we're just taking it less seriously when it happens. It usually means one of us either needs more freedom or wants more reassurance he's loved. And if the other can accept that without being threatened by it, the tension defuses.”

Gwen stared at him, her mouth open.

“That's an astonishing insight for…”

“For what?”

“Umm…”

Kevin grinned slyly.

“You were going to say a man, weren't you? An astonishing insight for a man. Oh my God, Gwen! I am so disappointed. You are the last person I would have suspected of such blatant sexism. I guess it just goes to show how ingrained the prejudice men have to deal with is. In fact, you're a textbook demonstration of why we're so oppressed. It's terrible that mothers still pass on such garbage to their daughters. Even someone as enlightened as you can't shed the bigotry.”

“Stop,” Gwen giggled. “I was going to say ‘a person of your age.'”

Kevin shook his head no.

“After I said ‘a man,'” Gwen admitted, “I was going to say ‘and a person of your age, but...'”

“Gotcha,” Kevin exulted, pecking victoriously at her with his index fingers.

“Stop,” she laughed. “You're very lucky. Do you know that?”

“What do you mean?”

“I don't have that kind of openness with Rick. I tell him what I'm feeling, but he's the ‘still-waters-run-deep' type. And I'm never sure how deep they are or where they're running.”

“Rick? He seems pretty extroverted to me.”

“Now you're being dense, Kevin. I'm talking about what he says to me when he's pissed off.”

“What does he say?”

“Nothing.”

“And you know he's pissed because…?”

“That's the point. Sometimes I don't know whether he's angry or not, and he won't admit to it. I know he's no saint. You should hear what he says about the demanding parents at his school. They can push his buttons.”

“I can't believe you're all that difficult to live with.”

“I'm not perfect.”

“Maybe he doesn't expect perfect. Maybe you're good enough. Maybe he doesn't have anything to complain about.”

“Kevin, that's too good to be true.”

“Is it?”

“Oh, my goodness. You're more romantic than I thought.”

Kevin suddenly noticed Herb at the nurses' station and waved at him.

“Thanks for coming by,” said Kevin.

He stifled the impulse to ask why Herb was consulting on the case.

“Sorry to step on your toes, but this is a command performance,” said Herb. “The mayor's office called Ray at home an hour ago, and he paged me.”

“The mayor called the chief of medicine at home?”

“Mr. Miller's ‘an important member of her team.' I gather it's not so much his job in public housing as his role as a political advisor. She is
very
concerned he gets the best possible care here.”

Kevin frowned.

“You, my friend, have nothing to worry about. I heard you already made the diagnosis by telepathy.”

Gwen clapped. Kevin forced a weak smile.

“Look, Kevin, this is a great opportunity for us. The mayor will find out first hand what the reality of this epidemic is. She'll get how serious a problem it's going to be for San Francisco. She'll understand our commitment to caring for these people and what we need to be able to do it adequately. Department of Public Health money is our lifeline, and the DPH director reports directly to her.”

“Yeah,” said Kevin, now almost as uneasy about Herb's involvement as the mayor's.

After Larry Winton died, Herb had urged Kevin to get specialized training in infectious diseases. He didn't push Kevin to become a pulmonary specialist yet clearly wanted him to stay at City Hospital. As more cases of GRID were diagnosed during Kevin's fellowship, Herb encouraged him to develop ideas for GRID-related research and offered advice. But Flagler wanted Kevin at the bench, working with microbes and mice. That effort culminated in Kevin
submitting a funding proposal to the National Institutes of Health which was summarily NERF'd—not even recommended for further consideration.

Flagler had no intention of keeping Kevin in his division, but two weeks before the fellowship was to end, the chief of medicine at City Hospital drummed up salary support for a physician to manage the care of the hospital's increasing volume of GRID and pre-GRID patients. Kevin took the position, which came with a university faculty appointment in the department of medicine. Herb renewed his encouragement, suggesting Kevin investigate what was causing GRID and what factors predicted how long patients survived. Kevin wondered if Herb had somehow influenced the chief's decision to hire him, though he couldn't grasp why Herb thought he would be successful in clinical research after his failure in the lab.

Kevin led Herb into Miller's room where they found him unresponsive to shouting, shaking, or Herb's grinding his knuckles on the patient's sternum.

“That's it.” Herb said. “We need to intubate and hyperventilate him. The house staff can do another tap after we're done.”

Kevin concurred, and Gwen collected the equipment to pass a plastic tube down Miller's windpipe. As Herb was setting ventilator dials, a man with a thick mane of gray hair appeared. He wore an Armani suit and a blue power tie.

“I'm Tom Redding from the mayor's office. She's on a trade mission in Mexico. Otherwise, she'd be here. How's Michael?”

Kevin froze, so Herb took over.

“I'm Herb Wu, in charge of the ICU today. This is Dr. Bartholomew, our expert in immune deficiency diseases.”

“Michael has the gay cancer? Is he going to die?”

Mastering his timidity, Kevin said, “Mr. Miller has a fungus infection in his brain. He's in a coma. I don't want to be rude, but we have to put him on a breathing machine and drain out spinal fluid right away.”

Redding, horrified, stepped back.

“I didn't mean to interrupt. I'm just. ..devastated.”

“No need for apology. Please understand we're doing everything we can to control the infection and prevent permanent brain damage.”

Eyes welling with tears, Redding stuttered, “How can…How can this be happening to
him
? He's brilliant, unselfish. He doesn't deserve this.”

Over the next two hours, Mr. Miller was stabilized. Dana helped Gail pass a needle into his spinal canal and remove enough fluid to normalize his pressure for the moment. But Miller remained comatose. By one o'clock, there was nothing else they could do except hope the antifungal drug would work. Kevin and Herb left the ICU together.

“Wednesday afternoon at four-thirty?” said Herb at the hospital entrance.

“I'll be there. The protocol's almost finished. I'll bring the latest version.”

“Outstanding!”

Looking at the ground, Kevin formulated a delicate question.

“Herb?” he asked, glancing up.

Herb was already halfway across the street. As Kevin watched Herb walk to the parking lot, he thought of their discussion last summer, just after he'd been hired as City Hospital's immune deficiency specialist. Herb was pressing him to write a protocol outline, and Kevin had probed Herb's motivation.

“So, why are you so interested in Pneumocystis?”

“It's a mysterious pathogen. No one can grow it
in vitro
. There are no good animal models for understanding how it causes pneumonia
.
Treatment outcomes are unpredictable.”

Kevin gazed at him for an impertinently long time.

Herb sighed and conceded, “Guess I'm drawn to diseases that are fatal to young people. Like leukemia when I was at NIH. Moth to the flame maybe...”

The next day, Kevin agreed to take on the project.