Sensing Light (9 page)

VII

O
N
W
EDNESDAYS
, K
EVIN HAD
a morning clinic and came to work early to look in on his hospitalized patients beforehand. Today would be Mr. Miller's fourth day in the ICU, and Kevin wasn't hopeful about his recovery. He decided to see Miller last, after checking on two ward patients who had Pneumocystis pneumonia.

One was nearing the end of treatment, able to stomach medication by mouth and being weaned from nasal oxygen. He could likely go home tomorrow. A thirty-five year old investment banker with a private doctor in Pacific Heights, he had never been to City Hospital before collapsing in his office downtown and being brought to the ER by ambulance.

The banker was staring at the wall, expressionless, when Kevin peeked into the room.

“How's it going?” said Kevin as he entered.

“How much time do I have?” asked the man in a monotone. “A few months? A year?”

Kevin sat down on the edge of the bed. He had learned by trial and error it was better to listen first, get a handle on a patient's understanding of his disease and what he feared, then discuss prognosis. But this man's replies to open-ended questions had been “I don't know” up to now. He had shown no curiosity about his condition. Kevin presumed he was reacting to his diagnosis with disbelief and numbness—it can't be happening to me. Clearly, he had moved to the next stage, depression. No, Kevin reconsidered, anger and bargaining are supposed to occur before depression.

The banker was mute, waiting for him to speak. Kevin couldn't deflect the question and maintain credibility. He had to take a stab at it.

“Maybe longer, if you're monitored closely, if we get on top of infections like this one sooner.”

“That's pathetic! You don't even know what's causing the disease, do you? All you can do is try to treat the complications of having a crippled immune system, right? And mine has already been destroyed, hasn't it? It's not going to get better, so it's just a matter of time. And not much time. And most of it spent feeling shitty, right?”

Kevin was at a loss. The banker had moved the wrong way, from depression to anger, in a blink. These stages of grief weren't as orderly as one would think from reading the literature on death and dying. And patients like this were the most difficult, the ones with penetrating, merciless intellects that turned on themselves and their physicians. The best he could do now was to apologize.

“I'm sorry…I can promise we'll do whatever we can to help you. There is research going on. We might have answers soon.”

Still refusing to look at him, the banker screamed, “
I am fucked. Fucked!
”

He lay down, covered his head with a pillow, and asked Kevin to leave.

Across the hall was a patient Kevin knew well, Danny, a fifty-two-year-old denizen of the South of Market bondage-and-discipline scene. Underneath the metal spikes and chains was a puckish, sweet-tempered man reconciled to the inevitable. Danny had been admitted the previous night with his third episode of Pneumocystis, a severe one. What little was left of his lungs was full of frothy fluid that blocked oxygen from diffusing into his blood. The pulmonologist on call had told Kevin it was futile to put him on a ventilator. Kevin hadn't argued. Danny would die in a few days no matter what they did.

He stood in the doorway watching Danny's labored breathing. Though he saw morphine dripping into Danny's vein and knew his patient wasn't conscious, Kevin couldn't help but imagine being frantic with air hunger, the desperate compulsion to expel smothering liquid inside his lungs, the clawing need to inhale more air, the inability to gratify either urge. He left the ward trying to erase the intrusive picture in his mind of an abandoned car being crushed by a metal compactor.

In the ICU, Kevin found Dana looking at a printout of Miller's blood test results. He glanced at the numbers, which indicated no further deterioration, and began lecturing her on how important it was they stay aggressive
in lowering the pressure squeezing the patient's brain. He stopped when her medical student, Gail, walked past carrying a long spinal needle.

Dana changed the subject.

“So what do you think?” she asked. “Is the culprit behind GRID a toxin, a virus, or an autoimmune disease?”

Dana had worked in an immunology laboratory between college and medical school and planned to do an oncology fellowship. Her interest in GRID had been piqued when Kevin informed her that scientists at UCLA had discovered a subset of lymphocytes called helper T cells were greatly diminished in the blood of GRID patients. This deficit was almost certainly the proximate reason for their vulnerability to opportunistic infections like Pneumocystis pneumonia or cryptococcal meningitis—infections caused by microbes unable to invade people with intact immune systems.

“I don't know,” Kevin answered. “Those are the major suspects. Most epidemiologists think some kind of virus is knocking off helper T cells. But the jury's out.”

“You're too cautious. Don't you like to speculate?”

“Not really, but you can.”

“Hey, I just thought of something. This is a chance to figure out which T cell functions are critical in preventing opportunistic infections. Cancer and transplant patients get Pneumocystis, but their immune systems are too blitzed by chemotherapy for anyone to get useful data. If an immunologist compared lymphocytes from your pre-GRID patients and those with full-blown GRID, maybe she could tease out exactly
how
T cells prevent opportunistic infections.”

“Sounds like you're describing your future fellowship research.”

“Maybe so. Thanks for the idea!”

“It's
your
idea.”

“I wouldn't have thought of it if I wasn't taking care of
your
patient.”

The irony of this conversation wasn't lost on Kevin. He'd chosen his specialty over oncology largely because infections often had definitive cures and cancer didn't. Yet, here he was attempting to treat the “gay cancer” with no effective medications other than short term fixes for the opportunistic infections that complicated the syndrome. He was constantly dealing with death and dying. Now he'd inspired the career of a future oncologist.

VIII

H
ERB WAS IN
G
OLDEN
Gate Park at dawn on Wednesday, jogging under a cotton ceiling of fog. He loved this type of sky, the range of hues—off-white, pearl, cinder, gunmetal, silver, slate—and the bracing clarity, nothing bleached by direct sunlight or hidden by glare. The fog also made it cool enough to run comfortably in a polypropylene shirt that wicked away the sweat. After two miles, he had passed through the stiffness, burning in his sternum, and cramping in his side. It was effortless now. He was being carried by the rhythm of running, the cadence of his pace and breathing in four-four time. Soon there would be an exhilarating taste in the back of his throat, like glacial water with a pinch of gunpowder. He could sustain this pace for an hour, a slower one for two or three, before lactic acid accumulating in his muscles finally undid him in a surge of nausea and exhaustion.

Herb began running seriously as a fifth grader, motivated by his father's enthusiasm for the upcoming 1948 Summer Olympics, the first to be held since the 1936 games in Berlin. Like all United Nations staff, his father viewed renewal of the Olympics as a perfect metaphor for the fledgling organization—an amicable competition that all countries could participate in equally and peacefully.

Herb was the fastest boy in his elementary school and fantasized about track-and-field record holders. His favorite athlete was Jesse Owens, the black American who had won four gold medals in 1936. Looking in a full-length mirror, Herb focused on his long, muscular legs instead of his eyelids, which made him the butt of classmates' jokes. What if he trained to be the fastest boy in his town, Herb wondered, or the whole of Long Island? Who would dare tease him then?

He wheedled his mother into driving around the neighborhood while he studied the odometer and a street map until settling on the best course. He
started jogging every other day, adding a kilometer to his distance each week. As soon as he could run ten kilometers without stopping to catch his breath, he ratcheted the effort up, and his times came down. He read about training regimens at the library. He searched local newspapers for reports of high school track meets and went to several, making notes on the runners' form and clocking their speeds.

Once the Olympics began, Herb rode a bus each afternoon to UN headquarters where he watched newsreels of the day's highlights with his father. They had good-natured arguments over which countries would win. Herb had more conversation with him in those two weeks than the entire rest of his childhood.

Herb was fascinated by Emil Zatopek, the Czech who broke the world record for ten kilometers, running it in under thirty minutes—a superhuman feat to a boy who couldn't cover the distance in less than an hour. The agony on Zatopek's face in finish-line phsotos convinced Herb that anyone capable of enduring great pain could be a winner in life. He vowed to emulate his hero's example.

The following summer, he trained for a one-mile race in a countywide competition. The day before the event, his father called from the UN. There was an international crisis. He couldn't leave.

His mother drove him to the Nassau county fairgrounds. Surrounded by dense forest in full leaf, they milled awkwardly among the young athletes and proud parents—all white. Herb's race was the last. Their wait was interminable. He kept expecting to hear a disparaging comment, but every glance in their direction was politely tolerant. Herb's mile was over in six minutes. He came in second and was satisfied. This was no village contest, he explained to his mother. It represented half the population of Long Island.

Afterwards, they went to an exhibition hall. Each boy who had won or placed in a dash, jump, or throw was escorted to the stage by his father and received a medal. The mile awards were given at the end of the ceremony. Herb's mother leapt up when his name was called. He glared at her, shaking his head no, and walked to the stage alone.

Herb was in the ICU by nine, seated at a small conference table, ready for the interns to present their new admissions. He raised his baton, a ballpoint pen wrapped in black electrical tape to conceal the pharmaceutical company logo. The first act opened—a tale of an elderly emphysematous man brought to the ER in respiratory distress. Herb listened carefully, taking notes as the drama unfolded. He enjoyed the house staff, their alternating banter and solemnity. It still surprised him when they appreciated the constructive feedback he could provide.

Next, he had consultation rounds with his new fellow, Harry Simpson, and Gwen. Harry had earned a PhD in physiology during medical school and planned a laboratory-based career in academic medicine. Herb had heard from pulmonologists at the other university-affiliated hospitals that Harry was bright, knowledgeable, and reasonably competent as a clinician. Once Harry started his rotation at City Hospital, Herb learned something else about his new fellow. Harry was terrified by GRID.

Ward residents and attending physicians complained that Harry tried to talk them out of requesting consults on GRID patients. Those Harry couldn't brush off, he assigned Gwen to evaluate. He called in sick both times GRID cases were scheduled for bronchoscopy.

“Bronchoscopy entails minimal exposure to blood,” Herb pointed out to him. “Plus, you're wearing a protective gown, a mask, gloves, and goggles.”

Herb showed his fellow epidemiologic papers as evidence there was no risk from such contact. Though Harry claimed to concur, his behavior didn't change. More disappointed than outraged, Herb was counting the days until Harry's month at City Hospital would be over.

Herb, Harry, and Gwen began at the bedside of a young man just admitted with severe abdominal pain. Exploratory surgery was being considered. Because he had two prior episodes of Pneumocystis pneumonia, the surgical team wanted advice from a pulmonary consultant before operating. Harry's pallid complexion whitened a shade as they entered the room.

While Herb was listening to the patient's lungs, a group of scrub-clad residents and students came in, led by their attending surgeon, Jared Hart. The descendant of three generations of Montana ranchers, Hart was a
remarkable character even by City Hospital standards. Five feet, two inches tall, with a huge handlebar mustache, he had a basso voice, swore liberally, kept the pocket of his long, white coat full of Havana cigars, and occasionally addressed female students and interns by their chest circumference and breast cup size rather than their name. Herb stepped aside, yielding access to the surgeon.

Hart pressed the back of his ungloved hand against the delirious young man's wet forehead.

Holding up one finger and flicking off a drop of sweat, he announced, “Fever!”

He dug his heel of his palm into the patient's abdomen. The man flinched. Hart abruptly pulled his hand back. The patient howled in agony from the ripping sensation this maneuver induced.

Holding up two fingers, Hart said, “Right lower quadrant
rebound
tenderness!”

He snatched the chart from an intern and thumbed through the pages with a flourish to the laboratory results section.

“Leukocytosis!” he shouted and held up three fingers. “His white count is 18,000. That's three out of three criteria for appendicitis. We'll operate today.”

All of Hart's coterie, as well as Harry and Gwen, stood wide-eyed and silent. Herb had seen this performance before and wasn't impressed.

“Any objections, Dr. Wu?”

“He won't survive without surgery, Jared. Please proceed. Just keep the ventilator pressures on the low side so the blebs I saw on his chest film don't rupture.”

“But, Dr. Hart,” objected a resident. “Is it safe for us to operate? We heard a lecture by Dr. Bartholomew, and he said these patients' immune deficiency might be transmitted by contact with their blood.”

Hart eyed him coldly and said, “We're surgeons, Dr. Bryan. We take those risks. We might experience fear, but we aren't influenced by it. A resident I trained with contracted hepatitis B from an accidental scalpel wound. He died of cirrhosis. In Vietnam, two of my colleagues were blown to smithereens in an operating theater ten yards away from mine.”

With a sneer, Hart delivered the coup de grâce.

“It's an occupational hazard, Dr. Bryan. If it makes you uncomfortable, find another job.”

Hart marched out of the room. His team docilely followed.

Herb had never heard this soliloquy and rather liked it, though he suspected its veracity. Given his height, had Hart really been inducted into the military? Herb turned to share the question but checked himself on seeing Harry's crimson cheeks and ears. Better to save it for later, he decided, when he and Gwen would be alone.

In the afternoon, Harry went to a seminar, and Gwen helped Herb with bronchoscopies. Their first patient was a scrawny, wrinkled man who had smoked a pack of cigarettes a day for fifty years. A week ago, his doctor ordered a routine chest x-ray that revealed a spot the size of quarter in his right lung.

The man's pupils dilated when Gwen rolled a gurney into his room. The fear he exuded didn't abate until she gave him an intravenous sedative in the bronchoscopy suite. Now he was in a dopey, half-sleep state.

While Herb advanced the bronchoscope, Gwen looked through a second eyepiece. She could see images from the tip of the fiberoptic cable as it snaked past the vocal cords and headed south along the trachea, past glistening pink mucosa stained with nicotine. Herb made a sharp turn into the right mainstem bronchus and came to a sudden halt in front of a fungating mass that blocked any further passage. Gwen cringed. It was the coin lesion on the x-ray, magnified to the size of a boulder.

She held the bronchoscope as he manipulated a sheathed wire running alongside the cable and connected at the tip to a tiny forceps. Before the procedure, Herb had showed her how squeezing the trigger at his end of the wire closed the sharp metal teeth at the other end. Through the lens, she watched the instrument bite off a piece of tumor.

“Ugh,” she cried and immediately regretted her outburst.

She whispered an apology.

“Don't worry,” said Herb. “He's too deep to remember any of this.”

“Poor guy.”

“It is what it is.”

To Gwen, his comment didn't sound callous. She heard simultaneous sympathy, philosophical detachment, and sadness. An ideal attitude, she thought. After working with Herb for three weeks, she was in awe of how centered he was, always balanced between objectivity and empathy. Gwen wished she could do that. She had contemplated asking him to teach her how, though it was inconceivable making such a request wouldn't embarrass both of them. He was handsome, too. She momentarily wondered why she hadn't married someone like him instead of Daniel. Instantly, she knew the answer. It would be intimidating to live with anyone so perfect.

The forceps bit off two more pieces of the tumor, and Herb retracted it into the sheath. Gwen set the bronchoscope down, donned latex gloves, and opened a vial of formalin. Herb withdrew the wire. When the forceps appeared, Gwen grabbed the stainless steel pincers and placed it in the formalin. Herb released the trigger. They watched, neither commenting, as shreds of malignant tissue floated to the bottom of the vial.

Gwen rolled the patient back to the wards. She finished gathering information on two new consults, then met up with Herb in his office where she presented the new cases. Herb took note of how efficient, thorough, and concise she was. It made listening to her presentations a pleasure, and it spoke volumes to him about her character. He had observed that those who went into medicine solely for prestige or money tended to invest little energy in being accurate or to the point.

He also enjoyed her sense of humor. Gwen was the kind of resident he wanted his division to recruit into its fellowship program. However, she clearly wasn't excited enough by procedures to become a pulmonologist. Perhaps an infectious diseases fellowship, he mused. Not that it mattered because Kevin would have to expand his GRID clinic soon, within a year at most, and his affection for Gwen was transparent. He was certain Kevin would find a position for her.

The two new consults were a routine exacerbation of emphysema and a rare autoimmune lung disease. After discussing the cases, Gwen had a question about the man they had biopsied earlier.

“What do you think his prognosis is?”

“Based on the big mediastinal lymph nodes we saw on his chest film, it has to be bleak.”

“It could still be small cell, couldn't it? Then chemo would be an option, even with metastases, right?”

“True, which is why we had to get tissue. But a small, asymptomatic tumor like this; odds are less than one in five a small cell lung cancer would present that way.”

“Based on the literature or your own experience?”

“Both.”

He opened a drawer of photocopied articles and handed her one.

“Here's a large series. I've seen the same thing here. We get a case or two a month. Nearly all the small, asymptomatic tumors are squamous cell carcinomas. And as you well know, once they've metastasized, school's out.”

Gwen considered the implications of regularly giving this news to people for whom chemotherapy couldn't help, having to tell each one he had at most a year or two to live.

“Herb, does telling these patients their diagnosis depress you?”

She's definitely not going into pulmonology, he thought. She might not join Kevin either.

“It makes me sad for them, but not depressed.”

Been there done that, he thought.

“The sadness doesn't stay with you, doesn't bleed into the rest of your life?”

“Not anymore.”

“That's a neat trick,” sighed Gwen. “I need to learn how to do it.”

“You're a quick study. Stick around. It won't take you long.”