Twelve Patients: Life and Death at Bellevue Hospital (10 page)

I stayed in my office for some time after walking Lila and Enrique to the elevator bank. It was my job to tell Tani what had happened. First I took down some pictures and hung up her Chagallesque flying animals. I put her black journal under my arm and walked toward the express elevators to the twenty-first floor.

Frank Sinatra was not what I felt like hearing. His
Greatest Hits
album filtered through the jet-engine noise of the Varian linear accelerator at nine o’clock on a sunny Monday morning, October 13. I preferred Steely Dan and made a note to bring
Aja
or “Black Friday” the next morning. A middle-aged Latino radiation technician, who had converted from merengue to mild-mannered U.S. love songs, hit the Play button. He wasn’t just my deejay. He was also my radiation therapist, and he had bolted my head onto the hard metal gantry that would slide first upward and then backward into an overhead arc, sending high-energy electrons into my head and neck.

The black formfitted mask covering my face was a plastic rectangular grid that had been heat-melted onto my profile two weeks earlier. My name was printed in black Magic Marker on the outside silver metal frame, “MANHEIMER, E.” It was mine and only mine. It sat on a shelf with dozens of others, like fencing masks at a Midtown sports club, waiting for their owners to claim them. I was about to receive my first radiation treatment for throat cancer. That afternoon, I would start my first round of chemotherapy. It was happening. And I was stunned, in shock, and exhausted.

Alexei, my older child, had called the night before to tell Diana and me that his wife, Gladys, was in labor. Even though it was the night before my first cancer treatment, Diana and I got in the car and drove to the hospital. We pulled into the empty south parking lot at Bellevue around ten p.m. I showed my ID to the guard in front of the main elevator banks, and he waved us through. Alexei and our daughter,
Marina, were anxiously waiting in the hall of the maternity ward for us and for the new arrival as the stages of labor progressed.

Gladys was smiling, though clearly in pain. We held her hands. Esther, Gladys’s mother, had come up from Washington, DC. The nurses on the floor were helpful and very pleased to see me. They were happy that my family was delivering at the city hospital where they worked and received their own care. The fact that Gladys was from Douala, the mercantile city of Cameroon in Francophone West Africa, made it even sweeter. The many Haitians among the nurses switched from their native patois to upscale French. We were now part of a larger diasporic family of displaced persons. On the delivery floor where babies were born, the precise details didn’t matter.

For Diana the long-awaited day of the baby’s birth would have been perfect… had it come at a better time. The waiting grew intolerable. At one in the morning, I told Diana I had to go home. My first treatment, a few hours away, consumed my thoughts. We said good-bye, Diana grudgingly but understanding, me impatient to be gone. The fluorescent lights and incessant beeping of the labor and delivery areas were making me nauseous. Our kids pretended to be okay with our heading home and promised to call as soon as the baby was born.

Bolted to the table, willing myself to keep my eyes open, I thought about what had happened to me. How had I gone from being a doctor to patient in just a few weeks? A month earlier, I was in Morelos, Mexico. Diana and I were at the end of a late-summer vacation. This was rainy season in central Mexico: biblical late-afternoon downpours and hour-long lightning displays that would take out our neighborhood transformer and with it our electricity for several days. Rolling thunder ricocheted between the craggy vertical cliffs of the Tepozteco. Eagles and hawks drifted in the updraft. We had come to Tepoztlán over many years revisiting Diana’s deep childhood roots. We made this stretch of ten-thousand-foot mountains and volcanoes our parallel universe. At our house, the shadows danced, the water streamed off the roof. I sat on the terrace wrapped in a sweatshirt and baseball cap. As summer drew to a close, I knew there was something wrong with my throat.

I returned to work after Labor Day and was immediately drawn into the dramas and emergencies that populated the round-the-clock routine of a big-city hospital. We had two patients in our emergency ward who had been declared brain-dead, and the families were making decisions about organ donation. Our ICU was full, and cardiac surgery transfers were being delayed. A stream of department chiefs wanted to meet and walk down the F-Link at lunchtime to the café where I always did a “business lunch.”

By September, I had a swollen yet discrete lymph node in my right neck. I outlined the node gently with the pads of my fingertips. It was soft and unattached to any surrounding muscles or tendons, or to the thyroid gland. I looked at the node in the mirror. It looked back at me, round, smooth, two centimeters in diameter, feigning innocence. That evening I went through my mail. A fresh copy of the
New England Journal of Medicine
came with the stack. A “State of the Art” review article on “Head and Neck Cancer” was listed in bold black type halfway down the cover page. My diagnosis was in hand courtesy of the U.S. Postal Service. I sat by myself in the living room and by the ebbing northern light read through the article line by line.

Unconsciously, I shifted gears. Splitting my personality neatly in half, like the hemispheres of my brain, I buried myself in technical jargon and Kaplan-Meier survival curves. Like my Russian and Romanian ancestral burial grounds, I had an apparently infinite cellar in my head that teemed with childhood demons, maternal warnings about the inevitable next pogrom, warnings issued before I could walk; and with demons from a medical career, dead patients who were more alive in their graves than they ever were in life.

The raspiness and voice fatigue sent off an insistent internal buzz. I ran through the range of diagnostic possibilities and came up empty.

Except for cancer.

It never occurred to me to ask
Why me?
There was no anger and no regret. It was a fact of life. I knew the details—up to a certain point—of what had to happen next: I had to get started on therapy, and quickly, to prevent progression of the disease and to prevent the abyss of anxiety that lay beneath my conscious awareness from
overwhelming my family. I knew what I didn’t know. The extent of the hole I was going to enter was uncertain. No one could lead me there or prepare me for that part of the journey to come. I would have to go there mentally alone.

As a physician, I knew all too well that a delayed diagnosis would allow the tumor stage, size, and metastatic status to change—and each bit of growth would drop my survival rate by 25 percentage points like a plunge in the stock market. I had seen it happen for breast, lung, ovarian, melanoma, and other cancers. Ordinary symptoms, a negative exam, a reassuring comment, a trial of medications, a pat on the back, and delayed follow-up equaled a recipe for disaster for many patients. I didn’t consider my diligence luck. I have a suspicious nature.

The biopsies were simple and painless. Guided by ultrasound, the needle found the liquid center of the node, and the blood-tinged fluid was hurried off to the pathology lab. My doctors’ faces were expressionless, the waiting room full of anxious couples. The secretary wanted to update my insurance information. I walked out plotting the next steps while shifting into autopilot.

I stopped at the East Bay diner on the way back to Bellevue to deliberately linger in solitude in the few minutes I had before the diagnosis was official. Like a guilty man waiting for the deliberating jury’s verdict, I had a finite period before hearing my sentence. Before my colleagues in pathology peered into their microscopes and found the traitorous cells with a Rorschach nucleus of inkblot mitotic spindles in disarray. Before the ICD-9 official diagnostic codes entered the computer system. Through the large windows fronting First Avenue the red-brick men’s shelter, Bellevue’s former psychiatric hospital, sat in moldering decay, littered with garbage, water stains resembling stalactites hanging from the window edges. Ageless bearded black men with long dreadlocks loitered on the corner bumming cigarettes. Their grocery carts overflowed with scavenged high-tech backpacks and bulging transparent plastic garbage bags. The collected detritus of New York City’s excrescence of garbage oozed from its pores, piled in front of the condos and co-ops in Kips Bay.

It was comfortable inside, familiar waiters, the owner chatting
behind the register, a buzz of conversation. I sat sipping coffee by myself, brooding over where I was heading and what would follow. The diner filled up with hospital staff in their multicolored uniforms, a brief pause from the Brownian motion of the eight-hundred-bed hospital a block away.

My cell phone vibrated on my belt. I didn’t recognize the number. When I answered, Dr. Kepal Patel came on the line. He told me the biopsy had come back. I had cancer. Squamous cell carcinoma. We talked for less than one minute. I called Diana, who answered before one ring. She knew what was coming—the diagnosis, that is. But not what was coming over the next year. That was unknowable. Very quickly, I had to tell my family, friends, and colleagues. Autopilot was where I would live for the next three weeks, until the therapy began.

The walk from the diner to my office can take five minutes or an hour depending on whether I take the long loop around the Bellevue campus—not to mention greeting everyone I see and performing the small negotiations and acknowledgments that are at the heart of the small city that is this public hospital. Today I took the long loop, down First Avenue, past the nursing school and the emergency vehicles strewn out on the access road. I had been through many conversations with patients and their families about death and dying. Now I would be having a variation of that conversation with myself. I had lived through the Kübler-Ross fiction about the stages of death, defining for several generations a reality where there were often not stages, just a Munchian scream. The idea of “the good death” had been attractive and provided a lodestar for my own behavior toward my patients. But finally, as Montaigne said, it was useless to “worry about death, it will take care of itself. Worry about life, that needs management.”

I had thought of death often. I had read about it and dreamed about it. My greatest fears were Holocaust survivor fantasies that tormented me and my family, and had been handed down directly to my daughter. Marina’s identification with her chosen tribe went back to the destruction of the Second Temple and the replays of diasporas upon diasporas. “Countries don’t love you,” my mother had warned. “Collect passports, you never know when you may need them,” she added
as a practical note. Her worldview included death, dying, killing, and being both the hunted and the hunter. My way of dealing with the stress of mortality on a daily basis was to bury it for another day. If it wasn’t exactly the elephant in the room, then it was a smell somewhere in the basement that wouldn’t go away.

I believed that everyone feared death. That mortality petrified everyone. That very few would go gently into the night. And that those who did had reached a state of radical acceptance or had their souls stolen by their disease—the one gratuitous positive thing a terminal illness might offer. The soul would be kidnapped slowly, allowing the disease its final victory lap. Now, as I walked the long way around, I was scared shitless. But I had my methodology: I would focus on the here and now. Tasks that had to be completed. Lists to be made and checked off. Supplies to be purchased, people to be notified. My soul would have to wait for another day.

Secured to the radiation table, replaying the events that had brought me here, I became hyper-alert to everything that went on around me, despite the din from the radiation machine. Music is my drug of choice, and my body was rejecting Ol’ Blue Eyes. Dominican
bachata
was my anti-depressant.
Vallenato
from Colombia an intravenous hit of an amphetamine stimulant. Bach meditation in the lotus position. Piazzolla’s jazzy tango journeys to the pleasure of longing and short-circuited desire. Qawwali Sufi chants by Nusrat Ali Khan hypnotically induced trances that erased consciousness. Dylan, of course, aspirin and penicillin, the all-purpose poly-pill appetizer, dessert, or main course. Time ticked by slowly. Trifling delays were magnified. Idle chitchat among the staff about girlfriends and last night’s baseball game annoyed me.

Squamous cell carcinoma, SCC, was well known to me from decades of contact with patients. It would not have been my first choice at the Bureau of Tumor Assignments; nor would I have guessed it in a million years for me, as it usually showed up in heavy smokers and drinkers.
I am fucked
is the first thought that crossed my mind. The SCC had lodged in my buccal mucosa. My entire aerodigestive tract was vulnerable: trachea, esophagus, the whole works. “Cancerization,” Nick, the
head and neck specialist, had called this as he explained the radiation treatment designed to attack the entire area. That was a new word for me. So it wasn’t
Why me
, but
Why this particular disease?
I could have been sipping aged tequila or hundred-dollar-a-bottle single-malt Scotch and drawing in deeply on fragrant Cuban cigars for the last thirty years while looking at the snow-covered volcano Popocatépetl from the terrace in Tepoztlán. At least then there would have been a reason.

Squamous cells were common skin cells or lining cells of the mouth or reproductive organs whose DNA had gone independent of all controls. They were resistant to treatment if not removed surgically, but slow to metastasize or spread beyond their original rogue cell. All it took in my case was one cell that had gone “viral.” That’s what cancer is: A rogue cell replicates, unresponsive to the internal signaling system that tells it to stop. If untreated, the errant cell duplicates relentlessly and eventually spreads through the lymphatic system to regional lymph node collection centers, where the independent cells continue to reproduce and spread again. Cells then escape into the blood and are carried to the lungs, bones, and brain, where distant metastases will flourish. Different tumors have their own predilections for different areas.