Flawless

by Joshua Spanogle

  I sighed. “So, the big question: What does path say?” Pathology would clench it. Tissue, as they say, is the issue.

  “Monica can take that.”

  I smiled. “Ravi said you like skin.” As soon as the words were out of my mouth, I wished I could pull them back. Monica turned red again.

  “She’s the only person in the world who did a derm residency and still ended up in public health,” Ravi said. “That’s why I love her.”

  “Ravi…”

  “See? She loves me, too.”

  “What’s the path say?” I asked again, wanting to get a diagnosis on this thing that was turning entire faces into tumor.

  “Histologically, it looks like an extremely aggressive dermatofibrosarcoma protuberans, with areas of fibrosarcoma,” Monica said, sounding relieved to be moving to more professional topics. “That was my read and the pathologist’s.” Dermatofibrosarcoma protuberans is a rare cancer of fibroblasts, a soft tissue cell type ubiquitous through the body. She gnawed her lip. “I suppose the fibrosarcoma elements could account for the involvement of deeper structures, but clinically, it’s acting very weird…”

  “More like run-of-the-mill fibrosarcoma maybe?” I asked.

  She shook her head, looking worried. “But that doesn’t usually involve the head and neck. It’s being classified as DFSP-FS. Dermatofibrosarcoma protuberans–fibrosarcoma. But if it’s a form of DFSP-FS, and I guess it is, I’ve never seen anything this invasive. Or this extensive.”

  “That’s because you were too busy removing moles.”

  “Shut up, Ravi.”

  “History?” I asked.

  “Negative personal history for cancer,” Ravi answered. “Negative family history. Negative for exposure to toxins or chemicals. Travel history is significant only for a trip to Hong Kong last year.”

  “What happened in Hong Kong?”

  “Family and patient said nothing. The Lums visited family.”

  “No visits to shamans? No tours of toxic waste dumps?”

  “Nothing notable.”

  I asked Monica, “What are the risk factors for fibrosarcoma?”

  “Radiation, chemical exposure, genetic risk.”

  “And Beatrice Lum has none of these,” I said.

  They shook their heads.

  “So,” I said, “we have one confirmed case of the fibrosarcoma in San Francisco, Beatrice Lum. We have one suspected case in San Jose: a woman named Cynthia Yang, deceased. Lum’s disease is more extensive than anyone’s seen, correct?”

  “She’s been seen by ENT, plastics, dermatology, oncology. Ophthalmology even. No one’s ever even read a case report of these cancers being so aggressive. Like I said, its presentation is really weird. Multiple foci. It’s not looking as if she had one tumor which metastasized to other sites. It’s like they all popped up at once.”

  “Clonality?” Genetic analysis of the tumors would tell us if the cancer sprouted from the same cell or arose from different ones. If all the cancerous cells were clones, that suggested metastasis—spread—from a single cell and tumor.

  “That’s another weird thing,” Monica said. “They’re clones.”

  I thought for a moment, then asked, “Did you match her to the pictures I sent?”

  “Yeah,” Ravi said. “We got what we think is a match.” He reached into his shoulder bag. “Here—”

  He stopped abruptly and slid the folder back into his bag. His eyes and Monica’s moved to something over my left shoulder.

  “San Francisco,” Ravi said under his breath. I turned.

  Behind me stood a tall, gaunt man. Thirty-something, balding, bespectacled, a stethoscope slung around his neck. His khakis and frayed oxford shirt—his general inattention to fashion—screamed public health.

  “I don’t think there’s a lot here for us,” he said, by way of greeting. I caught Ravi’s eye; he looked relieved. “It is bad, though. She’s bad.” The man stuck out a hand sprouting long, thin fingers. “Giles Spangler, San Francisco Department of Public Health.”

  “Nate McCormick.” I shook the hand.

  Ravi spoke. “Dr. McCormick worked with me at CDC.”

  Dr. Spangler, instead of being impressed, scowled. “CDC is here? This is—”

  “I no longer work for CDC,” I said. “I’m…freelance.” I should clarify: there are not a lot of unaffiliated, freelance public health doctors out there. In fact, I might have been the only one.

  Spangler stared at me for a moment. His eyes were a green so pale they were almost colorless.

  “Nate’s helping out,” Ravi told him.

  “Fair enough. ‘Freelance.’” Spangler sighed. “Like I said, I don’t know what we can do about this. Not a lot there. Didn’t get a significant exposure history, no family history. Thanks for the heads-up, Monica, but I think we’ll just stay out of this for now.”

  I could see the gears and cogs whirring in Ravi’s brain. He was happy that the local boys weren’t going to jump all over this. At the same time, it put him in an odd position: trying to play in a game it didn’t look like state would be asked to join.

  But I didn’t have any institutional loyalty. I didn’t care who took ownership of this mess. I just wanted some get-up-and-go from someone.

  “There was a case in Milpitas,” I said.

  Ravi looked as if I’d just blurted out his SAT scores to a room full of strangers.

  Spangler blinked at me, surprised. “The dermatofibrosarcoma?”

  “Looked like it,” I told him. “That patient is dead.”

  Spangler absorbed the information. “There are seven million people in the Bay Area, Dr. McCormick. Statistically, there are likely to be a few cases—”

  “This patient had the same multi-centric, extensive involvement,” I interrupted. “We have reason to believe there may be more cases.”

  Ravi was trying to waste me with his eyes.

  “What reason?” Spangler asked.

  “I can’t say now.”

  “Are these other cases in the Bay Area?”

  “We don’t know.”

  Spangler scratched his chin, thinking. “I’ll take this to my boss. But I have to be honest, I don’t see the public health angle yet. I don’t see a cluster.”

  He was right. Two people were not a cluster. Ten people—those people in Murph’s pictures, if they were all in the Bay Area—that would be a cluster. And we didn’t know where those ten people were.

  “Surveillance?” I asked, already knowing the answer.

  “We won’t be able to justify it,” Spangler replied, pale eyes on me. He looked at Ravi and Monica. “State?”

  “Nothing official,” Ravi said.

  Setting up disease or syndrome surveillance isn’t as easy as flipping a switch. It involves bulletins, faxes, and e-mails to thousands of hospitals, clinics, and doctors’ offices. It’s very official, and the threshold to put the word out is high. The will to set up a surveillance program for anthrax is easy after the stuff turns up in envelopes around the country. The will to set up a surveillance program for a rare form of cancer that cropped up in two people in a population of seven million is nil.

  “So,” I said, “we wait.”

  “Yes,” Spangler replied. “We wait.”

  “We wait,” Ravi echoed unhappily.

  I stood there, watching our highly trained, overeducated band of do-gooders shuffle their feet impotently. In our foxholes, in our bunkers, waiting.

  “I’m going to see her,” I said.

  48

  “WHAT ARE YOU DOING, MCCORMICK?” Ravi muttered as we walked to the patient’s room.

  “We want the locals involved.”

  “No, we don’t. Not yet.”

  “Well, you got your wish. Everyone’s staying out of it.”

  “Just check things out with me before you blab, will you?”

  “Ravi,” I said, “no one’s going to touch this. I want people to touch it.”

  “We are.”

&
nbsp; “No, you are. And somehow you roped Monica into it. Who else at your office knows about this?”

  Ravi said nothing.

  “Exactly,” I said. “I appreciate the help. I do. But you’re walking a fine line. Keeping this unofficial and quiet as long as you can so you have ownership over it when it pops could kill people.”

  Ravi refused to be provoked. “It’s unofficial because we’re maxed out now. State and CDC have their hands full of flu and another E. coli outbreak. You saw local’s response.”

  “Why do you want to deal with it?” I asked.

  “Because we’re buddies, right, McCormick? And because you got a nose for the big thing, right?”

  A nose for the big thing. I felt a spurt of anger, thinking of the ruined faces in Murph’s photographs, of the dead woman, of the woman in the room we were about to enter. “Just stop playing games, okay?”

  Ravi didn’t answer me, just pushed forward into Room 15.

  Beatrice Lum was awake. She occupied the bed close to the door, a curtain separating her from the patient in the window bed. A man sat holding her hand. Her husband, I guessed. The television played what looked to be a soap opera. Unfamiliar language squawked from the TV remote control/speaker on the bed next to her. Her face was heavily bandaged above the lip on the left side and on the lower jaw. An egg-sized mass rose from the area around her left eye. She looked like she’d been smacked with a baseball bat.

  The distribution of Beatrice Lum’s tumors—along the nasolabial fold, at the corner of the eye—was identical to the distribution of tumors in the pictures.

  I noticed a morphine drip hung next to saline.

  “You’re popular today,” Ravi said, smiling. Mr. Lum forced a smile. The bandages on his wife’s face shifted; I assumed underneath she was trying to smile, too. Both looked exhausted.

  “This is Dr. McCormick from the Centers for Disease Control,” Ravi told them. I shot a hard look at him. I was getting sick of the lying. Bad enough when I did it myself; worse when it was done on my behalf. “You’ve heard of the CDC, right?”

  Mr. Lum nodded.

  “Pictures?” I asked. Ravi produced his folder and slid out a blowup. He handed it to me and I held it up to Mrs. Lum.

  When they saw the picture, the Lums’ faces contorted; you’d think I’d just dropped my pants. “I showed them before,” Ravi said in a low voice. “They don’t seem to like the photos.”

  “Why?”

  “They won’t say.”

  I handed the reproduction back to him and it disappeared into folder and bag.

  “Now,” Ravi told the Lums, “I know we covered this before. But I was hoping you could tell Dr. McCormick when you first noticed anything wrong.”

  “We noticed a little bump about five or six months ago. It was here.” Mr. Lum pointed to the left side of his upper lip. “It grew bigger and then we saw other bumps here”—he pointed to his left eye—“and here.” He touched his jaw.

  “Did you go to the doctor at that time?” I asked.

  Glances between the two. “No.”

  “Why?”

  “We couldn’t go, Dr. McCormick.”

  “Why not?”

  “We answered these questions for Dr. Singh before. And for Dr. Spangler after that—”

  “Sorry. This is something doctors do,” I said, trying to win him over with a smile. “We ask the same questions over and over. But we’re very concerned for your wife, and for you, and we need to make sure all the questions have been asked. There may be other people who have what your wife has.”

  Mr. Lum’s lips pressed together. I persisted, “Was your wife feeling well otherwise?”

  “Yes.”

  “Any recent sicknesses?”

  “No.”

  “Any sweating during the night?”

  “No.”

  “Any contact with sick—”

  “We did not have contact with any sick people. She did not have exposure to any chemicals. We have taken one trip in the past year, to Hong Kong. She was not sick then. We do not have any pets. She works as an accountant—”

  “Okay, Mr. Lum.”

  “—in a software company. We have two children. They are fifteen and seventeen. She takes no medication—”

  “Mr. Lum—”

  “—except for multiple vitamins. She has never been exposed to radiation. She has always been healthy except for a hysterectomy for benign fibroid tumors—”

  I put my hand on his shoulder, silencing his volley of bitter answers. “It’s okay, Mr. Lum. Mrs. Lum? Are you in pain?”

  “Yes,” Mr. Lum said for his wife. “She’s in great pain.”

  “Your wife speaks English?” I asked him.

  Something I’d swear was hatred sparked in his dark eyes. Mr. Lum said, “Of course.”

  “Then, I’d like to speak with her. Alone, if you don’t mind.”

  “I don’t think—”

  Mrs. Lum said something—tired and sharp—in Chinese. Her husband’s face darkened. His response was in Chinese, but I could guess the meaning; it sounded like “Do whatever the hell you want.”

  “I am going for coffee,” Mr. Lum announced.

  I turned and caught Ravi’s eye, nodded. “I’ll get some coffee, too,” Ravi said. When they left the room, I sat in the chair, still warm from the husband’s body.

  “I’m sorry to send everyone out. I just wanted to talk to you.” I spoke softly, so as not to disturb—or interest—the patient on the other side of the curtain.

  The bandaged woman nodded.

  “You’re still in pain, aren’t you?”

  “No,” she breathed. Because of the surgery near her mouth, her words were indistinct. “Not now. The morphine…”

  “Good.”

  The pain was a thread. I followed it. “Were you taking pain medications before you came here?”

  “Yes…”

  “What medicine?”

  “Vicodin. Percocet. We told the doctors this.”

  “Who prescribed the medicine?”

  Mrs. Lum sighed, shook her head slightly.

  “Who wrote the prescriptions?”

  “No prescriptions.”

  “Who gave it to you?”

  She said nothing.

  “Mrs. Lum, you need to talk to me. Otherwise, I can’t help you.”

  I wouldn’t have been able to tell she was crying if not for the tears draining slowly from her eyes, across the bumps on her face.

  “It’s okay,” I told her, though we both knew it was not. “I’d like to take a look at your wounds, if you don’t mind.”

  “I don’t mind,” she said softly.

  Carefully, I undid the tape that tacked down the gauze over her lip. I looked first at the surgical site. The wound was enormous, raw and glistening, about four centimeters square and crossing the vermilion border of the lip. I could see the contours of bone and muscle, what was left over after the tumor’s excision. I assumed the plastics folks were talking skin grafts at this point. Even with the best reconstructive medicine, Mrs. Lum would never look normal again. Whatever normal meant.

  I sat back in the chair, reached into my shoulder bag, and retrieved Murph’s photos. “These are people who have what you have,” I told her. I paged through them, one after the other, trying to match Lum’s face to a face in the ugly images.

  She was not there.

  “There are others who are sick,” I said.

  “Yes,” she agreed.

  I felt my heartbeat quicken. “You knew there were others?”

  Mrs. Lum stared at me.

  “Where? Here? Hong Kong? You recognize these people?” I held the pictures up to her.

  “There are so many…” she whispered. Then, “Please. Stop.”

  I did. I sheaved the pages. “What happened to you? Do you know why you are ill? Mrs. Lum?” My gaze drifted to the mound of flesh heaped next to her eye, to the gaping wound at her mouth that would forever change the sound of her voice.
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  “I don’t know,” she said.

  “What happened in Hong Kong?”

  “I cannot help you,” she said.

  “I need to know what’s going on. I want to keep others from getting sick.”

  “I know,” she said. “I cannot help you.”

  Hundreds of patient interviews taught me to know when the end has come, when one more question would be nothing but wasted breath.

  Gently, I reattached the bandages to her face and sat. I picked up her hand and held it cupped between mine. We sat in silence, listening to the faint sounds of the Chinese-language soap opera on the television. The skin of her hand was smooth, perfect.

  “I’m sorry,” she said. Her eyes met mine. She was asking for help that I could not give her.

  I looked at the undulating landscape of her ruined face, at the serum stains seeping through the gauze. “So am I,” I told her.

  49

  I STAYED WITH BEATRICE LUM for another ten minutes, doing the only thing left to me at that point: to give a little comfort. No more questions, no discussion of what protocol—surgery? radiation?—to evaluate or follow. I held her hand and watched a television show I could not understand.

  Perhaps Brooke was right. Perhaps I don’t like real people. Perhaps I only like the sick, the desperate. So be it.

  The gaze of the bandaged woman in the bed unnerved me. It was the look of someone who knew she was dying.

  I felt my anger rise.

  I tore off a corner of the folder that contained the photos and scrawled my contact information on it. “My business card,” I said, and smiled. Mrs. Lum smiled back and broke my heart.

  “I’ll come back tomorrow,” I promised. “Maybe we can talk again then.”

  Mrs. Lum surprised me. “Yes,” she said. “Yes.”

  My spirits lifted for the first time in days.

  “We’re trying to save her life—”

  “Dr. Singh, I—”

  “—and you’re not telling us squat.”

  “I know nothing. I am not a doctor.”

  I was in the hall outside Mrs. Lum’s room watching Ravi seriously invade Mr. Lum’s space. Ravi, two inches shorter than the other man, had his finger pointed like a stiletto.