Hospital

by Julie Salamon

  I remembered Estee Altman’s evaluation: Dr. Kopel is very brilliant but very rational, scientifically makes the decisions about what needs to be done. He could seem cold.

  “Some people think I’m too arrogant,” he acknowledged, as though reading my thoughts. “Because I will actually voice an opinion and strike out in a direction and say, ‘Here’s what I think you ought to do.’”

  He tried to be deferential to Sharon’s physicians, but he didn’t allow himself the relief of relinquishing responsibility. He couldn’t. When Sharon and Sam began dating and it was obvious to her they might marry, she sat with him on a bench in a garden by a pool on the Brooklyn College campus. She told him she had something very important to tell him.

  When she told him she had diabetes, he didn’t fully comprehend the gravity of her condition—he hadn’t yet started medical school—but he recognized that it was serious. Instead of being scared off, however, he found himself drawn by her need. It was an attraction as vital as her cute face and deceptively insouciant reddish pixie haircut. Sam told me, “I grew up in a household with a father who was a double amputee. I was used to taking care of someone. Sharon being ill . . . somehow made it more compelling.”

  Over the years he abdicated to her physicians—and he didn’t. He was Sharon’s husband but also her medical adviser and medical director at the hospital where the fatal illness was discovered. When she went for the spine MRI the day before the groundbreaking of the cancer center, the radiologist didn’t call the patient with the results; he called her husband, the medical director, with his report: The radiologist saw some kind of growth, involvement of the right kidney.

  Sam Kopel and I discussed many things over the next few months following Sharon’s death, but more than a year would pass before he sat in his office in the cancer center and showed me his wife’s CAT scan on his computer screen. It was one of a few dozen images of Sharon’s insides that had been taken over the years; some part of her was now stored in the hospital’s hard drive.

  First we looked at a CAT scan taken in February 2003. On the computer I saw a swirling bunch of lines, resembling a satellite radar map on the Weather Channel, settling into definable shapes. Sam pointed. “Now, liver looks perfectly okay. Vena cava, normal bile ducts.” He pointed to splotches. “That’s fat.” Then: left kidney, right kidney, guts, aorta, pelvis, uterus, fibroids, rectum, bladder, vagina. Click. Click.

  Then he brought up the fatal picture, taken seven months later, on September 25, 2003. Kopel showed me what he saw when he stood behind the technician and watched the computer monitor as sixty-four X-ray detectors beamed in on his wife, integrated the data, and generated a high-speed image in maybe ninety seconds.

  First he saw tiny speckles in her lungs, which didn’t worry him. Seconds later the pulsing picture came into focus as her liver. “To my horror I see these big lesions, and they’re instantly recognizable,” he said, pointing to the screen. “A normal liver looks smooth, like a slice of pâté,” he said in a professorial voice. “The lesions are actual holes, like Swiss cheese.”

  “Were you anticipating what you saw?” I asked. We both kept our eyes on the screen.

  “I deliberately made myself blank,” said Kopel. “I’ve been in this business long enough to know that in an individual patient anything can cause anything. You can jump to conclusions about a population of patients, but not an individual.” He told me, “I knew there were ten benign things it could be. A large fibroid or a kidney stone or a band of adhesions from a previous appendectomy. But it also could be malignant.”

  He knew the possibilities, hopeful and dire. Yet he said, “I was not anticipating what I saw next.”

  The screen showed a large mass. “Almost the size of a grapefruit,” said Kopel. “A large orange.” He had little doubt. This was cancer.

  He was honest with Sharon and he wasn’t. “I didn’t tell her everything,” he said. “I told her there was a mass. I wasn’t going to lie to her. I told her there was a mass blocking the kidney and we’d take some steps to take care of it.”

  During this conversation Sam Kopel said, “If you were to write it the way it was, it would seem too operatic.” That’s when he talked to me about Violetta, the doomed heroine in La Traviata and why he loved opera. You know she’s a striver, that she’s good, that she is doomed by illness, Sam said. In the first minutes of the overture. Those high violins, those dissonant notes. Go home and listen to it. That is a musical depiction of tuberculosis, of disease. It’s perfect.

  “Forget the opera,” I said. “What was your life with Sharon like in real life?”

  His thin face seemed to shrink behind his glasses. “We had our ups and downs,” he said slowly. “We were very different people. I had a very difficult time getting used to her circumscription. She was afraid of going out and daring to do things—hiking, skiing, exploring. She was more into people and relationships, and I was into new adventures. So that was a friction. On the other hand, she kept me safe and I provided whatever I did for her.”

  He leaned forward to turn off the computer. “I had one major regret, in the distant past,” he said. “Because of the diabetes, she didn’t want to have any more kids after Lisa. That was a big problem. The pregnancy accelerates complications of diabetes, that’s true. You can minimize that by taking very tight control of the diabetes, also true. But she never took tight control of the diabetes until very late in life. She ate whatever she felt like. She gained weight, so be it. That was a friction.”

  I looked at the photograph on the wall, showing Sam leaning in to kiss Sharon’s neck on his fortieth birthday, his eyes closed dreamily, a big grin on her face.

  A false positive?

  Kopel was trained to keep a poker face but his voice trembled. “In some ways she was my lightning rod,” he said. “She was all emotion. I’m all analysis and intellect. We fought. But we were partners. She could sense who was good and who wasn’t. She really, really hated folks who took advantage. She was a rock through all those hassles with the cancer center, completely and unambiguously my compatriot. She could hate, but good.”

  “Was that a good thing or a bad thing?” I asked.

  He paused for just a second. “I think it was overall a good thing,” he said.

  The afternoon of the cancer center’s groundbreaking, Sharon and Sam stayed in his office in the old oncology practice, a block away from where the new center would be. Sam called a Maimonides surgeon to arrange for a stent and a chemotherapy port. He called a former colleague of Jay Cooper’s at NYU, who agreed to manage Sharon’s treatment. They decided she would have the chemotherapy at Maimonides, by Dr. Huang, for convenience, because sometimes it would take all day for the chemo to drip into her veins. Beth Popp handled her pain; Sharon’s internist took care of her diabetes. Sam Kopel acted as intermediary.

  What about Ingelfinger and his recommendation to relinquish responsibility?

  “I have to straddle,” Kopel said. “I saw to it she had doctors rather than a million doctors. I tried to step away, but you can’t do it. She expected me to give her advice. I went with her to the oncologist to remind her of the side effects she wouldn’t mention. I might tell him about a new symptom I had seen or that she wouldn’t tell him about. Most patients don’t tell their doctors bad news.”

  He prepared a detailed history for the NYU doctor:

  Diabetes since teenage; complications include:

  CAD with multiple angioplasties & stents. Most recent in 2000.

  Retinopathy treated successfully with laser, mid 90s.

  Charcot’s foot, now stabilized, 2001.

  No renal, peripheral vascular or neuropathic issues of note.

  Medications:

  Cardizem, 180 mg daily

  Zestril, 10 mg daily

  Atenolol, 25 mg bid

  Imdur

  Plavix

  Lipitor

  Insulin: lantus, 25 u hs. Humalog 5,5,10 before meals; 0-5hs prn.

  Breast can
cer, stage I, Aug., 1996. Lumpectomy, RT & Tamoxifen for 5 years.

  Vaginal bleeding, 2000, while on TMX & Plavix; D&C neg.

  Low back pain; severe in 1996 (12 weeks bed rest); intermittent since.

  Acupuncture & physical therapy, ongoing. Bextra, 20 mg. hs prescribed 2003.

  Irritable bowel diagnosis, 2002, based on spasmodic pain with defecation, constipation etc. Never clear whether pain related to bowel, GYN, or lower back. Workup included colonoscopy (6/02), AP CT (2/02), AP MRI 7/02, pelvic sono 1/03. All non diagnostic. Consultation with anorectal surgeon 11/02—confirmed spasm & uncoordinated peristalsis. UGI/SB series 3/03 “to complete the workup of irritable bowel”—negative. No hint of a pelvic mass.

  Treated variously with Bentyl, Elavil, stool softeners etc.

  Consultation with pain specialist 3/03; Bextra prescribed with partial relief for 2-3 months.

  Unprovoked sweating since Jun ’03.

  Sharon had described her progress under treatment. “The first few treatments were pretty good, because I weighed 182 pounds, so I looked healthy for a while,” she told me. “Then the heavy-duty vomiting started. I swear to you, one morning I looked in the mirror and I was green and had no hair and the clothes were hanging off me and I was scared. I looked like a concentration-camp victim. Not a survivor, but a victim.

  “We tried four or five treatments,” she said. “Should I count the ways they’ve been trying to kill me? The first one I had my head in the toilet. Then I had a pulmonary embolism. They got me to the hospital, and I felt, ‘This really is the end.’ Little did I know bigger and better were in store for me.

  “They took me once to the hospital in an ambulance, because Sam couldn’t wake me up,” she said. “I had gone into diabetic shock. That was a horror. I didn’t know what was happening. Vomiting, rashes, dizzy, then nonstop diarrhea. Why do people do this?”

  I asked Sam whether he thought Sharon was prepared for death.

  “She was always asking me if there was something else to be done,” he said. “But she was prepared.”

  I asked him about the concept of “the good death.”

  He replied without hesitation. “The dignified death is a myth,” he said flatly. “Unless you just keel over and drop dead, and there’s not much dignity there either. People dying of chronic illnesses like cancer or Alzheimer’s, it’s an awful process. Evolutionarily, the body wants to keep going. The struggle can be mitigated by judicious use of medications and not overdoing the medical procedures. But it’s always a struggle.”

  On the day of Sharon Kopel’s funeral, after finishing my milky tea at the Chinese bakery, I went back into the rain and continued up Eighth Avenue to the cancer center. I found Nella Khenkin, the cancer center’s social worker, in her small office filled with books and paraphernalia—wigs, makeup, pamphlets—meant to help cancer patients deal with the indignities of treatment. A full-bodied woman of fifty, Khenkin had immigrated to the United States fifteen years earlier from the former Soviet Union, where she taught Russian language and literature. Steeped in her ancestral home’s appreciation of suffering and melancholy humor, she was a wise and comforting presence.

  “Friday was his birthday,” she said by way of greeting. Kopel had turned sixty two days before his wife’s death.

  Unlike Sam Kopel, who spoke with both the sorrow of a man who has lost his wife and the sense of failure doctors often express when patients die, Khenkin saw aspects of a “good death” in Sharon Kopel’s final days.

  “I understand that she suffered a lot, so for her it is the end of her suffering,” she said. “It is amazing she let him have his birthday on Friday. Didn’t spoil it. Didn’t make it sad. Can you imagine if it had happened on Friday? At least he will be able to celebrate his birthdays many, many years—and then a couple days later, of course, it will be a memorial day.”

  Khenkin told me that her own husband had died almost exactly three years earlier. “I remember when we came to the funeral home, Kopel was the person who met me there. Dr. Kopel,” she said. “It was very important to me he was there with support, though he didn’t know me very well. And then later, when I was sitting shivah, he took time, the medical director! I just came to the practice at that time. I was amazed to receive such respect. I expected the little people would not be interesting to someone in that position, but he took the time.”

  She told me car pools were being organized for the Kopel funeral. “A lot of people want to go,” she said. “He brought her here to the New Year’s party in a wheelchair. She was very frail, but I’m glad she was here, able to see the center. It was his baby; he was building this center and thinking about it all the time.”

  She sighed. “So how are you?”

  I rode to the funeral home on Coney Island Avenue in a car with Alan Astrow and Jay Cooper. I met Astrow in his office, and he told me that his mother had given away her jewelry and informed her children that she’d prepared a will. She told him she was going into the hospital for a cataract operation. Astrow called her oncologist to see if she was well enough for surgery. “The disease is progressing slowly,” he was told.

  In the car the two doctors avoided mention of where we were going and why. Instead Cooper complained about American Airlines changing his flight on the way to a conference in Florida and losing his luggage on the way back. They discussed a story on the front page of the New York Times about a breakthrough in ovarian cancer and how misleading drug trials are. They avoided the obvious connection between the news and our destination. Cooper gave directions to the cabdriver and said he grew up three blocks from the funeral home. We passed a cemetery; he told us Mae West was buried there. When he leaned forward to instruct the driver further, the driver raised his hand and said, “Stay calm, sir, I’m born and raised in Brooklyn.”

  “So am I,” said Cooper tersely.

  The funeral home had capacity for 315 and was overflowing. The Maimonides crew was there in full force, from Marty Payson on down. Lisa Kopel-Hubal, Sam and Sharon’s only child, spoke. Then Sam Kopel stood at the podium, poised and elegant in his black suit.

  I didn’t take notes, but I remember the speech as a kind of aria, composed by a man who appreciated operatic emotion but rarely showed it.

  If you were to write it the way it was, it would seem too operatic.

  At Sharon’s funeral he made a joke about how his computer had a virus, not cancer, so his speech was handwritten.

  He said he and Sharon loved opera and ranked individual ones according to hankies needed. Falstaff zero, Madame Butterfly off the charts.

  He noted that his grandsons were the first in his family to be born in the United States; Lisa, their daughter, was born in Italy, when he was in medical school.

  He said Lisa was Sharon’s masterpiece, her capolavoro, and he used both the Italian and the English. Sharon’s product, not his. He had missed every parent-teacher meeting—not proud of it, just reporting.

  (Lisa later told me that this wasn’t true, that she remembered him home for dinner every night, that he taught her how to ride a bike, he took her to see The Magic Flute at the movies, he took her ice skating.)

  He said Sharon had taught science for years at a Jewish day school and that she was beloved. That when the principal once asked the children who the most famous Jewish scientist of the twentieth century was, the children did not, as you would expect, offer up the man who declared that e equals mc squared. No, the children said, the most famous Jewish scientist of the twentieth century was Mrs. Kopel. The audience laughed through tears.

  Sam described their meeting, at summer school. He was there because he’d flunked a course; she was merely industrious. He copied her papers. For thirty-six years she took care of him, he said: investments, shopping, everything. He went to an ATM for the first time three months earlier, he said. He was still afraid of supermarkets, he said, but he guessed he would have to get over that.

  Then he paused and said dramatically that he wanted to say it publicly
, that Sharon never resented her late diagnosis. She never discussed recrimination.

  (Later Sam told me he saw one of Sharon’s doctors walk into the funeral home just then, and he wanted to reassure him. I remembered Lili Fraidkin once whispering when she was irritated with Kopel that Sam felt guilty for not diagnosing his wife’s cancer earlier. When I asked him whether he felt guilty, he said, “When I said Sharon never resented the late diagnosis, was I subconsciously giving myself absolution? Probably. My analyst would probably say yes. I don’t reject that. Why didn’t I see something the others didn’t see. Like everyone else, I rationalize.

  “Ovarian cancer can be cured, even in late stages,” he said. “When it’s the sort of typical ovarian cancer, presents with fluid and swollen belly, those patients respond to chemotherapy beautifully. I have lots and lots of patients like that. Every oncologist does. Sharon’s cancer was different. This was a variant, and it behaved in a more malignant fashion.

  “If you’re asking, do I have sleepless nights about it? I would say no. Was it the subject of analytic sessions? Absolutely.”)

  He said taking care of her the last three years was a privilege.

  Sharon always came through for him, he said. After being in a coma for a week, she woke up for a few hours on Saturday, the day after Sam’s birthday. “I don’t know how or why,” said Sam. He corrected himself. “I do know why, but not how.” She wished him happy birthday. That was the why.

  He concluded by repeating something he said often: that the four years they spent in Italy in their youth were the best years of his life.

  Three weeks passed. After a balmy interlude, winter asserted itself, with the biggest snowfall ever recorded in New York, 26.9 inches in Central Park. By the next day, the sun came out, melting the snow, leaving the streets a mess. The hospital felt dank, dispirited. Brier’s husband had had yet another operation, another attempt to restore mobility to his knee, at New York-Presbyterian Hospital/Weill Cornell Medical Center. On her daily visits to Aschkenasy, Brier tried, unsuccessfully, not to be overcome with envy of the clean hallways, the beautiful rooms, the unscuffed elevators, the hospital’s $1 billion capital campaign. Plus, HealthGrades had just issued its 2006 report; after receiving the Distinguished Hospital Award for Clinical Excellence for three years in a row, achieved by only 5 percent of the country’s hospitals, Maimonides was dropped from the list because of an uptick in mortalities. And January surgery numbers, in Brier’s words, were “in the toilet.”