“I’ll start my own research. I know several Ph.D. physiologists at Stanford. Maybe they can point us in the right direction.”
Jack hesitated, smiling a challenge. “Arnie, if you didn’t have your nose to the grindstone, maybe your nose wouldn’t get out of joint.”
I grinned and accepting his dare. “I always find time to stop and smell the roses. But, something fishy is going on.”
“Watch out for the stench of evil or you’ll have to pay through the nose.”
“You hit it right on the nose, Jack. You have a nose for the truth and it’s time I woke up and smelled the coffee.”
“A rose by any other name might smell as good or stink to high heaven.”
“That idea stinks or is a little overripe.”
Jack smiled. “It ain’t over until the fat lady sings.”
I looked at Jack, momentarily confused, and then smirked. “I smell a rat, and I don’t like the smell of it.”
We looked at each other, shook our heads, and laughed.
“One more thing, Jack. Your sterilizing machine is still on, someone forgot to flush your toilet, and something’s dead in your refrigerator.”
As the clock approached five the next afternoon, Beverly Ramirez came in holding a chart. “One last patient.”
Karen Adams began her apology as I entered the examination room. “I’m so sorry to bother you, Dr. Roth. I know you’re busy, but I’m having a problem. Maybe you can help.”
She sat on the examining table in a pale blue gown that seemed to swallow her up. At thirty-two, she looked more like someone in her fifties. She was pale, skeletal thin, and had the coarse facial wrinkling of the heavy cigarette smoker. Her brown stained index and middle fingers confirmed that impression.
“What’s the problem, Karen?”
“I can’t sleep. I’ve never been what you’d call a great sleeper, but in the last six months I’m lucky if I get two hours a night.”
I glanced at the front of Karen’s chart.
We organized our patient charts by listing their problems, the so-called Problem Oriented Medical Record. Sleeplessness had appeared before in Karen’s chart as number twelve of thirty problems. Reading them again reminded me of my previous impression that Karen’s problems had their roots in depression.
“I see you’ve had that problem before, Karen.”
“It’s much worse now, Doctor.”
“When I look at your chart, Karen, many of your symptoms suggest to me that you’re depressed.”
“I’m not depressed, Dr. Roth. I’m not laughing all the time, but I’m usually in a fairly good mood. I try not to let things bother me, but even when they do, I soon forget about them.”
“We’ve talked about this before, Karen. This isn’t the first time that I thought you might be depressed. Now, I’m more certain. Having trouble sleeping is one of the most common symptoms of depression.”
She stared at her feet. “I’m not depressed, Doctor.”
We discussed her daily life, her diet, her tobacco use, her alcohol and drug frequency, but I failed to find a smoking gun. Besides asking questions about sex, drugs, alcohol, and unusual cravings like eating starch, dirt, etc., there was one question that too many physicians resisted; asking about spousal abuse.
I girded myself, and began obliquely. “Sometimes when a woman is depressed, we need to look at how things are going on at home, especially between her and her husband.”
Her hands trembled and her eyes were glued to the floor. “I told you, I’m not depressed. Harold and me, we get along.”
Suddenly, there it was again, that tangy, musty, and repulsive aroma of deception, as distinct to me as the oscillations of the polygraph needle.
I grasped her hands and looked into her eyes. “I can help you, if you let me. I can see to it that he never hurts you again.”
Karen collapsed in tears.
Karen’s truth, like Bob Dylan’s answers, were blowin’ in the wind. Literally, in her case, for someone perceptive enough to smell it.
Chapter Thirty-Nine
I phoned Jordan Goodman, the oncologist. “Jordy, I’m concerned about giving the combination of Platinol and Taxol to Beatrice Hodges in the office. It may be too complicated for us.”
“I think you’re right, Arnie. Let’s work together with her and use the Comprehensive Cancer Center for the infusions. We do it daily, so it’s routine.”
My experience with Platinol, the metal-platinum complex, was limited, and the side effects profile of this potent anticancer drug was horrific.
Irving and Beatrice Hodges sat before me so we could talk about chemotherapy. I obtained informational packets about Platinol and Taxol from the university and the cancer center. They described in graphic detail the drugs, their usefulness, and their long lists of side effects.
I held up the brochures. “The side effects of these medications would have me running for the door, Beatrice.”
She gave me the ‘that’s okay, honey’ smile. “But, if that’s what it takes to get well, Dr. Roth, then let’s get to it.”
Was she taking this too casually?
How much of this was denial?
Did she really know what was ahead?
“I’m not trying to scare you off, but these are powerful drugs designed to kill cancer cells, the bad guys. Often, the medication can’t tell the difference between the good cells and the bad cells. That’s what makes people so sick when we treat them.”
Irv held up the information packet and shook its pages. “This scares the hell out of me, Doc. Are you sure it’s okay?”
“It’s not okay. It’s what’s available if we’re going to try to treat this cancer. I hate it. I hate giving people I care about medication that I know will make them so horribly sick.”
“What do you mean, ‘if we try’?”
“Some people don’t try to treat this form of cancer.”
I went over the major side effects of both medications. The Hodges were intelligent, but medically unsophisticated. I doubted they could remember half of what I told them.
Irv stared at me. “Maybe this is too much for her, Doc.”
Maybe, I thought.
The courts have made it clear that physicians must receive from every patient an informed consent before procedures or treatments with medication. Consent was a fantasy and a straw man, a clever ploy by aggressive personal injury attorneys. It went like this: first, create unrealistic and largely unobtainable expectations for consent, and then slam those who can’t achieve it. Anyone in the business of treating high-risk patients knew that the objective, patients understanding all aspects of complex treatments, was largely impossible.
“Until recently, I thought people in their seventies were old. Not anymore. I see more and more people living into advanced age in good health. I can’t decide this for you. Some people, although I often disagree with them, opt out of chemotherapy.”
“No way, Irv,” Beatrice said, grasping his hands. “I’m tougher than you think, besides, we have too much to live for.”
When Irving and Beatrice came to the cancer center for her first infusion, I greeted them as the nurse sat Bea in the recliner. Each combination chemotherapy infusion lasted three hours. The first and most common side effect, nausea, generally occurred during this time and often lasted for a full twenty-four hours.
“I’m going to have the nurse give you medication to minimize the side effects. If you start to feel nauseated, push the call button and the nurse will give you something else.”
“Don’t worry so much Dr. Roth. I didn’t get to this age by being a princess. I’m a tough old bird.”
I reached over and grasped Irv’s shoulder. “I’ve called in several prescriptions to Horizon Pharmacy for Bea. They’ll help you deal with side effect you might see at home.”
Irv sat by Beatrice’s side holding her hand. “I’ll take care of it, Doc.”
Jordy Goodman and I hoped for eight cycles of chemotherapy, but into
the second month, Beatrice was so sick with nausea, vomiting, loss of appetite, and weakness, that we had to curtail several scheduled infusions.
“Her kidney function is declining, Arnie,” the oncologist said. “We can’t give any more Platinol until your kidneys recover. We should continue with the Taxol as she’s tolerating it well.”
I drove to the Hodges’s for a home to check on Bea. I’d asked the visiting nurse to come each day and report on her condition. Each time, the report was the same. “She feels and looks miserable. She’s not eating, and rarely makes it out of bed unless forced to the toilet.”
Irving Hodges greeted me at the door and led me through the gloomy house to their bedroom. His wrinkled face, with lines usually arcing upward in a smile, had turned downward in grim depression. The air was an acrimonious confusion of vomit, pine disinfectant, spoiled food, and again, that strange tonic water fragrance.
When I entered the darkened room, Beatrice’s form lay under the covers. She had pulled up her legs to her chest in the fetal position. Her back faced me as I sat next to her in bed and grasped her shoulder. “Bea, it’s Dr. Roth. How are you feeling?”
Irv snorted and grumbled an unintelligible response.
“Let me die…dear God, let me die,” came in a whisper from Bea’s cracked lips.
“Turn, so I can see you, Bea.”
“No, Doctor. Please. I’m too sick. It’s too late.”
Gently, I grasped her shoulders and turned her to face me. If I didn’t know this house and if Irv weren’t beside me, I would not believe that the person in this bed was Beatrice Hodges. She was wasted to the bone, especially her head, which showed taut sallow skin stretched over a hairless scalp. Her mottled skin was canvas painted blue-purple, to gray-blue to yellow-green with large bruises. Several thin-skinned areas over pressure points on her hips were red, and one was broken down to form a shallow ulcer. By aroma, our old bacterial friend, pseudomonas had infected the wound.
“Look what you’ve done to her. She’s dying, can’t you see that?”
I picked up the bedside phone and dialed East Bay Ambulance.
“I’m taking her to Brier Hospital, Irv.”
Chapter Forty
Debbie Wallace sat at the side of the bed while Matt snored softly. The clock’s red LEDs showed 3:09 a.m. She’d been a world-class sleeper most of her life and only in the midst of radiation and chemotherapy did she have difficulty in getting a full seven to eight hours. Tonight was the third in a row that she awakened around three. She tried to read in bed despite Matt’s grumbling about the light, but she was too tired to concentrate. She got up, did crocheting, and cleaned the house. Although she yawned until her jaws ached, she still could not fall back to sleep.
If this continues, I’ll have to give Arnie a call.
Matt’s alarm jarred her back into reality at 6:30. She’d finally slept since 4:30 a.m.
“My head’s killing me, Matt. I’m not getting enough sleep.”
“Maybe it’s time to go back to decaf coffee, Babe.”
“It’s not that. I’m drinking coffee only in the morning.”
Debbie got in the shower, luxuriating under the steamy hot water. Her headache lessened, but when she stepped onto the bath mat, it recurred in full force. Suddenly, she felt nauseated and leaned over the sink in preparation for the vomiting that didn’t come.
Debbie dressed, moved into the kitchen where the strong aroma of coffee filled the air. She loved the smell of coffee in the morning, but today it made her nausea recur. She grabbed two aspirins and downed them with a small glass of orange juice.
Matt looked up from the morning paper. “What’s up today, baby?”
Debbie sat, head down, on the dinette table. “I’m sorry, what did you say?”
“I asked what you’re doing today. Maybe I can get home for lunch if you can fit me into your busy schedule,” he said smiling.
“Make it a habit, honey,” Debbie said, and then rose and rushed to the kitchen sink where she vomited and retched repeatedly. The sink filled with orange juice and undigested aspirins. She sweated and choked each time a new wave of misery crashed into her stomach.
“My God, what’s wrong?” shouted Matt. “I’d better call Arnie.”
“No, it’s okay. I’m feeling a little better now that all that stuff is out of me.”
Matt walked Debbie to the table and helped her into a chair. She was pale and covered with a fine sheen of perspiration. He grabbed a washcloth, ran it under the cold water, and placed it on Debbie’s forehead.
“My head’s killing me Matt, and my vision is a blur. You’d better call Arnie.”
As I prepared to leave my office for hospital rounds, the answering service called. “I have Matthew Wallace on the line. He says it’s an emergency.”
My stomach contracted in dread. “Put him through.”
“Arnie, it’s Debbie. She woke up with a severe headache this morning and can’t stop vomiting. She says her vision is blurred, too.”
My God, I thought. Is there no justice in this fucking world?
“Bring her to Brier Emergency. I’ll be there shortly.”
Modern medicine had many things going for it, but the speed by which you could establish a diagnosis was a two-edged sword. Early diagnosis gave you a leg up on treatment, but it slammed your sails and slashed them to shreds before you had an opportunity to shorten them in preparation for the storm.
Debbie’s brain CT scan, completed within thirty minutes of her arrival in the emergency room, showed a single brain mass, a tumor. The odds were overwhelming that this was metastatic breast cancer.
I would give anything to be somewhere else. To be in a different profession. To be a craftsman, an artist, or any job where I didn’t have to talk to Debbie and Matt.
I approached the gurney. For the third time, I detected the scent of tonic water emanating from Debbie. What the hell was that? In addition, I noted a tangy, musty, and repulsive emission from Debbie’s body—the cancer itself?
Matt was on the other side holding Debbie’s hand. They could read me, I was sure, since they brought themselves to attention and looked expectantly into my eyes.
Matt clutched Debbie’s hand. “What is it, Arnie?”
My tongue had stuck to the roof of my mouth. I felt my eyes shifting, unable to meet their gazes. I knew what message this behavior delivered, but I was helpless to control it.
“Arnie, what is it?” Debbie cried, holding her head in pain.
“What I’m about to say will shock you. It shocked me, too. Hear me out before you think the worst.”
“The worst?” shouted Matt. “What the hell is going on, Arnie?”
“I’m so sorry to tell you this, but it’s a brain tumor.”
Matt stood. “A brain tumor! Are you crazy?”
Debbie began to sob. “A brain tumor, how can I have a brain tumor? Even I can’t be that unlucky.”
I reached for her shoulder and rubbed it softly. “The odds are overwhelming that the brain tumor has spread from your breast cancer. We call that metastatic cancer.”
“I thought we got rid of that. You, everybody, promised that if I went through that miserable chemotherapy I’d be done with it. You promised!”
We all knew better, but what would you expect from Debbie given her devastating diagnosis.
I pulled a chair to the side of the gurney, sat, and held Debbie’s hand. “I can’t expect to fully understand what this means to you, but somehow I do. This is what we call an isolated metastasis, a single tumor, and in contrast to widespread metastases, we can treat it.”
“Treat it.” Debbie said. “What about the rest of it that’s spread all over my body. What can you do about that?”
“Don’t assume anything. This may be it as far as spread goes. We need to find out, and even if other sites are involved, there’s still much that we can do.”
“Don’t bullshit us, Arnie,” Matt said. “You’ve been straight with us all along. Don�
��t start to lie now.”
“I’m not, and I won’t. I’m not giving up, and neither should you. We still have a good chance to beat this, and I’ll give it everything I have.”
“What happened, Arnie?” Debbie asked. “Everyone, including the experts at UC said the chemotherapy would finally kill these cancer cells.”
“I don’t know, Debbie, and if there’s a reason, I’m sure going to find it.”
When I returned home that night, Lois greeted me with a warm kiss and an icy glass of Chardonnay that she placed on the table by my La-Z-Boy recliner. “How was your day?”
I slumped into the soft cushion. “Don’t ask.”
“Too late now, I already did. What’s wrong, you look so glum?”
“It’s Debbie Wallace.”
“Don’t tell me the cancer’s back.”
“Worse.”
“What could be worse?”
“It’s spread to her brain.”
“My God…she has three girls, doesn’t she?”
“Three wonderful girls and an incredible husband, but that’s as far as her luck goes. Luck seeks those who need it least and avoids those who depend on it most.”
“What’s going to happen now?”
“It’s a solitary brain metastasis. Hopefully, we can deal with it. This whole thing sucks, babe.”
I swivelled the chair to face Lois. “Even today, where pharmaceuticals offer so much promise, it’s impossible for us to understand why some patients fail treatment while others do well. It’s easy to say, and the statistics confirm, that each medication has a failure rate. Is that why Debbie has a recurrence or could it be something else? Something about her course keeps nagging at me. The whole picture’s out of focus. If I can only sharpen the image, maybe I can sense what’s really going on.”
Chapter Forty-One
After a two-week stay in the Skilled Nursing Facility, Connie Rinaldi was physically ready for discharge, but she wasn’t emotionally prepared to return to her own apartment. She agreed to move back in with Tina and Joseph temporarily.
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