Sensing Light

by Mark A. Jacobson

  “He could be septic. He has a temperature of a hundred and two. Blood cultures are cooking. I already started him on broad-spectrum antibiotics.”

  “That’s good. No downside to covering him for sepsis. But why would he have bacteria in his blood?”

  “I don’t know. His spinal fluid showed no cells, so it’s not meningitis. The chest x-ray and brain scan are clear.”

  “You sure it’s not meningitis? What about cryptococcal meningitis? That’s a GRID-related infection, and the patients can’t mount an inflammatory response when the fungus invades their brain. So, typically, we don’t see cells in the spinal fluid.”

  Dana flushed and left to find a telephone. While she dialed the laboratory, Kevin explained the test she was requesting to Gail.

  “India ink stain. Very low-tech assay. A fourth grader could do it. The lab will put a drop of Miller’s spinal fluid on a slide, then add a drop of India ink. Cryptococcus has a capsule that can’t absorb the ink. If the bug is there, they’ll see white dots on a black background. Which reminds me, Dana, when you tapped Miller, what was his opening pressure?”

  “Sorry,” said Dana, now mortified, “We were in a rush to get samples to the lab. I forgot to measure the pressure.”

  “I was watching the pressure.” Gail interjected. “When the intern got the needle in, spinal fluid rose up the manometer so fast it would have spilled over the top if he hadn’t opened the valve to fill specimen tubes in time.”

  “Good observation skills, Gail.” Kevin said. “That’s exactly what we need to know. So Miller does have elevated intracranial pressure. If the India ink is positive, he’ll need repeated spinal taps, every twelve hours, to lower the pressure on his brain. Done a tap before, Gail?”

  “No,” she replied timidly.

  “This is your chance. If you just saw a lumbar puncture, then you’re ready to do one.”

  Gail beamed.

  The phone rang. Kevin picked it up and listened for a moment.

  “It’s Cryptococcus,” he announced.

  Dana hurried out, Gail in tow, to write orders for an antifungal medication and gather equipment for another spinal tap.

  III

  KEVIN RETURNED TO MILLER’S room and was surprised to find Gwen at the bedside making notes on a clipboard.

  “Hey, how come you’re here?”

  “I just started a pulmonary elective. It’s the fellow’s day off, so I’m pre-rounding before the attending comes in. Herb paged me and said I should see Miller. But he doesn’t have any respiratory issues. I don’t get why we’re consulting. What’s up?”

  Kevin couldn’t enlighten her, and it troubled him that Herb had already heard about the case. He was certain Dana wouldn’t have asked for a pulmonary consult, which meant someone higher up in the hospital chain of command must have contacted Herb. He deflected her question.

  “What do you think is going on with him?”

  “He has GRID, that’s for sure. I’m guessing some kind of opportunistic infection, too.”

  “You’re right. It’s cryptococcal meningitis. How do you know for sure he has GRID?”

  Gwen bent Miller’s left ear forward, revealing a small purplish nodule.

  “And there’s more,” she added, rolling the patient on his side and pointing at a tiny, similar lesion on Miller’s back, hidden in a skin fold.

  “Wow! Good pick-up.”

  “You’re a good teacher.”

  “Maybe, but you seem to be better at putting knowledge into practice than me.”

  “That’s not true. Doing a thorough skin exam is a spinal cord reflex for me from all those years in the Haight Street clinic hunting for signs of secondary syphilis.”

  “Yeah, right,” he said dryly. “I’m sure no higher cortical function is involved.”

  Unable to dodge the compliment, she grinned.

  Trifecta, he thought, happy with himself for provoking her amusement, pride, and affection, all with one remark.

  When Gwen began her residency, Kevin was still in his fellowship, toiling in Flagler’s laboratory to make sense out of how the mouse immune system responded to bacterial infection. During her first rotation at City Hospital, he was glad to show her the ropes on the medical wards. It was an excuse to escape from what was becoming tedium. Once he appreciated how at ease she was with herself and others, he sought opportunities to be with her, hoping it might rub off on him. She took the next step, suggesting they double-date. Their respective boyfriends, Marco and Rick, found each other kindred spirits and poked gentle fun at the two more reserved doctors. The evening was a wild success.

  “How are things at home?” asked Gwen.

  “OK. Better, actually. You?”

  “Good enough.”

  “Good enough?”

  “Maybe they could be better. I shouldn’t complain. So what happened with you two? You’d been fighting a lot.”

  “I don’t know…”

  She waited.

  “OK,” he confessed. “We decided to get some relationship advice from friends, an older gay couple who’ve been together for years. Now we’re working at not letting conflicts stew. They call it ‘immediate decompression of tension.’”

  “Kevin, that sounds like New Age psychobabble. I can’t picture you and Marco constantly talking about your feelings.”

  “Hardly. Come on, you know what I mean. Don’t you?”

  “Not really. Have you guys figured out how to avoid getting annoyed with each other?”

  “No, we’re just taking it less seriously when it happens. It usually means one of us either needs more freedom or wants more reassurance he’s loved. And if the other can accept that without being threatened by it, the tension defuses.”

  Gwen stared at him, her mouth open.

  “That’s an astonishing insight for…”

  “For what?”

  “Umm…”

  Kevin grinned slyly.

  “You were going to say a man, weren’t you? An astonishing insight for a man. Oh my God, Gwen! I am so disappointed. You are the last person I would have suspected of such blatant sexism. I guess it just goes to show how ingrained the prejudice men have to deal with is. In fact, you’re a textbook demonstration of why we’re so oppressed. It’s terrible that mothers still pass on such garbage to their daughters. Even someone as enlightened as you can’t shed the bigotry.”

  “Stop,” Gwen giggled. “I was going to say ‘a person of your age.’”

  Kevin shook his head no.

  “After I said ‘a man,’” Gwen admitted, “I was going to say ‘and a person of your age, but...’”

  “Gotcha,” Kevin exulted, pecking victoriously at her with his index fingers.

  “Stop,” she laughed. “You’re very lucky. Do you know that?”

  “What do you mean?”

  “I don’t have that kind of openness with Rick. I tell him what I’m feeling, but he’s the ‘still-waters-run-deep’ type. And I’m never sure how deep they are or where they’re running.”

  “Rick? He seems pretty extroverted to me.”

  “Now you’re being dense, Kevin. I’m talking about what he says to me when he’s pissed off.”

  “What does he say?”

  “Nothing.”

  “And you know he’s pissed because…?”

  “That’s the point. Sometimes I don’t know whether he’s angry or not, and he won’t admit to it. I know he’s no saint. You should hear what he says about the demanding parents at his school. They can push his buttons.”

  “I can’t believe you’re all that difficult to live with.”

  “I’m not perfect.”

  “Maybe he doesn’t expect perfect. Maybe you’re good enough. Maybe he doesn’t have anything to complain about.”

  “Kevin, that’s too good to be true.”

  “Is it?”

  “Oh, my goodness. You’re more romantic than I thought.”

  Kevin suddenly noticed Herb at the nurses’ station an
d waved at him.

  “Thanks for coming by,” said Kevin.

  He stifled the impulse to ask why Herb was consulting on the case.

  “Sorry to step on your toes, but this is a command performance,” said Herb. “The mayor’s office called Ray at home an hour ago, and he paged me.”

  “The mayor called the chief of medicine at home?”

  “Mr. Miller’s ‘an important member of her team.’ I gather it’s not so much his job in public housing as his role as a political advisor. She is very concerned he gets the best possible care here.”

  Kevin frowned.

  “You, my friend, have nothing to worry about. I heard you already made the diagnosis by telepathy.”

  Gwen clapped. Kevin forced a weak smile.

  “Look, Kevin, this is a great opportunity for us. The mayor will find out first hand what the reality of this epidemic is. She’ll get how serious a problem it’s going to be for San Francisco. She’ll understand our commitment to caring for these people and what we need to be able to do it adequately. Department of Public Health money is our lifeline, and the DPH director reports directly to her.”

  “Yeah,” said Kevin, now almost as uneasy about Herb’s involvement as the mayor’s.

  After Larry Winton died, Herb had urged Kevin to get specialized training in infectious diseases. He didn’t push Kevin to become a pulmonary specialist yet clearly wanted him to stay at City Hospital. As more cases of GRID were diagnosed during Kevin’s fellowship, Herb encouraged him to develop ideas for GRID-related research and offered advice. But Flagler wanted Kevin at the bench, working with microbes and mice. That effort culminated in Kevin submitting a funding proposal to the National Institutes of Health which was summarily NERF’d—not even recommended for further consideration.

  Flagler had no intention of keeping Kevin in his division, but two weeks before the fellowship was to end, the chief of medicine at City Hospital drummed up salary support for a physician to manage the care of the hospital’s increasing volume of GRID and pre-GRID patients. Kevin took the position, which came with a university faculty appointment in the department of medicine. Herb renewed his encouragement, suggesting Kevin investigate what was causing GRID and what factors predicted how long patients survived. Kevin wondered if Herb had somehow influenced the chief’s decision to hire him, though he couldn’t grasp why Herb thought he would be successful in clinical research after his failure in the lab.

  Kevin led Herb into Miller’s room where they found him unresponsive to shouting, shaking, or Herb’s grinding his knuckles on the patient’s sternum.

  “That’s it.” Herb said. “We need to intubate and hyperventilate him. The house staff can do another tap after we’re done.”

  Kevin concurred, and Gwen collected the equipment to pass a plastic tube down Miller’s windpipe. As Herb was setting ventilator dials, a man with a thick mane of gray hair appeared. He wore an Armani suit and a blue power tie.

  “I’m Tom Redding from the mayor’s office. She’s on a trade mission in Mexico. Otherwise, she’d be here. How’s Michael?”

  Kevin froze, so Herb took over.

  “I’m Herb Wu, in charge of the ICU today. This is Dr. Bartholomew, our expert in immune deficiency diseases.”

  “Michael has the gay cancer? Is he going to die?”

  Mastering his timidity, Kevin said, “Mr. Miller has a fungus infection in his brain. He’s in a coma. I don’t want to be rude, but we have to put him on a breathing machine and drain out spinal fluid right away.”

  Redding, horrified, stepped back.

  “I didn’t mean to interrupt. I’m just. ..devastated.”

  “No need for apology. Please understand we’re doing everything we can to control the infection and prevent permanent brain damage.”

  Eyes welling with tears, Redding stuttered, “How can…How can this be happening to him? He’s brilliant, unselfish. He doesn’t deserve this.”

  Over the next two hours, Mr. Miller was stabilized. Dana helped Gail pass a needle into his spinal canal and remove enough fluid to normalize his pressure for the moment. But Miller remained comatose. By one o’clock, there was nothing else they could do except hope the antifungal drug would work. Kevin and Herb left the ICU together.

  “Wednesday afternoon at four-thirty?” said Herb at the hospital entrance.

  “I’ll be there. The protocol’s almost finished. I’ll bring the latest version.”

  “Outstanding!”

  Looking at the ground, Kevin formulated a delicate question.

  “Herb?” he asked, glancing up.

  Herb was already halfway across the street. As Kevin watched Herb walk to the parking lot, he thought of their discussion last summer, just after he’d been hired as City Hospital’s immune deficiency specialist. Herb was pressing him to write a protocol outline, and Kevin had probed Herb’s motivation.

  “So, why are you so interested in Pneumocystis?”

  “It’s a mysterious pathogen. No one can grow it in vitro. There are no good animal models for understanding how it causes pneumonia. Treatment outcomes are unpredictable.”

  Kevin gazed at him for an impertinently long time.

  Herb sighed and conceded, “Guess I’m drawn to diseases that are fatal to young people. Like leukemia when I was at NIH. Moth to the flame maybe...”

  The next day, Kevin agreed to take on the project.

  IV

  HERB CAME HOME TO find Martin donning his cleats and shin guards. At three o’clock, they met the other Jaguars at Dolores Park. Although team sports had never captured Herb’s imagination, soccer had captured Martin’s. Herb embraced the opportunity to share his son’s passion. The previous summer, he had even spent eight consecutive weekends in a coaching course so the Jaguars could move up to Class III competition.

  Once the boys were done with stretching exercises and dribbling drills, Herb split them into squads for scrimmaging. He was pleased to see the defense, where Martin always played, forcing the offense to the sidelines where angling a shot through the goal was difficult. Martin, as sweeper, was the last defender protecting the goalie. Any mistake he made gave the opposition a fifty-fifty chance to score.

  Herb watched the offense methodically pass the ball from one side of the field to the other, even backwards, as they attempted to spread the defense apart. A large enough space opened near the goal for the team’s best striker to sprint downfield in time to receive a well-placed pass. He was about to take a shot when Martin arrived and booted the ball away.

  As the coach, Herb couldn’t demonstrate favoritism.

  He calmly called out, “Good move, Martin.”

  Martin showed no acknowledgement.

  Excellent, Herb thought, he doesn’t need to revel in his victories.

  Next, Herb had the boys do a passing drill, which required no supervision on his part. He sat on a bench and let himself enjoy watching Martin gracefully swivel and feint.

  The boys scrimmaged again. This time, the striker made an excellent foot fake. Martin took the bait. His opponent tapped the ball in the other direction, ran past Martin, and was inside the goalie’s box before Martin recovered.

  Herb had to clench his jaw to keep from laughing.

  “Nice touch, Jeremy,” he shouted neutrally and nodded for them to play on.

  In the final half hour of practice, Herb had the Jaguars work on their greatest weakness, defending against corner kicks. It was just a matter of communication, he believed. In the chaos that ensued as the ball sailed from the corner of the field into a crowd of boys jockeying for position directly in front of the goal, leadership was essential. Someone had to see that every offensive player was covered. This had to be the sweeper’s responsibility.

  But kick after kick, the defenders invariably clustered around the best strikers, leaving others free to score when the ball came their way. Martin repeatedly lost the boy he should have been guarding and doubled up against a player who was already covered. He paid no
attention to what the other defenders were doing.

  After the offense scored on three successive corner kicks, Herb raised his hands in frustration.

  “What are you doing, Martin?” he yelled.

  The boys looked back and forth between father and son. Martin stood with his arms crossed, waiting for play to resume. He stubbornly ignored his father’s question.

  Herb recognized his error, but it was too late to retract.

  “Scrimmage,” he called wearily and rolled the ball into the middle of the field.

  All Herb wanted to be was a better, or at least a kinder, father than his own had been. When Martin was born, he had been confident of his ability to do that. Now he wasn’t so sure.

  By five, the boys could no longer see the ball in the growing darkness. Herb ended practice with three short whistles and dolefully picked up the orange cones he had set down to mark boundaries on the park lawn.

  It was an unseasonably warm evening, and Cecilia asked Herb to go for a walk with her after dinner. Still regretting his lapse on the soccer field, he told Cecilia about it. She was sympathetic but had no advice.

  “It’s inevitable, honey,” she said. “Sooner or later, he needs to separate from you.”

  “At ten? Isn’t that a little early?”

  “It’s uglier when it happens in the teens. Think about my sisters’ kids.”

  Herb had to assume she was right. Cecilia and Robbie Cohen, his best friend since college, were the only people with whom he had ever substantively discussed parenting. He trusted their judgment more than his own. My God, he thought, what if I had to do this alone? What could be harder than that?

  V

  GWEN LEFT THE HOSPITAL at noon and met Rick and Eva at a nearby BART station. They had lunch at a taqueria Eva chose from the dozens of Mexican restaurants in the neighborhood before driving to Ocean Beach. Now, beneath a hazy, late afternoon sky that seemed finger-painted blue, the three padded barefoot on the sand. An angry surf hurled bright wet sparks at them. Gwen and Rick, holding hands, trailed behind Eva.