In the exam room, Kevin asked how he was feeling.
“Not great,” he replied, quickly adding, “But no worse than when I started the trial.”
“More fatigue?”
“Not really.”
“All right if I examine you?”
“Sure.”
Kevin shone a light in Hubert’s mouth, palpated his neck and under his arms for lymph nodes, listened to his heart and lungs, and pressed a hand on his belly. Everything looked, sounded, felt normal.
Despite three years of working with people who had a fatal disease, Kevin still hated giving bad news. He calmly told Hubert about the lab results while suppressing a deluge of guilt. Hubert must have been receiving real suramin, he said, not placebo, because there was no other plausible reason for the kidney damage. It was severe enough that the medication had to be discontinued at once.
“No!” Hubert protested. “I don’t want to stop. This is my last chance.”
Kevin had been at international meetings, cultivating connections with NIH scientists and pharmaceutical companies, learning all he could about drugs developed for other chronic viral infections. He knew Hubert was right. There was little on the horizon more promising than suramin. Given that Hubert’s helper T cell count was less than two hundred, it was hard for Kevin to spin this as anything other than the final door closing.
“Hubert, more suramin infusions would permanently destroy your kidneys. You’d need dialysis forever.”
“So the choice is between living with kidney failure or dying from AIDS? That’s a no brainer.”
“Sorry, I’m not being clear. There is no choice. According to the protocol rules, if toxicity this serious occurs, the drug has to be stopped. Permanently.”
Hubert sat still, his lips pressed tightly together.
“If I gave you another dose of suramin, I’d be violating the most fundamental rule of human research—do no harm. And if the FDA or the university found out, they wouldn’t let me, wouldn’t let anyone at City Hospital conduct another treatment trial for AIDS.”
Hubert’s head drooped.
“Let your kidneys recover. Then you could be eligible for the next study that comes along.”
Hubert gave a short snort of disgust. Kevin wheedled him into making an appointment in two weeks to check how his kidneys were doing off the drug. Hubert’s mechanical consent intimated he might never be back. He left without acknowledging Kevin’s good bye. From the exam room doorway, Kevin watched him shuffle toward the elevator.
“Fuck,” Kevin swore. “I can’t do this anymore.”
He stared at Hubert’s folder, blinking, his vision blurred.
“I don’t have time for this bullshit,” he hissed, wiping his eyes with a sleeve.
He grabbed the next folder and marched out to get the patient.
XXIII
IT MUST BE A dream. How could she not have felt the earthquake? Still, the ER staff were saying it had been the big one. She heard sirens approaching the emergency room.
“Ambulance alert!” screamed a ward clerk. “Six hundred AIDS patients on their way, all critically injured. ETA five minutes.”
In moments, they would be awash in infected blood. Men in white plastic jumpsuits walked through the hallways fumigating doctors and nurses in preparation for the onslaught. Covered with oily disinfectant, damp hair stuck to her neck, she waited. The sirens kept howling but didn’t come closer.
Waking in the dark, Gwen realized the telephone was ringing. Her digital clock showed five a.m.
She picked up the receiver and mumbled, “Hello.”
“Dr. Howard, it’s the answering service. I have a Terrell Hunt on the line. He says your patient, Ed Greames, is dying. I told him he should call an ambulance, but he insists Mr. Greames told him not to.”
Gwen remembered the two prescriptions she had written and sat upright, wide awake.
“Connect me please.”
Gwen had met Ed Greames’ boy lover once in clinic. She thought his name was Timmy, perhaps because he looked like the child actor who shared top billing with Lassie in her favorite girlhood television show. Allegedly nineteen years old, Terrell acted the part of a devoted son or nephew.
She heard the operator say, “Dr. Howard is on the line.”
A pleading voice, punctuated by static from the tenuous phone connection, said, “I don’t…to do. How…know when he’s dead?”
“Slow down, Terrell. Tell me what happened.”
“Ed took the death cocktail.”
“Is he breathing?”
“Sort of…stops and starts.”
“Terrell, find the pill bottles and see if they’re empty.”
“What difference…” he shouted. “Are the police…arrest me? Do I need to get out of here?”
“Don’t go anywhere, Terrell! Give me your address. I’ll be there in half an hour.”
Her mind raced as she sped across the Bay Bridge. This was the first time she had intentionally given a patient the means to end his life. She hadn’t thought through how it might play out. What if Greames didn’t swallow all the pills or couldn’t keep them down, and then Terrell called an ambulance? Would Terrell, or Ed, if he woke up, tell the ER doc that Gwen had written the fatal prescriptions? Would that trigger a criminal investigation? Or if Ed did die at home, would people from the coroner’s office come and find empty morphine and phenobarbital bottles that had her name printed on them as the prescribing physician? Would they call the police? How could she honor Ed Greames’ wishes without losing her medical license and facing manslaughter charges?
A band of orange light rose above the East Bay hills as she descended into Eureka Valley. It was spreading across the sky when she found the address, a second floor Victorian flat off Castro Street. She rang the bell. The door promptly buzzed open.
Gwen climbed a dark stairway and entered a high-ceiling living room decorated with splendid millwork. Ed Greames lay on a couch. He didn’t respond to her shouting his name or rubbing his collarbone. He was breathing, intermittently, and had faint heart sounds. She couldn’t feel a pulse.
From behind her, Terrell asked, “Is he dead yet?”
“No,” she answered, thinking minutes, an hour at most.
Then she reconsidered. What if his phenobarbital levels had already peaked? God, what is the half-life of that drug? It’s long, isn’t it?
She turned to the boy and said, “Timmy, I mean Terrell, what did he take? Which medications?”
“I don’t know”
“Think hard. It’s important.”
“He told me he was going to take the death cocktail, but I didn’t see him do it.”
“When did he take it?”
“Probably when he went to sleep, maybe two in the morning.”
Gwen demanded he show her all of Ed’s pill bottles. Terrell led her into the kitchen where medication containers littered the breakfast table. She inspected each bottle, several times. None were labeled morphine or phenobarbital.
“Are you sure this is everything?”
“I don’t know,” he answered defensively. “I just fed him and cleaned him. I didn’t deal with his pills.”
Gwen couldn’t remember the precise words of their conversation, but she had seen Ed write down the names of the drugs and the number of pills. She studied the boy. Nineteen might be pushing it a year or two. Gwen chose to believe him. Ed must have taken the pills four hours ago. In his terminal state, he would absorb the medication slowly. That meant his blood morphine levels should be peaking now, possibly the phenobarbital as well.
Terrell twitched. His eyebrows knitted. Gwen saw a frightened kid, only a few years older than Eva. She was appalled by the questions she had just asked him, the tone she had used. This had to stop being about what she was risking and start being about what he had already lost.
“Terrell, you did the right thing. No one is going to accuse you of a crime. OK?”
He looked doubtfully at her.
&n
bsp; “We have to wait until he goes. It won’t be long. Are you OK with that?”
“Like I have some other choice? If I leave now, you can tell the police I killed him.”
“As soon as he dies, I’ll call the coroner. They’ll send people to take the body away. I’ll do the talking. There won’t be any police.”
Terrell crouched on a stool with the posture of a dog about to be struck.
“Look, they’ll see evidence that someone else has been living here. They just need to see you here, so it won’t look like we’re hiding anything. OK?”
He reluctantly acceded then slipped away to the bedroom.
Gwen sat next to Ed Greames. She watched him breathe in crescendo-decrescendo cycles, each ending in a protracted period of no movement. Then his airflow would fitfully recover and his respirations mount again in depth and frequency.
It had been over a year since Gwen’s last death vigil. She’d done it many times during her training and again in the first months after City Hospital opened a special AIDS ward. Gwen believed being present at a death was a great privilege. As an intern, she had hoped witnessing the transition from warm, pulsatile life into cold, motionless death might give her insight into the mystery of her own being, of all life. She would hold patients’ wrists, feel their pulse stop, their skin temperature drop, their bodies transform from a volitional creatures into inanimate objects. There was a disconnect, like the reversal between figure and ground in an optical illusion, but there was never an epiphany. The only revelation was how unfathomable the mystery remained.
Ed’s gasping was more forlorn than desperate. He was tired out, ready to quit. Gwen concentrated on the rise and fall of his chest, which calmed her. After another half an hour, Ed paused at the end of a cycle. Five minutes later, he still hadn’t taken a breath. Gwen placed her stethoscope over his heart. There was no sound. His skin was distinctly cooler. She covered him with a blanket.
Gwen dialed information and asked the operator to connect her to the coroner. While listening to the rings, she again worried the coroner’s staff would search the apartment. What if they found the two pill bottles she had missed—the ones with her name on the label? Would Terrell say something indiscreet?
On the twelfth ring, there was a click.
“Coroner’s office,” a gruff voice said.
“This is Dr. Gwen Howard from City Hospital. I’m on a home visit. I have a death to report.”
XXIV
HERB AWOKE ON WEDNESDAY feeling more like his old self. Morning ICU rounds went well. A case of bacterial pneumonia in an elderly woman, complicated by septic shock, kidney failure, and allergies to the antibiotics usually administered, didn’t flummox him in the least. As he was writing progress notes, Herb hummed a melody, a tune he first heard in a blues club while living in Washington DC. Recalling the title, I Got My Mojo Working, he laughed out loud.
“It’s nice to see you in a good mood.”
He looked up to see Laurie Hampton. She had her arms folded and an amused smile.
“It’s nice to be pain free,” he said touching the pea-size lump on his head. “I guess you know about my little accident last weekend?”
“Do you think there’s anyone in this unit who doesn’t know about it?”
He shrugged amiably.
“Sorry to rain on your parade, Herb, but Boyce’s parents want to talk to an attending.”
He knew the case well, a twenty-four year old with severe Pneumocystis pneumonia. The patient’s family and friends were absolutely certain he wasn’t gay or bisexual and that he had never injected drugs.
“They still don’t believe he has AIDS,” she said. “They’ve heard about the new antibody test and asked the resident to order it. He told them it’s not available yet. Now they’re demanding to see the ‘doctor in charge.’”
Laurie pointed her finger at Herb.
“The resident’s right. The assay hasn’t been approved by the FDA. It can only be used in a research protocol.”
“They need to hear it from you, Herb.”
She pointed at the door of the family room.
“Will do.”
When Herb left the room, Laurie was hovering outside the door.
“How did it go?” she asked.
“They’re having a hard time coping, and I validated that’s a normal, appropriate response. They’re willing to face facts and not make unreasonable demands.”
Instantly ashamed of what he had just said, Herb berated himself. Who am I to tell her about coping? She’s known for three years her fate is a coin toss that might land tails-down at any moment. How could I have been so stupid?
Laurie didn’t react to his remark.
Maybe she’s in Gwen’s study, he hoped. Maybe she found out she’s not infected.
He glanced at Laurie, who was gazing pensively at the young man lying unconscious and paralyzed while a ventilator kept him alive. She turned to Herb with unguarded eyes, seeming as fragile as when she had told him about the needle-stick in 1981. They hadn’t spoken of it since. He felt his neck pulse bounding. He thrust his hands into his pockets so she wouldn’t see them trembling.
“Herb, do you have a few minutes to talk?”
He waited a second too long before answering, “Sure.”
By then, Laurie had reset the corners of her mouth into a managerial smile.
“Actually, I need to start an IV,” she said. “I’ll catch you later.”
XXV
HERB WENT TO HIS office after rounds. He was on the phone when Kevin tapped on his half-open door. Herb waved him in, motioning him to sit down. While Herb finished his call, Kevin inspected the leaded-glass lamp on his desk and the photographs of the Chrysler and Empire State buildings hanging on his walls.
Before this week, Kevin had assumed Herb’s fondness for geometric patterns simply resonated with his cerebral, tranquil, interior reality. Now he wondered if Art Deco was a metaphor for the serenity Herb still aspired to have. That thought further discouraged Kevin. If inner peace was a mirage for Herb, what chance did he have of ever finding contentment.
Kevin kept glancing back at the Chrysler Building’s terraced crown as he told Herb about Hubert’s kidney damage.
“There’s nothing worse than harming someone you’re trying to help,” Herb commiserated. “I saw that happen in spades with patients on experimental chemotherapy at NIH. Many of them died as a direct result of the drugs’ bone marrow toxicity. It was hard to watch, Kevin, but it was better than giving up. Those people were under a death sentence, and the investigational regimens were their final appeal. Sound familiar? Most did survive a little longer, and that time was huge for them and their families. I got to see a lot of unadulterated love there. It was inspiring.”
“Yeah,” sighed Kevin, his eyes moist. “Thanks for the pep talk.”
“I should thank you. I’m realizing I could have that experience again if I got more involved with your patients. Please don’t take this the wrong way. I have no desire to poach on your territory. But there are other AIDS opportunistic infections nobody here is working on—like Mycobacterium avium, for example.”
Kevin stared at Herb, raised his palm, and said, “That’s an offer I can’t refuse.”
Their hands slapped.
“Let’s go for it, Kevin. We should be testing all kinds of treatment strategies here. There’s cytomegalovirus and Cryptococcus, too.”
“All right! If we can be this fired up when we’re teaching our residents and fellows about AIDS, they’ll happily recruit patients for us.”
“Brother, you’ve seen the light. The only missing piece is talking a pharmacologist into joining us. Oh, and getting some of the local private practice docs to refer their AIDS patients here.”
“Yeah,” said Kevin, his enthusiasm fading as the image of Hubert Wilson shambling toward the elevator came back to haunt him.
“Damn, Herb, what can I do for this poor guy? It’s not like I can tell him a grateful nation appre
ciates his sacrifice. He might have to end his life on dialysis.”
“Hmm. What’s the mechanism of suramin nephrotoxicity?”
“Renal tubular injury from what I’ve read.”
“I heard a nephrologist on the Hill give grand round rounds last year on renal tubular toxins. His name is…um…Hightower. He’s investigating prostaglandin infusions to prevent kidney failure after toxin exposure. Call him. Maybe there’s something you can do to reverse your patient’s kidney damage or at least keep it from getting worse.”
“What a great idea! I should have thought of that. Say, Herb, what exactly is your problem-solving deficit?”
Herb gave him a faint smile.
As Kevin was departing, Herb’s pager sounded. He dialed the number displayed. Gwen answered on the first ring. She asked him to come to her office.
“It’s about Laurie Hampton,” she said.
XXVI
GWEN JUMPED UP FROM her chair when Herb arrived and closed the door behind him. She made him sit down and showed him a slip of paper. Herb looked at Laurie’s antibody result. He put his head in his hands.
“We’re telling her Monday afternoon.”
“I can be there.”
“No! Christ, I’ve already violated confidentiality by letting you know.”
Furious with herself for this lapse, for her weakness in needing to confide in someone, nearly in tears over it now, Gwen apologized which led to further explanations until the whole Ed Greames story flooded out.
“I’ve never done anything like that before,” she said, only half believing she had really been in Greames’ apartment a few hours ago, that it wasn’t part of her earthquake dream.
“I understand,” he said. “I’ve done something like that, worse actually. I didn’t just write a script. I administered the medication myself.”
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