The Perfect Treatment

‘I want you to have a routine chest X-ray this morning, Mr Barlow,’ she said, ‘as soon as we’ve finished seeing you here. I’ll call them to fit you in right away.’ There was no way she was going to let him get out of the hospital without one. ‘And I want to have some blood tests done as well, then we’ll see you here two weeks from now with the results.’

‘Ok,’ he said, a certain bravado in his voice. ‘Have I got bronchitis?’

‘I’ll be better able to answer that question maybe when I’ve examined you,’ she said, ‘which I’m going to do right now. I want to listen to your chest, take your blood pressure, and so on. I’d rather wait for the chest X-ray before saying anything definite.’

The lungs did not expand well. Abby listened to the breath sounds in those lungs as she placed her stethoscope here and there on her patient’s chest when he was lying on the examination couch a few minutes later. It was probable that he did have a chronic lung disease, bronchitis or emphysema, which did not rule out cancer as well. There was also the possibility of tuberculosis, which was increasing in prevalence these days.

When she had done a very thorough examination, she lifted the telephone to tell the receptionist that she was ready for Dr Wharton to see her patient.

‘He’s just gone in with one of the other young doctors,’ Sue informed her. ‘Dr Contini might be free between his cases. Would you like him?’

‘Oh…um…yes, if that’s all right with Dr Wharton.’ Abby felt herself to be a little flustered, not a state to which she was accustomed. Indeed, she prided herself on her sang froid.

‘Dr Wharton’s in full agreement,’ Sue said chirpily, giving Abby the impression that the receptionist was coming under the influence of the new head of medicine. ‘He’s running late, and Dr Contini wants to learn the ropes here.’

While waiting for Dr Contini, Abby called the X-ray department to make an appointment for Gary Barlow, stressing that she needed it done that morning, soon. As a chest X-ray could be done very quickly, they gave her a time which would coincide with the end of Mr Barlow’s appointment in Outpatients. Considering that he might leave the hospital without the X-ray she resolved to escort him to the X-ray department herself.

She was also keeping a close eye on the time, mindful of her obligation to go to 2 East.

Dr Contini came in after a peremptory knock. ‘What can I do for you, Dr Gibson?’ Again he reminded her of a racehorse, lean yet muscular, with a graceful, contained power.

‘Would you confirm my physical findings, please, Dr Contini?’ she said, handing him her written notes. ‘That’s what Dr Wharton does. Here’s the history.’

She watched his dark head as he bent over her notes on the desk, his arms propping him up as he stood reading intently, yet ready to take flight.

‘You take a good history, Dr Gibson,’ he said, looking up suddenly.

‘Of course,’ she said, pursing her lips a little. ‘I’m well known for my good histories…among other things. I’ve pencilled in my provisional diagnosis.’ Moving over next to him, she put her finger on what she had written, not wanting to say anything in front of Mr Barlow. Quickly, she moved back, oddly aware as she did so that Blake Contini knew she was distancing herself from him.

With an astute look, he smiled at her slightly—there seemed to be a sadness in that look. Instantly she regretted her pursed mouth, her touch of primness, which wasn’t really ‘her’. Then that name came to mind again…Kaitlin. Who was she? His wife, perhaps? A child? The words that Mrs Ryles had uttered echoed in her mind. ‘Any change there?’ the woman had said. His dead voice had answered, ‘No, nothing.’

Abby knew then that she did not want him to be married, to be committed. It meant that her own resolve was weakening. And she had another year to go of training. ‘I appreciate this,’ she said. ‘There might be something that I’ve overlooked.’

‘We’ll see,’ he said, taking a stethoscope from the pocket of his lab coat. ‘Hello, Mr Barlow. I’m Dr Contini. I understand you have a chronic cough.’

It was five minutes after eleven o’clock when she arrived breathlessly on 2 East, having managed to escort Mr Barlow to X-Ray, just to make sure he would actually go there, and to see two more patients as well.

‘If you’re looking for Dr Contini,’ a nurse said, ‘he’s down that way. Room six.’ She gestured down the corridor of the general medical floor.

‘Thanks.’

‘We’re keeping that patient, Mr Simmons, in isolation,’ the nurse said. ‘You’ll find the stuff you have to put on in the anteroom.’

There was a small glass panel in the door of room six, through which Abby could see Blake Contini, dressed in a gown, cap and mask, talking to the patient.

Mr Ralph Simmons, a man in his early sixties, had a diagnosis of acute myelogenous leukemia, a disease which left him anemic and generally debilitated and thus more susceptible than normal to infections which he might pick up from other people. Abby put on a gown in the small anteroom, covering her own clothes, then a disposable cap that covered her hair and a face mask. Last, she put on a pair of latex gloves.

‘Ah, Dr Gibson,’ Dr Contini said, as she let herself into the room, his eyes going over her quickly. ‘We’ve been waiting for you. I’ve told Mr Simmons to expect you.’

‘Good morning.’ Ralph Simmons smiled tiredly at Abby.

‘Good morning,’ she answered, moving to stand near Blake Contini at the bedside. He held the patient’s chart.

Mr Simmons lay on the only bed in the room. He was a large man, who had most likely once been very fit and muscular, Abby surmised as she looked at him. He seemed to be still in reasonable shape, although very pale and tired-looking.

‘Did you have time to read the computer printout I gave you earlier?’ Dr Contini asked.

‘Yes, I did.’

‘Good. Here’s the case-history chart.’ He handed it to her so that she could read about their patient in more detail, see the results of the blood tests that had been done so far in order to make the diagnosis and assess the degree of development of the disease. ‘Mr Simmons knows his diagnosis.’

He meant, Abby supposed, that they could talk reasonably freely about it in front of the patient.

‘How are you feeling, Mr Simmons?’ she asked.

‘Tired,’ he said. ‘Very, very tired.’

Before Abby had entered medical school she had been under the impression that it was children who commonly suffered from the various types of leukemia that were known—only later had she discovered that it was just as common in adults, right up to the elderly. In fact, the incidence of the disease peaked in the sixth and seventh decades.

She knew now that the prognosis for anyone over the age of sixty was not as good as for a younger person, mainly because the greater a person’s age the less likely they were able physically to tolerate the toxic effects of the very potent chemotherapy treatments that were required to put the disease into remission.

‘As I’m sure you know,’ Dr Contini said quietly, looking over her shoulder at the open chart, addressing both her and the patient, ‘the cause of acute leukemia is unknown, although some links with toxic chemicals have been demonstrated in some cases. We’ve been discussing possible future treatment, Dr Gibson.’

‘I see,’ she said.

Mr Simmons nodded his understanding, his eyes on Dr Contini. From before his admission to hospital, he had known the probable diagnosis from his GP, and had insisted on being told the truth. ‘I would like to know as much about it as I can,’ he said.

‘It’s a disease characterized by the proliferation of immature blood cells arising in the bone marrow, where blood cells are made,’ Abby’s colleague continued, addressing Mr Simmons. ‘All it takes is the transformation of a single bone marrow cell into a malignant form…From then on, this one cell produces clones of itself, which gradually spread to other parts of the body, especially to the spleen and liver, where they accumulate and cause problems.’

‘What sort of time frame are we talking about here?’ Mr Simmons asked.

‘Well, acute leukemia can develop in three months,’ Dr Contini said, while Abby kept her eyes on the chart, ‘which seems to be so in your case.’

What he did not say, Abby noted, was that some patients had a preleukemic syndrome, which could last for very much longer than three months. The ultimate outcome for patients who had that syndrome was not as good as for those who developed the acute phase more quickly. From the evidence before them, it seemed that Mr Simmons had had a fairly abrupt onset, if he were not glossing over any earlier symptoms.

‘Mmm…that’s about right,’ their patient murmured. Apparently a very intelligent and perceptive man, he would have a good idea of his chances for recovery.

‘He’s had a lot of investigations,’ Abby commented quietly to Dr Contini as she carried the chart to the end of the bed and stood there, looking through it.

‘Yes,’ he murmured, having moved to stand beside her, his head close to hers as they looked at the hematology lab reports together. ‘As you know, it’s a guide in good medicine that when making a diagnosis one should think of the common things first, before going on to the more unusual and to the exotic. Hence all these blood tests.’

‘Yes,’ she agreed, conscious of his closeness.

‘You may know the saying with regard to making a diagnosis—“When you hear the sound of galloping hooves, think of horses, not zebras.”’

Abby smiled. ‘Yes, I have heard that. And certainly not unicorns,’ something prompted her to add.

‘No, not unicorns.’ He smiled slightly in return. ‘Not that leukemia is difficult to diagnose. We have to be sure of the type, though.’

Abby nodded.

Dr Contini turned again to their patient. ‘These immature cells—which never develop to full maturity, Mr Simmons—are unable to perform the functions of the mature cells that they gradually replace…thus the symptoms that you experience, especially the anemia,’ he said.

‘Yes.’

‘Because you have fewer and fewer normal red blood cells, with less and less hemoglobin as a result, you gradually become unable to carry as much oxygen on your red blood cells…which is why you get breathless on exertion.’

Their patient nodded. He seemed avid for information, as though that in itself might help him to fight this vicious disease, if only on a psychological level.

‘Mr Simmons has been in here for two days, Dr Gibson, waiting for the results of more blood tests. I’m here today to discuss treatment with him. Any questions you want to ask him?’

‘Has a bone-marrow biopsy been done?’ she asked.

‘Yes,’ Dr Contini said. ‘That, as you know, is the other diagnostic test, which shows up the abnormal bone marrow cells, the immature forms.’

Although most of the background information was already in the chart, Abby preferred to hear it directly from the patient. He would most likely have a need to talk. ‘What were your initial symptoms, Mr Simmons?’ she asked, moved by his air of abject exhaustion, his outward calm, she suspected, masking a great deal of underlying apprehension.

‘Well…I was pretty tired all the time, much more so, I suspected, than was warranted by my age,’ he said, ‘although I lead a hectic life. I teach at the university—political science—and this is a busy time, coming up to the end of the academic year. Even so, I suspected that something was wrong with my health.’

‘I see,’ Abby said kindly, encouraging him to go on.

‘Also, my skin was very pale and I got breathless easily on the slightest exertion, whereas before I could walk for miles. I felt unwell for a lot of the time and I got several colds, as well as chest infections, which I couldn’t shake off.’

‘Do you smoke?’

‘No. Never have done.’

‘Anything else?’

‘I noticed that I bruised easily, and I couldn’t remember having injured myself in any way to cause the bruises,’ the patient went on. ‘Then my dentist noticed that my gums were bleeding more readily than usual, so when I told him my other symptoms he advised me to see my doctor right away. Then when I went to my GP for a check-up he found out I was very anemic…Then things progressed from there.’

‘He had some nausea as well, which indicates some involvement of the gastro-intestinal tract—either infection or bleeding, or both,’ Dr Contini said quietly.

‘I see.’ Abby nodded. ‘And what is the planned treatment?’

‘I’m getting on to that now,’ Dr Contini said. ‘What I’m going to do, Mr Simmons, is build up your general resistance before we start you on a course of chemotherapy. If you agree, that is. Since you’re very anemic, I’m going to give you a blood transfusion of packed cells, plus some fresh plasma which will help the clotting function of your blood, which gets out of whack with this disease.’

‘When am I going to get that?’ Mr Simmons asked.

‘We’ll start this afternoon. The hematology lab is getting you cross-matched. When we’ve done that, we’ll discuss the treatment further. If we decide on chemotherapy later, you get a combination of drugs over a period of five to ten days—that’s called the “induction therapy”.’

‘I’ve read something about that,’ Mr Simmons said ruefully. ‘It kills off all the abnormal cells. Right? Or almost all? I guess it makes you feel pretty awful, as well as making your hair fall out.’

Blake Contini nodded.

CHAPTER THREE

WHEN the consultation was over and the two doctors were out in the wide corridor again, divested of their protective clothing, Blake Contini drew Abby to one side, out of the way of the pedestrian traffic, and queried her about aspects of the disease.

‘How would you make the final diagnosis here, Dr Gibson?’ he asked, fixing her with an astute glance from those rather unnerving blue eyes.

Abby cleared her throat, feeling a little like a student taking an exam. At the same time, she was grateful to have this opportunity for learning—even if her feelings towards her teacher were a little mixed. There was no time now to dwell on that.

‘Well,’ she began, ‘there are abnormal cells in the blood and in the bone marrow—tests for those would be decisive. The cells in the bone marrow never mature beyond the myeloblast level.’ Abby met his glance squarely, warming to her subject. ‘And, of course, the proliferating leukemia cells accumulate in the bone marrow, eventually suppressing the production of normal blood cells and the normal bone-marrow elements.’

‘Yes.’

‘He would have evidence of abnormal blood-clotting function—an elevated prothrombin time and low fibrinogen levels, as well as the clinical findings,’ she added decisively.

‘Right.’

Mr Simmons had manifested two common clinical signs. Abby had felt those distinctly when she had examined him as well—an enlarged spleen and an enlarged liver. They were signs indicative of a blood disease. ‘He has hepatomegaly and splenomegaly,’ she said, ‘two other diagnostic signs.’

He nodded. ‘Quite right. After the transfusions that we’re going to give him, how would you proceed with treatment, Dr Gibson?’

‘Well…’ Abby took a deep breath. ‘I would give him the remission induction chemotherapy that you mentioned—provided we think he’s a good candidate. We hope to induce a complete remission. We would need to really build him up first, including, probably, the giving of broad spectrum antibiotics to try to get rid of residual infection, particularly if he has some gastrointestinal involvement.’

‘Yes…good. I can see that you know your stuff Dr Gibson,’ Blake Contini conceded, raising his dark eyebrows at her and giving her a small smile, a gesture that transformed his lean face.

They had moved well away from the door of room six to discuss their patient, yet Abby glanced at it, feeling a familiar sense of pity. ‘I expect he was generally a very fit man before this,’ she said. ‘He doesn’t smoke, has always exercised regularly.’

‘Yes,’ he agreed. ‘We’ll see what the packed cells and the plasma do for him over the next day or two. I try to be as hopeful as I can with these patients. After all, what’s the point of trying to play God when each case is somewhat different from the next. We can only talk in probabilities. Do you agree?’

‘Yes.’

‘There’s nothing to stop him from getting hold of a medical book, of course, and reading about probabilities for himself,’ he commented dryly.

‘No, he’s obviously done some reading.’

‘Do you think he’s a candidate for a bone marrow transplant?’ he asked, looking at her quizzically again.

Abby shrugged, indicating her uncertainty. ‘Statistically speaking…I’m not sure,’ she said slowly. ‘His age is not on his side.’ She considered how well Mr Simmons would stand up to the effects of the toxic drugs that would be required prior to a transplant of bone marrow. ‘But I…I wouldn’t want to rule it out.’

‘Quite right, on both counts,’ he said crisply, ‘so I don’t think that’s an undisputed option. We’ll see. Before we start chemo, we need to do another liver function test and make sure his kidneys are in good working order.’

A small silence ensued, while other staff moved busily past them in both directions.

‘Well…’ Abby said, thinking of her outpatient clinic yet oddly reluctant to bring this teaching session to an end, ‘thank you for the time you’ve taken to go over this case with me, Dr Contini. I guess I ought to be getting back…’

Dr Contini looked at his wrist watch. ‘That’s the least I could do since you missed the presentation because of Will Ryles. A quick cup of coffee is in order, I think, don’t you?’

‘Definitely,’ she agreed.

‘Come to my office,’ he said lightly, ‘then I can quiz you about your attitudes and biases, Dr Gibson.’ The smile he gave her surprised her once again, as did his almost playful propensity to goad her in a gentle way, just out of the blue. Although he would not suffer fools gladly, she suspected, he would also be quick to burst any bubble of pomposity wherever he found it…and there was certainly plenty of pomposity in a hospital setting. For this reason, she found herself warming to him even more.

As she gave him a quick sideways glance, Abby reconfirmed her convictions about the false veracity of first impressions; she didn’t know what to think about Dr Contini. Two things were certain—he was an unusually attractive man, and knowing him was going to be a challenge, both personally and professionally.

‘You said you were good at other things, as well as taking histories,’ he said. It seemed that he was determined to shake off the slightly sombre mood that had been engendered by Mr Simmons’s condition. ‘Tell me what some of those other things are.’ His hand lightly under her elbow indicated that they should walk and talk at the same time.

‘Well…’ Enjoying his touch, she walked slowly. ‘I’m pretty good in a crisis.’ Looking at him sideways again, she challenged him to contradict her, her full lips curving up at the corners in an involuntary smile.

‘I expect you are,’ he conceded thoughtfully, his voice husky.

‘Even though you think I’m a bit klutzy?’ Her smile broadened.

‘You said that—I didn’t,’ he reminded her. ‘I would have come up with a word that was more complimentary.’

‘I’m not sure I believe that,’ she said.

As he led the way to a quiet side corridor off the main second-floor corridor, where the department of internal medicine offices were situated, Abby considered, a little nervously, what he might query her about, and she began to think that maybe she should have declined the offer of coffee.

‘Dr Wharton will be wondering what’s taking me so long,’ she ventured, as he led the way into his cosy office.

‘I spoke to Dr Wharton. It’s all right,’ her colleague informed her. ‘This is a teaching hospital after all. You haven’t told me what else you’re good at…outside work. I like to know who—and what—I’m dealing with in my new colleagues.’

‘Well…’ Abby racked her brains. ‘I’m good at gardening, and I make a pretty mean rum baba when I’m in the mood for it.’

Although she had not intended to make him laugh, his uninhibited amusement at her response was very gratifying.

‘Perhaps you’ll let me experience that some time,’ he said, still grinning. ‘I shall look forward to it. Coffee?’

‘Please. I’m desperate for coffee and was beginning to think you weren’t going to give me any after all.’ Trying to cover up overt signs of her growing attraction to him, she pushed her unruly hair away from her forehead and fussed around with her attachè case which she placed on his desk.

‘A coffee now in exchange for a rum baba at a date yet to be decided. Right?’ The tone was light.

‘Right,’ she said unthinkingly, aware only that her heart was beating faster than normal and that she wanted more than anything to be able to meet him outside a work setting—not thinking beyond that.

‘Back to serious things. Tell me about your personal ethics, Dr Gibson,’ he said, as he handed her a cup of coffee. ‘Would you like to sit—get more comfortable?’

‘I…I prefer to stand,’ she said.

‘So I’ve noticed,’ he said.

As her face flushed, he shook his head in a self-deprecating way. ‘I’ve done it again, haven’t I? As I said before, I don’t mean to be unkind. I’ve got into a habit of…insensitivity with women.’

‘It’s all right,’ she insisted. Then, like a litany, she mentally went over the many rules for good medicine which she had made for herself, trying to answer his question. While he poured himself coffee, his back to her, Abby took a swallow of hers and collected her thoughts.

‘As for my ethics…well, do not force or coerce a patient into having a treatment he or she does not really want, even if the prognosis without it would be poor,’ she stated. ‘Sometimes “treatments” can kill—many are not without risk. If a patient wants a second, or a third, opinion, before agreeing to a course of treatment or an operation, make sure he or she gets it.’

‘Hmm. Go on.’ He sipped coffee, eyeing her thoughtfully. Abby had no idea what he was thinking. This was a snatched interlude that must soon be over.

‘Know your biases. Even the very best doctors have them,’ she said, hoping that he would not press her further. What, she wondered, were Dr Contini’s biases and weaknesses? Maybe finding out would be interesting. ‘Try to know your strengths and weaknesses.’

‘What do you think of euthanasia?’ he asked unexpectedly.

For a few seconds Abby looked at him, sensing something other than curiosity about her opinions in his question, yet she could not have analyzed why she thought that.

‘I know that some doctors advocate euthanasia,’ she said slowly, averting her gaze from his shrewd perception. This was something that she felt very strongly about. ‘I’m not one of them.’

‘Tell me why,’ he said softly.

‘I—I’m not particularly religious,’ she said, stammering a little, ‘but the admonition “thou shalt not kill” figures very large in my personal philosophy, I guess. I haven’t really analyzed it very thoroughly…In my experience, people do not want to have their life taken from them—they want to be relieved of their pain. We all love life, we cling to it.’

‘Hmm,’ he murmured, watching her.

‘To…er…to take a life is extreme arrogance,’ Abby went on. ‘I deplore arrogance of any kind.’

‘I agree with you absolutely. It is not in our mandate to take a life. Not actively.’ There was a bleakness in his voice, as though this were a question that he had been forced to consider many times. Abby knew that must have been the case.

Encouraged, she went on and felt her cheeks tinge with warm colour as she disclosed her thoughts, struggling to find the appropriate words. ‘To me, the trust that a sick person has in his or her doctor is a sacred trust, never in any circumstances to be breached. As you say, it is not our mandate…We are not in a position to have, or to take, that sort of power over the life of another. It’s abhorrent…obscene.’