Fever

Five

Crossing the river by way of the Harvard Bridge, Charles struggled with a recalcitrant heater. He could not get the control arm to move to the heat position. As a consequence of his efforts, the Pinto swerved, to the dismay of neighboring motorists who responded by pressing their horns. In desperation, he hit the control with the heel of his hand only to be rewarded with the plastic arm snapping off and falling to the floor.

Resigning himself to the chill, Charles tried to concentrate on the road. As soon as he could, he turned right off Massachusetts Avenue and skirted the Back Bay Fens, a neglected and trash-littered park in the center of what once was an attractive residential neighborhood. He passed the Boston Museum of Fine Arts and then the Gardner Museum. As the traffic cleared, his mind wandered. To Charles it seemed emotionally cruel of Cathryn to leave him dangling, a victim of his own imagination. Could Michelle’s nosebleed have started again? No, that seemed too simple. Maybe they needed to do some test like an IVP and Cathryn didn’t want to give permission. No, there would be no reason why she wouldn’t explain that over the phone. It had to be some medical problem. Maybe appendicitis. Charles remembered the abdominal tenderness, the low-grade fever. Maybe it was a subacute appendicitis and they wanted to operate. And Charles knew how hospitals affected Cathryn. They made her crazy.

Entering Dr. Jordan Wiley’s office, Charles was engulfed by a sea of anxious mothers and crying children. The crowded waiting room… that was a part of private practice that Charles did not miss. Like all doctors, his secretaries had an irritating propensity to book new, full workups in time slots reserved for simple return visits, resulting in a hopeless backup of patients. No matter what Charles had said, it had made no difference. He had always been behind in the office and had always been apologizing to the patients.

Charles searched for Cathryn in the press of women and children, but he didn’t see her. He worked his way over to the nurse who was being besieged by a covey of mothers demanding to know exactly when they would be seen. Charles tried to interrupt but soon realized he had to wait his turn. Eventually he got the woman’s attention and was impressed by her composure. If she was affected by the chaos around her, she did a superb job of not showing it.

“I’m looking for my wife,” said Charles. He had to speak loudly to make himself heard.

“What’s the name?” asked the nurse, her hands folded over a pile of charts.

“Martel. Cathryn Martel.”

“Just a moment.” As she rolled back in her chair and got to her feet, her face became serious. The women grouped around the desk eyed Charles with a mixture of respect and vexation. They were clearly jealous of the rapid response he’d elicited.

The nurse returned almost immediately, followed by a woman of impressive dimensions who Charles thought would make an appropriate mate for the Michelin tire man. He noticed her name tag: Miss A. Hammersmith. She motioned to Charles, and he obediently stepped around the desk.

“Please follow me,” said the nurse. Her mouth, suspended between two puckered cheeks, was the only part of her face that moved as she spoke.

Charles did as he was told, finding himself hurrying down a hall behind the bulk of Miss Hammersmith who effectively blocked his view. They passed a series of what Charles imagined were examining rooms. At the end of the hall she opened a paneled door and moved aside for Charles to enter.

“Excuse me,” said Charles, squeezing past her.

“I guess we both could lose a few pounds,” said Miss Hammersmith.

As Charles stepped into the room, Miss Hammersmith remained in the hall and softly closed the door behind him. Bookshelves lined one wall, filled with stacks of medical periodicals and some textbooks. In the center of the room was a round, blond oak table surrounded by a half dozen captain’s chairs. One of them abruptly scraped back as Cathryn stood up. She was breathing audibly; Charles could hear the air enter and exit from her nose. It wasn’t a smooth sound. It trembled.

“What…” began Charles.

Cathryn ran to him before he could speak and threw her arms around his neck. Charles put his hands on her waist and let her hold him for a few moments to regain her equilibrium. “Cathryn,” he said at last, beginning to experience the bitter taste of fear. Cathryn’s behavior was undermining his thought of appendicitis, of an operation, of something ordinary.

A horrid, unwelcome memory forced itself into Charles’s mind: the day he’d learned of Elizabeth’s lymphoma. “Cathryn,” he said more sharply. “Cathryn! What is going on? What’s the matter with you?”

“It’s my fault,” said Cathryn. As soon as she spoke she started to cry. Charles could feel her body shudder with the force of her tears. He waited, his eyes moving around the room, noticing the picture of Hippocrates on the wall opposite the bookshelves, the rich parquet floor, the Nelson’s textbook of pediatrics on the table.

“Cathryn,” said Charles at length. “Please tell me what’s going on. What’s your fault?”

“I should have brought Michelle in sooner. I know I should have.” Cathryn’s voice was broken by her sobs.

“What’s wrong with Michelle?” asked Charles. He could feel panic tightening in his chest. There was a terrifying sense of déjà vu…

Cathryn strengthened her grip on Charles’s neck as if he was her only salvation. All the control she’d marshaled before his arrival vanished.

Using most of his strength, Charles managed to break Cathryn’s hold on his neck. Once he did so, she seemed to collapse. He helped her to a chair where she sank like a deflated balloon. Then he sat down beside her.

“Cathryn, you must tell me what is going on.”

His wife looked up with great effort, her teal-blue eyes awash with tears. She opened her mouth, but before she could speak the door opened. Dr. Jordan Wiley stepped into the room.

Charles, his hands still resting on Cathryn’s shoulders, turned at the sound of the closing door. When he saw Dr. Wiley he stood up, searching the man’s face for a clue to what was happening. He had known Dr. Wiley for almost twenty years. It had been a professional rather than a social relationship, beginning while Charles was in medical school. Wiley had been his preceptor for third-year pediatrics and had impressed Charles with his knowledge, intelligence, and empathy. Later when Charles needed a pediatrician he’d called Jordan Wiley.

“It’s good to see you again, Charles,” said Dr. Wiley, grasping Charles’s hand. “I’m sorry it’s under such trying circumstances.”

“Perhaps you could tell me what these trying circumstances are,” said Charles, allowing annoyance to camouflage his fear.

“You haven’t been told?” asked Dr. Wiley. Cathryn shook her head.

“Maybe I should step outside for a few moments,” said Dr. Wiley.

He started to turn toward the door, but Charles restrained him with a hand on his forearm. “I think you should tell me what this is all about,” he said.

Dr. Wiley glanced at Cathryn, who nodded agreement. She was no longer sobbing but she knew she’d have difficulty speaking.

“All right,” said Dr. Wiley, facing Charles once again. “It’s about Michelle.”

“I gathered that,” said Charles.

“Why don’t you sit down,” said Dr. Wiley.

“Why don’t you you just tell me,” said Charles.

Dr. Wiley scrutinized Charles’s anxious face. He saw that Charles had aged a lot since he was a student and was sorry that he had to be the messenger of more anguish and suffering; it was one of the few responsibilities of being a doctor that he detested.

“Michelle has leukemia, Charles,” said Dr. Wiley.

Charles’s mouth slowly dropped open. His blue eyes glazed as if he were in a trance. He didn’t move a muscle; he didn’t even breathe. It was as if Dr. Wiley’s news had released a flood of banished memories. Over and over Charles heard, “I’m sorry to inform you, Dr. Martel, but your wife, Elizabeth, has an aggressive lymphoma… I’m awfully sorry to report that your wife is not responding to treatment… Dr. Martel, I’m sorry to say, but your wife has entered a terminal leukemic crisis… Dr. Martel, I’m terribly sorry to have to tell you that your wife died a few moments ago.”

“No! It’s not true. It’s impossible!” shouted Charles with such vehemence that both Dr. Wiley and Cathryn were startled.

“Charles,” began Dr. Wiley as he reached out and placed a sympathetic arm on Charles’s shoulder.

With a lightning movement, Charles knocked Dr. Wiley’s hand away. “Don’t you dare patronize me!”

Despite her tears, Cathryn jumped up and caught Charles’s arm as Dr. Wiley stepped back in surprise.

“Is this all some elaborate joke?” snapped Charles, shrugging off Cathryn’s hand.

“It’s not a joke,” said Dr. Wiley. He spoke gently but firmly. “Charles, I know this is difficult for you, especially because of what happened to Elizabeth. But you have to get control of yourself. Michelle needs you.”

Charles’s mind was a jumble of incomplete thoughts and emotions. He wrestled with himself, trying to anchor his thoughts. “What makes you think Michelle has leukemia?” He spoke slowly, with great effort. Cathryn sat back down.

“The diagnosis in unequivocal,” said Dr. Wiley softly.

“What kind of leukemia?” asked Charles, running his hand through his hair and looking out the window at the neighboring brick wall. “Lymphocytic?”

“No,” said Dr. Wiley. “I’m sorry to say but it’s acute myeloblastic.”

I’m sorry to say… I’m sorry to say… a stock medical phrase that doctors resorted to when they didn’t know what else to do and it echoed unpleasantly in Charles’s head. I’m sorry to say your wife died… It was like a knife plunging into the heart.

“Circulating leukemic cells?” asked Charles, forcing intelligence to struggle against memory.

“I’m sorry to say, but there are,” said Dr. Wiley. “Her white count is over fifty thousand.”

A deathly silence descended over the room.

Abruptly Charles began to pace. He moved with quick steps, while his hands worked at each other as if they were enemies.

“A diagnosis of leukemia isn’t certain until a bone marrow is done,” he said abruptly.

“It’s been done,” said Dr. Wiley.

“It couldn’t have,” snapped Charles. “I didn’t give permission.”

“I did,” said Cathryn, her voice hesitant, fearful she’d done something wrong.

Ignoring Cathryn, Charles continued to glower at Dr. Wiley.

“I want to see the smears myself.”

“I’ve already had the slides reviewed by a hematologist,” said Dr. Wiley.

“I don’t care,” said Charles angrily. “I want to see them.”

“As you wish,” said Dr. Wiley. He remembered Charles as a rash but thorough student. Apparently he hadn’t changed. Although Dr. Wiley knew that it was important for Charles to substantiate the diagnosis, at that moment he would have preferred to talk about Michelle’s extended care.

“Follow me,” he said finally and led Charles out of the conference room and down the hall. Once the conference room door opened a cacophony of crying babies could be heard. Cathryn, initially unsure of what to do, hurried after the men.

At the opposite end of the corridor they entered a narrow room which served as a small clinical lab. There was just enough space for a counter and a row of high stools. Racks of urine samples gave the room a slightly fishy aroma. A pimply faced girl in a soiled white coat deferentially slid off the nearest stool. She’d been busy doing the routine urinalysis.

“Over here, Charles,” said Dr. Wiley, motioning to a shrouded microscope. He plucked off the plastic cover. It was a binocular Zeiss. Charles sat down, adjusted the eyepieces, and snapped on the light. Dr. Wiley opened up a nearby drawer and pulled out a cardboard slide holder. Gently he lifted one of the slides out, being careful to touch only the edges. As he extended it toward Charles, their eyes met. To Dr. Wiley, Charles looked like a cornered animal.

Using his left hand, Charles took the slide between his thumb and first finger. In the center of the slide was a cover glass over what appeared to be an innocuous smudge. On the ground glass portion of the slide was written:

Charles’s hand trembled as he placed the slide on the mechanical stage and put a drop of oil on the cover glass. Watching from the side he lowered the oil immersion lens until it just touched the slide and entered the oil.

Taking a deep breath, Charles put his eyes to the oculars and tensely began to raise the barrel of the scope. All at once a multitude of pale blue cells leaped out of the blur, choking off his breath, and forcing the blood to pound in his temples. A shiver of fear as real as if he were looking at his own death warrant blew through his soul. Instead of the usual population of cells in all stages of maturation, Michelle’s marrow had been all but replaced by large, undifferentiated cells with correspondingly large irregular nuclei, containing multiple nucleoli. He was gripped by a sense of utter panic.

“I think you’ll agree it’s rather conclusive,” said Dr. Wiley gently.

With a crash, Charles leaped to his feet, knocking his stool over backwards. An uncontrollable anger, anger pent up from the exasperating morning and now fired by Michelle’s illness, blinded him. “Why?” he screamed at Dr. Wiley, as if the pediatrician were part of an encircling conspiracy. He grabbed a fistful of the man’s shirt and shook him violently.

Cathryn leaped between the two men, throwing her arms around her husband. “Charles, stop!” she shouted, terrified of alienating the one person she knew they needed to help them. “It’s not Dr. Wiley’s fault. If anyone’s to blame, it’s us.”

As if waking from a dream, Charles embarrassingly let go of Dr. Wiley’s shirt, leaving the surprised pediatrician’s bow tie at an acute angle. He bent down and righted the stool, then stood back up, covering his face with his hands.

“Blame is not the issue,” said Dr. Wiley, fumbling nervously with his tie. “Caring for the child is the issue.”

“Where is Michelle?” asked Charles. Cathryn did not let go of his arm.

“She’s already been admitted to the hospital,” said Dr. Wiley. “She’s on Anderson 6, a floor with a wonderful group of nurses.”

“I want to see her,” said Charles, his voice weak.

“I’m sure you do,” said Dr. Wiley. “But I think we have to discuss her care first. Listen, Charles.” Dr. Wiley reached out a comforting hand, but thought better of it. Charles’s fury had unnerved him. Instead he put his hands in his pockets. “We have here at Pediatric one of the world’s authorities on childhood leukemia, Dr. Stephen Keitzman, and with Cathryn’s permission I’ve already contacted him. Michelle is a very sick little girl, and the sooner a pediatric oncologist is on the case the better. He agreed to meet with us as soon as you arrived. I think we should talk to him, then see Michelle.”

At first Cathryn wasn’t sure about Dr. Stephen Keitzman. Outwardly he was the opposite of Dr. Wiley. He was a small, young-looking man with a large head and thick dark, curly hair. He wore rimless glasses on a skinny nose whose pores were boldly evident. His manner was abrupt, his gestures nervous, and he had a peculiar tic that he displayed during pauses in his speech. All at once he’d curl his upper lip in a sneer that momentarily bared his capped teeth and flared his nostrils. It lasted only an instant but it had a disquieting effect on people who were meeting him for the first time. But he was sure of himself and spoke with an authority that made Cathryn feel confidence in the man.

Certain that she would forget what was being told to them, she pulled out a small notebook and ballpoint pen. It confused her that Charles didn’t seem to be listening. Instead he was staring out the window, seemingly watching the traffic inching along Longwood Avenue. The northeast wind had brought arctic air into Boston and the mixture of light rain and snow had turned to a heavy snow. Cathryn was relieved that Charles was there to take control because she felt incapable. Yet he was acting strangely: angry one minute, detached the next.

“In other words,” summed up Dr. Keitzman, “the diagnosis of acute myeloblastic leukemia is established beyond any doubt.”

Swinging his head around, Charles surveyed the room. He knew that he had a precarious hold on his emotions, and it made it difficult to concentrate on what Keitzman had to say. Angrily he felt he’d spent the whole morning watching people undermine his security, dislocate his life, destroy his family, rob him of his newly found happiness. Rationally he knew there was a big difference between Morrison and Ibanez on the one hand and Wiley and Keitzman on the other, but at the moment they all triggered the same unreasoning fury. Charles had great difficulty believing that Michelle had leukemia, particularly the worst possible type, the most deadly kind. He had already been through that kind of disaster; it was someone else’s turn.

Listening half-heartedly, Charles examined Dr. Stephen Keitzman, who had assumed that typical condescending air of the physician in charge, doling out bits and pieces of information as if he were lecturing. Obviously Keitzman had experienced this scene many times before and his stock phrases like “I’m sorry to say” had an overused, insincere ring. Charles had the uncomfortable feeling that the man was enjoying himself, not in the same manner he’d enjoy a movie or a good meal, but in a more subtle, self-satisfied way: he was the center of attention in a crisis. This attitude abraded Charles’s already frayed emotions, especially since he was more than familiar with the general material Dr. Keitzman was covering. Charles forced himself to remain silent while his mind’s eye conjured up kaleidoscopic images of Michelle as she grew up.

“In order to allay the inevitable sense of guilt,” continued Keitzman as he bared his upper teeth in one of his nervous grimaces, “I want to emphasize that the cause and date of onset of leukemia like Michelle’s is unknown. Parents should not try to blame specific events for initiating the disease. The goal will be to treat the condition and bring about a remission. I’m pleased to be able to report that we have very favorable results with acute myeloblastic leukemia; something we didn’t have ten years ago. Now we are able to engineer a remission in about eighty percent of cases.”

“That’s wonderful,” said Charles, speaking for the first time. “But unlike the five-year cures you’ve been achieving with other forms of leukemia, can you tell us how long the remission lasts in Michelle’s form of the disease.” It was as if Charles had to goad Keitzman into revealing the worst news at once.

Keitzman pushed back his glasses and cleared his throat. “Dr. Martel, I am aware you know more about your daughter’s disease than other parents I deal with. But since your field is not specifically childhood leukemia, I don’t have any idea what you know and what you don’t know. Therefore, I felt it best to have this discussion as if you knew nothing. And even if you are already familiar with these facts, perhaps they are helpful to Mrs. Martel.”

“Why don’t you answer my question?” said Charles.

“I think it is a more fruitful approach if we concentrate on obtaining a remission,” said Dr. Keitzman. His nervous tic became more frequent. “My experience has shown that with the advances in chemotherapy, leukemia should be approached on a day-to-day basis. We have seen some spectacular remissions.”

“Except in Michelle’s type,” snarled Charles. “Come on, tell us what the probability is of a five-year survival with acute myeloblastic leukemia.”

Dr. Keitzman looked away from Charles’s challenging eyes to Cathryn’s frightened face. She had paused in her notetaking, gaping at Dr. Keitzman. He knew the meeting was going badly. He glanced at Dr. Wiley for support, but Dr. Wiley had his head down, watching his thumbnail play against his other fingers. Trying to avoid Charles’s stare, Keitzman said in a low voice, “The five-year survival is not impressive in acute myeloblastic leukemia, but it’s not impossible.”

“Now you’re getting closer to the truth,” said Charles, jumping to his feet and leaning over Dr. Keitzman’s desk. “But to be more exact, the median survival of acute myeloblastic leukemia if a remission is obtained is only one to two years. And, in Michelle’s case, with circulating leukemic cells, her chances of a remission are a lot less than eighty percent. Wouldn’t you agree, Dr. Keitzman?”

Taking his glasses off, Dr. Keitzman tried to think of how best to word his response. “There’s some truth in what you say, but it is not a constructive way to view the disease. There are lots of variables.”

Charles abruptly walked to the window, watching the dirty snow flutter past. “Why don’t you tell Mrs. Martel what the survival time of the nonresponder is… the patients who don’t have a remission.”

“I’m not sure what good this…” began Dr. Keitzman.

Charles whirled around. “What good? You dare to ask? I’ll tell you what good it is. The worst thing about disease is the uncertainty. Humans are capable of adapting to anything as long as they know. It’s the hopeless floundering that drives people crazy.”

Charles stormed back to Dr. Keitzman’s desk as he spoke. Eyeing Cathryn’s pad, he grabbed it and threw it into the wastebasket. “We don’t need notes on this gathering! It’s not a goddamn lecture. Besides, I know all too well about leukemia.” Turning back to Dr. Keitzman, Charles’s face was flushed. “Come on, Keitzman, tell us about the survival time of nonresponders.”

Keitzman moved back in his chair, his hands gripping the edge of the desk as if he were prepared for flight. “It’s not good,” he said finally.

“That’s not good enough,” snapped Charles. “Be more specific.”

“All right!” said Dr. Keitzman. “Weeks, months at the most.”

Charles didn’t answer. Having successfully backed Dr. Keitzman into a corner, he was suddenly adrift. Slowly he sank back down into his chair.

Keitzman’s face recovered from a series of sustained twitches as he exchanged sympathetic glances with Dr. Wiley. Turning to Cathryn, he resumed his recommendations. “Now, as I was saying. It is best to try to think of leukemia as a nonfatal disease and to take each day as it comes.”

“That’s like telling a man on death row not to think about death,” mumbled Charles.

“Dr. Martel,” said Dr. Keitzman sharply, “as a physician I would expect your response to the crisis to be significantly different.”

“It’s easy to respond differently,” said Charles, “when it’s not a member of your own family. Unfortunately I’ve been through this before.”

“I think we should discuss therapy,” offered Dr. Wiley, speaking for the first time.

“I agree,” said Dr. Keitzman. “We must start treatment as soon as possible. In fact, I’d like to start today, immediately after all the baseline studies are done. But of course, we are going to need consent to treat because of the nature of the drugs.”

“With the chance of a remission so slight, are you sure it’s worth subjecting Michelle to the side effects?” Charles was speaking more calmly now, but he had a terrible vision of Elizabeth during those last months, the violent nausea, the loss of hair… He closed his eyes.

“Yes, I do,” said Dr. Keitzman firmly. “I think it is well established that we have made significant advances in treating childhood leukemia.”

“That’s absolutely true,” confirmed Dr. Wiley.

“There have been advances,” agreed Charles, “but unfortunately in types of leukemia other than Michelle’s.”

Cathryn’s eyes darted from Charles, to Keitzman, to Wiley. She expected and wanted unanimity on which she could build her hope. Instead she could feel nothing but dissension and animosity.

“Well,” said Dr. Keitzman, “I believe in aggressively treating all cases, whatever the chances are for remission. Every patient deserves a chance at life, whatever the cost. Every day, every month, is precious.”

“Even if the patient would rather end her suffering,” said Charles, recalling Elizabeth’s last days. “When the chances of a remission—let alone a cure—are less than twenty percent, I don’t know if it’s worth subjecting a child to the additional pain.”

Dr. Keitzman stood up abruptly, pushing back his chair. “We obviously view the value of life very differently. I believe chemotherapy to be a truly remarkable weapon against cancer. But you are entitled to your opinion. However, it seems evident that you would prefer to find another oncologist or handle your daughter’s therapy yourself. Good luck!”

“No!” said Cathryn, leaping to her feet, terrified at the prospect of being abandoned by Dr. Keitzman, who Dr. Wiley had said was the best. “Dr. Keitzman, we need you. Michelle needs you.”

“I don’t think your husband shares your view, Mrs. Martel,” said Dr. Keitzman.

“He does,” said Cathryn. “He’s just distraught. Please, Dr. Keitzman.” Turning to Charles, Cathryn put a hand on his neck. “Charles, please! We can’t fight this alone. You said this morning you weren’t a pediatrician. We need Dr. Keitzman and Dr. Wiley.”

“I think you should cooperate,” urged Dr. Wiley.

Charles sagged under the weight of his brooding impotence. He knew he could not care for Michelle even if he were convinced the current approach for her particular disease to be wrong. He had nothing to offer and his mind was overloaded, an emotional jumble.

“Charles, please?” Cathryn pleaded.

“Michelle is a sick little girl,” said Dr. Wiley.

“All right,” said Charles softly, once again forced to surrender.

Cathryn looked at Dr. Keitzman. “There! He said all right.”

“Dr. Martel,” asked Dr. Keitzman. “Do you want me to serve as the oncologist on this case?”

With a sigh which suggested breathing to be a great effort, Charles reluctantly nodded his head.

Dr. Keitzman sat down and rearranged some papers on his desk. “All right,” he said at length. “Our protocol for myeloblastic leukemia involves these drugs: Daunorubicin, Thioguanine, and Cytarabine. After our workup we’ll start immediately with 60 mg/m2 of Daunorubicin given IV by rapid infusion.”

As Dr. Keitzman outlined the treatment schedule, Charles’s mind tortured him by recalling the potential side effects of the Daunorubicin. Michelle’s fever was probably caused by an infection due to her body’s depressed ability to fight bacteria. The Daunorubicin would make that worse. And besides making her essentially defenseless for a host of bacteria and fungi, the drug would also devastate her digestive system and possibly her heart… besides that… her hair… God!

“I want to see Michelle,” he said suddenly, leaping to his feet, trying to stifle his thoughts. Immediately he became aware that he had interrupted Dr. Keitzman in mid-sentence. Everyone was staring at him as if he had done something outrageous.

“Charles, I think you should listen,” said Dr. Wiley, reaching up and grasping Charles’s arm. It had been a reflexive gesture and only after he’d made contact did Dr. Wiley question its advisability. But Charles didn’t react. In fact his arm felt limp and after the slightest tug, he sat back down.

“As I was saying,” continued Dr. Keitzman, “I believe it is important to tailor the psychological approach to the patient. I tend to work by age: under five; school age; and adolescents. Under five it’s simple; constant and loving supportive therapy. Problems start in the school-age group where the fear of separation from parents and the pain of hospital procedures are the major concerns of the child.”

Charles squirmed in his seat. He didn’t want to try to think of the problem from Michelle’s point of view; it was too painful.

Dr. Keitzman’s teeth flashed as his face momentarily contorted, then he continued, “With the school-age child, the patient is told no more than he specifically asks to know. The psychological support is focused on relieving the child’s anxieties about separation.”

“I think Michelle is going to feel the separation aspect a lot,” said Cathryn, struggling to follow Dr. Keitzman’s explanation, wanting to cooperate to please the man.

“With adolescents,” said Dr. Keitzman without acknowledging Cathryn, “treatment approaches that of an adult. Psychological support is geared to eliminate confusion and uncertainty without destroying denial if that is part of the patient’s defense mechanism. In Michelle’s situation, unfortunately, the problem falls between the school age and the adolescent. I’m not sure what is the best way to handle it. Perhaps you people as parents might have an opinion.”

“Are you talking about whether Michelle should be told she has leukemia?” asked Cathryn.

“That’s part of it,” agreed Dr. Keitzman.

Cathryn looked at Charles, but he had his eyes closed again. Dr. Wiley returned her gaze with a sympathetic expression that made Cathryn feel a modicum of reassurance.

“Well,” said Dr. Keitzman, “it is an issue that demands thought. No decision has to be made now. For the time being, Michelle can be told that we are trying to figure out what’s wrong with her. Before we go, does Michelle have any siblings?”

“Yes,” said Cathryn. “Two brothers.”

“Good,” said Dr. Keitzman. “They should be typed to see if they match Michelle’s HLA and ABO loci. We’re probably going to need platelets, granulocytes, and maybe even marrow, so I hope one of them matches.”

Cathryn looked at Charles for support but his eyes were still closed. She had no idea what Dr. Keitzman was talking about but she assumed Charles did. But Charles seemed to be having more trouble than she was with the news.

On the way up in the elevator, Charles fought to control himself. He’d never before experienced such painfully conflicting emotions. On the one hand he could not wait to see his daughter, to hold her and protect her; on the other he dreaded seeing her because he was going to have to come to terms with her diagnosis. And in that sense he knew too much. She would see it in his face.

The elevator stopped. The doors opened. Ahead stretched a pale blue hall with pictures of animals affixed like decals directly on the paint. It was busy with pajama-clad children of a variety of ages, nurses, parents, even hospital maintenance men grouped about a stepladder fixing the lights.

Dr. Wiley led them down the hall, skirting the ladder and passing the busy nurses’ station. The charge nurse, seeing Dr. Wiley from behind the chart racks, scurried out and caught up with them. Charles glanced down at the floor and watched his feet. It was as if he were looking at someone else. Cathryn was beside him with her arm thrust under his.

Michelle had a single room, painted the same shade of pastel blue as the hallway. On the left wall beside the door to the lavatory was a large, dancing hippopotamus. At the end of the room was a shaded window. To the right was a closet, a bureau, a night table, and a standard hospital bed. At the head of the bed was a stainless steel pole supporting a small plastic bag as well as an IV bottle. The plastic tubing snaked down and entered Michelle’s arm. She turned from looking out the window when she heard the group enter.

“Hello, peanuts,” said Dr. Wiley brightly. “Look who I brought to see you.”

At the first glimpse of his daughter, Charles’s dread of seeing her vanished in a wave of affection and concern. He rushed up to her and scooped her head in his arms, pressing her face against his. She responded by throwing her free arm around his neck and squeezing.

Cathryn stepped around the bed to the opposite side. She caught Charles’s eye and saw that he was struggling to hold back tears. After a few minutes, he reluctantly released his hold, lowering Michelle’s head to the pillow, and smoothing out her rich, dark hair to form a fan about her pale face. Michelle reached out for Cathryn’s hand and grasped it tightly.

“How are you?” asked Charles. He was afraid that his precarious emotional state was apparent to Michelle.

“I feel fine now,” said Michelle, obviously overjoyed to see her parents. But then her face clouded and turning to Charles, she asked: “Is it true, Daddy?”

Charles’s heart leaped in his chest. She knows, he thought with alarm. He glanced at Dr. Keitzman and tried to remember what he had said about the proper psychological approach.

“Is what true?” asked Dr. Wiley casually, coming to the foot of the bed.

“Daddy?” pleaded Michelle. “Is it true I have to stay overnight?”

Charles blinked, at first unwilling to believe that Michelle wasn’t asking him to confirm the diagnosis. Then when he was sure she didn’t know she had leukemia, he smiled with relief. “Just for a few nights,” he said.

“But I don’t want to miss school,” said Michelle.

“Don’t you worry about school,” said Charles with a nervous laugh. He eyed Cathryn for a moment who also laughed in the same hollow fashion. “It’s important that you stay here for some tests so that we can find out what’s causing your fever.”

“I don’t want any more tests,” said Michelle, her eyes widening in fright. She’d had enough pain.

Charles was struck by how tiny her body was in the hospital bed. Her narrow arms looked incredibly frail as they poked out of the sleeves of the hospital gown. Her neck, which had always seemed substantial, now looked about the size of his forearm; she had the appearance of a delicate and vulnerable bird. Charles knew that somewhere in the heart of her bone marrow was a group of her own cells waging war against her body. And there was nothing he could do to help her—absolutely nothing.

“Dr. Wiley and Dr. Keitzman will only do the tests they absolutely need,” said Cathryn, stroking Michelle’s hair. “You’re going to have to be a big girl.”

Cathryn’s comment awakened a sense of protectiveness in Charles. He recognized he couldn’t do anything for Michelle, but at least he could protect her from unnecessary trauma. He knew too well that patients with rare diseases were often subjected to all sorts of physical harassment at the whim of the attending physician. With his right hand, Charles twisted the soft plastic bottle so he could see the label. Platelets. With his hand still holding the bottle, he turned to Dr. Wiley.

“We felt she needed platelets immediately,” said Dr. Wiley. “Hers were only about twenty thousand.”

Charles nodded.

“Well, I’ve got to be going,” said Dr. Keitzman. Grasping one of Michelle’s feet through the covers he said, “I’ll be seeing you later, Miss Martel. Also there will be a few other doctors coming in to talk to you sometime today. We’ll be giving you some medicine in that tube, so keep your arm nice and still.”

Charles peered at the plastic tube: Daunorubicin! A fresh wave of fear washed over him, accompanied by a new urge to reach down and snatch his beloved daughter from the clutches of the hospital. An irrational thought passed through his mind: maybe the whole nightmare would disappear if he got Michelle away from all these people.

“I’m available anytime at all if you’d like to speak to me,” said Dr. Keitzman as he moved to the door.

Cathryn acknowledged the offer with a smile and a nod. She noticed that Charles didn’t look up from Michelle. Instead he sat on the edge of the bed and whispered something in her ear. Cathryn hoped his silence would not further antagonize the oncologist.

“I’ll be right outside,” said Dr. Wiley, following Dr. Keitzman. The charge nurse who hadn’t spoken left, too.

In the hall Dr. Keitzman slowed his steps, giving Dr. Wiley a chance to catch up. Together they walked toward the nurses’ station.

“I think Charles Martel is going to make this a very difficult case,” said Dr. Keitzman.

“I’m afraid you’re right,” agreed Dr. Wiley.

“If it weren’t for that poor sick child, I’d tell Martel to stuff it,” said Dr. Keitzman. “Could you believe that bullshit about withholding chemotherapy? God! You’d think that someone in his position would know about the advances we’ve made with chemotherapy, especially in lymphocytic leukemia and Hodgkin’s.”

“He knows,” said Dr. Wiley. “He’s just angry. It’s understandable, particularly when you know he’s been through all this when his wife died.”

“I still resent his behavior. He is a physician.”

“But he’s in pure research,” said Dr. Wiley. “He’s been away from clinical medicine for almost ten years. It’s a good argument for researchers to keep one foot in clinical medicine to keep their sense of perspective alive. After all, taking care of people is what it’s all about.”

They reached the nurses’ station, and both men leaned on the counter surveying the busy scene about them with unseeing eyes.

“Charles’s anger did scare me for a moment,” admitted Dr. Wiley. “I thought he’d totally lost control.”

“He wasn’t much better in my office,” said Dr. Keitzman, shaking his head. “I’ve dealt with anger before, as I’m sure you have, but not like this. People get angry at fate, not the diagnosing physicians.”

The two men watched an OR orderly skillfully navigate a gurney carrying a recent post-op down the corridor from the patient elevator. For a moment they didn’t talk. The gurney carrying the child from recovery disappeared into one of the rooms, and several nurses hurried after it.

“Are you thinking about what I am?” asked Dr. Keitzman.

“Probably. I’m wondering just how stable Dr. Charles Martel is.”

“Then we’re thinking the same thing,” said Dr. Keitzman. “Those sudden mood shifts in my office.”

Dr. Wiley nodded. “Even given the circumstances, his reaction seemed inappropriate. But he’s always been an odd duck. Lives someplace in the middle of nowhere in New Hampshire. He claimed it was his first wife’s idea but after she died, he didn’t move. And now he’s got this wife living up there, too. I don’t know. To each his own, I guess.”

“His new wife seems fine.”

“Oh, she’s a peach. Adopted the kids, treats them like her own. I was afraid when they got married that she’d bit off more than she could chew, but she’s adapted remarkably. She was devastated when I told her Michelle had leukemia, but I was pretty sure she’d deal with it better than Charles. In fact, that’s why I told her first.”

“Maybe we should talk just to her for a moment,” suggested Dr. Keitzman. “What do you think?”

“Let’s try.” Dr. Wiley turned to face the nurses’ station. “Miss Shannon! Could you come over here for a moment?”

The charge nurse came over to the two doctors. Dr. Wiley explained that they wanted to speak to Mrs. Martel without her husband and asked her if she wouldn’t mind going down to Michelle’s room and trying to engineer it.

As they watched Miss Shannon walk briskly down the hall, Dr. Keitzman’s facial muscles jumped. “It goes without saying that the child is desperately ill.”

“I thought as much when I saw her peripheral blood smear,” said Dr. Wiley. “Then when I saw her bone marrow, I was sure.”

“She could be a very rapidly terminating case, I’m afraid,” said Dr. Keitzman. “I think she already has central nervous system involvement. Which means we have to commence treatment today. I want Dr. Nakano and Dr. Sheetman to see her right away. Martel is right about one thing. Her chance of a remission is very slim.”

“But you still have to try,” said Dr. Wiley. “At times like these I don’t envy you your specialty.”

“Of course I’ll try,” said Dr. Keitzman. “Ah, here comes Mrs. Martel.”

Cathryn had followed Miss Shannon out into the hall, half-expecting to see Marge Schonhauser because the nurse had said someone was asking to see her. She hadn’t been able to think of anyone else who knew that she was in the hospital. Once clear of the room, however, Miss Shannon confided that the doctors wanted to speak to her alone. It sounded ominous.

“Thank you for coming out,” said Dr. Wiley.

“It’s all right,” said Cathryn, her eyes darting from one man to the next. “What’s wrong?”

“It’s about your husband,” began Dr. Keitzman cautiously. He paused, trying to choose his words carefully.

“We’re concerned that he may interfere in Michelle’s treatment,” Dr. Wiley finished the thought. “It’s hard for him. First he knows too much about the disease himself. Then he already has watched someone he loved die despite chemotherapy.”

“It’s not that we don’t understand his feelings. We just feel Michelle should have every chance at remission regardless of the side effects.”

Cathryn examined the narrow, hawklike features of Dr. Keitzman and the broad, rounded face of Dr. Wiley. They were outwardly so different yet similar in their intensity. “I don’t know what you want me to say.”

“We’d just like you to give us some idea of his emotional state,” said Dr. Keitzman. “We’d like to have some idea of what to expect.”

“I think he will be fine,” assured Cathryn. “He had a lot of trouble adjusting when his first wife died, but he never interfered with her treatment.”

“Does he often lose his temper as he did today?” asked Keitzman.

“He’s had an awful shock,” said Cathryn. “I think it’s understandable. Besides, ever since his first wife died, cancer research has been his passion.”

“It’s a terrible irony,” agreed Dr. Wiley.

“But what about the kind of emotional outburst he demonstrated today?” asked Dr. Keitzman.

“He does have a temper,” said Cathryn, “but he usually keeps it under control.”

“Well, that’s encouraging,” said Dr. Keitzman. “Maybe it’s not going to be so difficult after all. Thank you, Mrs. Martel. You’ve been most helpful, especially since I know you, too, have had a terrible shock. I’m sorry if we’ve said anything disturbing but we’ll do our best for Michelle, I can assure you of that.” Turning to Dr. Wiley, he said, “I’ve got to get things rolling. I’ll speak to you later.” He moved quickly, almost at a run, and was out of sight in seconds.

“He has some strange mannerisms,” said Dr. Wiley, “but you couldn’t get a better oncologist. He’s one of the top people in the world in childhood leukemia.”

“I was afraid he was going to abandon us when Charles acted up,” said Cathryn.

“He’s too good of a doctor for that,” said Dr. Wiley. “He’s only concerned about Charles because of your husband’s attitude to chemotherapy, and aggressive treatment has to be started right away to get her into a remission.”

“I’m sure Charles won’t interrupt her treatment,” said Cathryn.

“Let’s hope not,” said Dr. Wiley. “But we’re going to count on your strength, Cathryn.”

“My strength?” questioned Cathryn, aghast. “Hospitals and medical problems aren’t my strong points.”

“I’m afraid you’ll have to overcome that,” said Dr. Wiley. “Michelle’s clinical course could be very difficult.”

At that moment she caught sight of Charles emerging from Michelle’s room. He spotted Cathryn and started toward the nurses’ station. Cathryn ran down to meet him. They stood for a moment in a silent embrace, drawing strength from each other. When they started back toward Dr. Wiley, Charles seemed more in control.

“She’s a good kid,” he said. “Christ, all she’s worried about is staying overnight. Said she wanted to be home in the morning to make the orange juice. Can you believe that?”

“She feels responsible,” said Cathryn. “Until I arrived she was the woman of the house. She’s afraid of losing you, Charles.”

“It’s amazing what you don’t know about your own children,” said Charles. “I asked her if she minded if I went back to the lab. She said no, as long as you stayed here, Cathryn.”

Cathryn was touched. “On the way to the hospital we had a little talk, and for the first time I felt she really accepted me.”

“She’s lucky to have you,” said Charles. “And so am I. I hope you don’t mind my leaving you here. I hope you understand. I feel such a terrible powerlessness. I’ve got to do something.”

“I understand,” said Cathryn. “I think you’re right. There isn’t anything you can do right now and it would be better if you can get your mind on something else. I’ll be happy to stay. In fact, I’ll call my mother. She’ll come over and take care of things.”

Dr. Wiley watched the couple come toward him, pleased to see their open affection and mutual support. The fact that they were acknowledging and sharing their grief was healthy; it was a good sign and it encouraged him. He smiled, somewhat at a loss for what to say as they arrived. He had to get back to his office which he knew was in chaos, but he wanted to be there if they still needed him.

“Do you have any extra of Michelle’s blood?” asked Charles. His voice was businesslike, matter-of-fact.

“Probably,” said Dr. Wiley. It wasn’t a question he had expected. Charles had the uncanny ability to unnerve him.

“Where would it be?” asked Charles.

“In the clinical lab,” said Dr. Wiley.

“Fine. Let’s go.” Charles started toward the elevator.

“I’ll stay here with Michelle,” said Cathryn. “I’ll call if there is any news. Otherwise I’ll see you home for dinner.”

“Okay.” He strode off purposefully.

Confused, Dr. Wiley hurried after Charles, nodding a quick good-bye to Cathryn. His encouragement regarding Charles’s behavior was quickly undermined. Charles’s mood had apparently tumbled off on a new and curious tangent. His daughter’s blood? Well, he was a physician.