Robin Cook - Fever

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.”