Читать книгу The Perfect Treatment - Rebecca Lang - Страница 7

THE coronary care unit was quiet, peaceful, set up in an area of the acute-care floor of the hospital where there was no through traffic and where noise could be kept to a bare minimum. They entered through a heavy door that closed silently behind them.

A nurse sat at a desk in the nursing station, looking at a bank of individual computer screens which were monitoring the four patients who were in her section. Each patient was connected up to leads going to the electronic equipment which would relay the information to the screen. Any irregularities of heartbeat, blood pressure and oxygen levels of the blood would immediately be known.

Although all was peaceful, Abby knew that she would not want to be a patient here, lying in bed, wondering if your heart would stop at any moment. Walking beside Dr Contini, she looked around her as they approached the nurse silently.

‘Is Dr Ryles here?’ he asked. The nurse gestured towards an area down a short corridor where there were a few individual rooms.

‘Room three,’ she said with a smile.

‘How is he?’ Abby said.

‘Pretty good, considering. He’s stable now. His wife’s with him at the moment,’ the nurse said. ‘He’s sleeping, so we don’t really want him to be disturbed.’

‘Sure,’ Dr Contini said. ‘We won’t wake him.’

In room three, Dr Ryles lay on his back in the narrow bed, the monitor leads attached to his bare chest. A small computer screen by the bed showed the spiky graph of his heartbeat, as well as the heart rate and blood pressure. Abby’s eyes went automatically to that screen as they entered silently. What she saw there confirmed that he was stable, his blood pressure near normal, the heartbeat good.

He was still on oxygen, his colour good now, while intravenous fluids dripped slowly from a litre plastic bag hung beside the bed. Abby felt her anxiety diminish somewhat. The team from the emergency department had been in time after all.

Mrs Ryles, who looked about the same age as her husband, was sitting beside the bed, her face turned to him. She rose to her feet as they stopped at her side. Her pale face showed evidence of tears, the eyelids swollen and red, and she registered surprised pleasure at seeing Dr Contini.

‘Hello, Ginny,’ he said softly, holding out his arms to her. ‘I’m sorry to be meeting you again so soon under these circumstances.’

‘Oh, Blake.’ The woman’s voice trembled as she went gratefully into the arms that Dr Contini offered her. They embraced in a silent hug. ‘Thank God you’re here.’

So they were friends after all. Abby stood aside, watching them, her own emotions very close to the surface as she saw the tears again on the wife’s face. When they had satisfied themselves that Dr Ryles was indeed all right, Dr Contini gestured that they should go outside to the main corridor where they could talk without disturbing anyone.

‘This is Dr Gibson,’ Blake Contini introduced her when they were outside. ‘She was the one who found Will.’

Mrs Ryles grasped Abby’s outstretched hand with both her own. ‘I want to thank you,’ she said, her voice trembling. ‘I understand that he was in the basement, where he might not have been found for some time. If you hadn’t found him…hadn’t known what to do, or what you were looking at…he might not have survived. Thank you. You saved his life.’

‘I—I’m very glad that I was there,’ Abby said. ‘I…really didn’t do a lot. I was just able to call someone.’

‘You were there—that’s the main thing!’ Ginny Ryles said emphatically. ‘It’s all this business about the downsizing that’s going on here, you know, that has brought this on with Will…all the budget cuts.’

‘That’s most likely a contributing factor,’ Abby agreed wryly, as the distraught woman articulated more or less what she had been thinking herself that morning.

‘It’s all the underhand business of deliberately running down departments, without telling the professional staff what has been planned, so that private companies can take over the radiology work of this hospital,’ Ginny Ryles went on with bitter passion, as though she had been waiting to speak to someone about it for a long time.

Abby nodded, while Dr Contini stood silent. ‘I don’t doubt that for one moment…not for one moment,’ Mrs Ryles went on. ‘He’s talked about nothing else for weeks. All the stress…It has to get to someone. It has to.’

‘Yes,’ Abby agreed, picking up the frustration in the woman’s words.

Blake Contini took the woman’s arm. ‘Come with me to the hospital cafeteria, Ginny,’ he said kindly. ‘I’ll buy you coffee, or anything you want. We can talk there. Dr Gibson has to get to Outpatients.’

‘Thank you, Blake. You’re very kind, and I do appreciate it,’ Ginny Ryles said.

‘Dr Gibson.’ Blake Contini turned to Abby. ‘I’ll see you in Outpatients in a little while. I have some patients to see there. I’ll square things for you with Dr Wharton about taking time off.’

‘All right. Thank you,’ Abby said. ‘Well, goodbye, Mrs Ryles. I expect I’ll see you again, I’ll probably look in later…He’s in good hands.’

‘Thank you again, Dr Gibson. I’m planning to spend most of the day here with Will. I’ll only go out of my mind if I stay at home,’ Mrs Ryles said quietly.

‘There’s every indication that he’s going to be all right,’ Dr Contini reassured her gently, while Abby looked at him surreptitiously with new eyes.

Yes, it was clear that he could be charming. She wondered momentarily what it would be like to be the object of that charm, that warmth and undivided attention. Perversely, uncharacteristically, she found herself longing for it—almost as though the incident with Will Ryles had jolted her out of a deep sleep, like Sleeping Beauty in the fairy-tale—then brought her face to face with the prince. Snap out of it, Abigail Gibson, she admonished herself once again. Get real!

‘Thank you for saying that,’ Mrs Ryles said tremulously, trying to inject some hope into her voice. ‘Here I am, going on about our affairs, but what about you, Blake? How’s Kaitlin? Any change there?’

‘No, nothing,’ Dr Contini said heavily.

‘Is there likely to be?’

‘I doubt it very much.’

As Abby made her way to Outpatients a little later, she puzzled over that last brief verbal exchange. It was evident that Dr Contini had known Dr Ryles and his wife for quite a long time.

She sighed, looking at her wristwatch and making an effort to shift her thoughts to the work ahead in the clinic. She was looking forward to it.

It was only too easy to become obsessional about the internal politics of a hospital, which were so closely connected to the broader political scene. It could sap one’s energy. Although it was of concern to her, as much as she knew that one had to get involved in some degree, she did not have time for that right now.

Who, she wondered, was Kaitlin? The question nagged at her persistently…as did the tone of Blake Contini’s voice when he had replied, ‘No, nothing.’

The voice had sounded dead, devoid of all emotion.

Dr Wharton’s clinic was well under way when she got to Outpatients. The young family practice doctors like herself were given new patients to see so that they could take detailed histories, do extensive physical examinations, order blood tests, urine tests, X-rays if necessary, and anything else that might be required before the consultant in charge—in this case Dr Wharton—saw each patient to confirm, or call into question, the preliminary diagnosis. This system saved the senior GPs a lot of time, as well as being a good training exercise for the young doctors, who were themselves MDs.

‘Morning, Sue’ Abby smiled at the receptionist sitting behind the desk off the main waiting room in the family practice unit. ‘Sorry I’m late. Anything interesting for me? I have to leave again for a while just before eleven o’clock to see a patient on 2 East, one of Dr Contini’s patients that I missed at the rounds. Is he—does he—Dr Contini, that is—have many patients here this morning?’

Although Abby felt her face flushing as she asked the question, and still feeling somewhat disturbed by all that had happened already that morning, it was good to be in the relative peace of the family practice clinic. Abby felt herself beginning to relax, her habitual confidence returning. This was her territory.

‘Hi, Dr Gibson.’ Sue, the young, efficient receptionist smiled back. ‘It’s going to be one of those days, I think. Lots of interesting cases for you to get your teeth into. Here’s your first.’ She handed over a folder that contained the patient’s basic statistics and initial complaint. ‘Dr Contini has a couple of patients to see. He told me he’d be available for any consultations here if anyone wanted him.’

‘That’s really great! Maybe I’ll take advantage of that offer, if Dr Wharton’s busy. Thanks.’ Abby took the folder, glancing at it to see the patient’s name and feeling an upsurge of anticipation at working in the same unit with Blake Contini, even though it was an anticipation tinged with remnants of irritation.

Dr Wharton would be there in the unit, plus two other family practice MDs in training like herself. At the moment there was no sign of them—no doubt they were already in the offices assigned to them, seeing patients.

‘Mr Barlow,’ she called out across the waiting room, ‘Gary Barlow.’

A thin man, wearing an old raincoat, got up from a chair, nodding to Abby. ‘This way, sir,’ she said. Leading the way, she proceeded to the small examination room which was to be her office for the duration of the clinic.

‘Take your coat off, Mr Barlow. Have a seat there next to the desk. I’m Dr Gibson. I’ll be seeing you first—taking a history, doing an examination—then Dr Wharton will see you.’

With the folder open on the desk in front of her, she read the chief complaint that this patient had. ‘Chronic bronchitis’ it read, followed by a question mark, then ‘Persistent chronic cough.’ That would have been written by Sue from the patient’s own description of what was wrong with him. Many of their patients came there without any reference letter from any other doctor; they simply telephoned the hospital, asking to see a GP. Many had never had a family doctor.

Mr Barlow, in his fifties, was thin and tired-looking, with a drooping face of loose skin that reminded Abby of a bloodhound. The top of his head was bald. In general, he did not look particularly healthy. He sounded slightly breathless from the simple effort of having walked from the waiting room and taken off his coat. He sat down heavily in the chair next to her desk. Abby took some history sheets from the pile on her desk to add to the file, prepared to do a fair amount of writing.

‘It says here that you have a chronic cough, Mr Barlow,’ she began, her pen poised above the paper, ‘Tell me when that first started, and any other symptoms associated with it.’

For the next few minutes she wrote busily while he talked. It seemed to her that he was trying to minimize the length of time he had had the cough, as well as his level of concern about it. He said he had had a cough for about a year, then it had got worse over the winter, showing no signs of going now that spring was here. He was the sort of man, she suspected, who would not go to a doctor for many years, then would only go finally when symptoms were such that he could not ignore them and his level of anxiety got to a point where he could not think of much else.

‘And do you smoke, Mr Barlow?’ Abby looked up.

‘Yes,’ he said.

‘For how many years have you smoked?’ she asked, keeping her voice neutral with no hint of judgement. ‘And how many cigarettes a day?’

‘Well…’ he said, thinking back, ‘I reckon I had my first cigarette when I was about fifteen. Now I smoke about forty a day, give or take a few.’

My God! Abby thought, keeping her face impassive as she wrote again. It was difficult to imagine getting through that many in one day, yet some people, she knew, got through more than that. ‘For how many years have you smoked forty a day?’ she asked, looking at him and watching his pale, watery eyes go blank as he stared across the room, trying to remember back that long.

‘Oh…’ He hesitated. ‘I suppose it must be at least ten years…about that.’

She wrote down the statistics. ‘When did you last have a chest X-ray?’ she said.

‘A chest X-ray?’ He looked surprised. ‘I’ve never had one.’

It never ceased to amaze Abby that many people who smoked heavily could tune out all the publicity and the statistics that were everyday knowledge about smoking and lung cancer. It was as though by some mental gyration they could dissociate it all from themselves, almost as though for health purposes they lived on another plane. That ability, if one could call it that, was very common, of course…and not just with smoking and lung cancer. It certainly applied also to hepatitis and AIDS, particularly among the population taking street drugs.

Maybe she shouldn’t be surprised, really, as nicotine was a powerful drug of addiction, although it was frequently not thought of as such. It produced a craving from which it was not easy to break free. Again, she was careful not to inject any hint of judgement in her tone. Sometimes patients would get up and leave if there was any hint of negative judgement about their behavior, past and present.

‘When did you last see a doctor?’

He hesitated, calculating. ‘Not for a long time. Never needed to,’ he asserted, with a hint of defiance. ‘Must have been about ten years ago, I guess. Had a tooth abscess. Had to have it pulled out. The guy gave me a quick once-over, then sent me to a dentist.’

‘I see,’ Abby said, writing that down. ‘Any other health problems?’

‘Nope,’ he said.

‘What about your general health? Your appetite?’ For the next little while she questioned him about the present, then went on to his medical history, starting from as early in his life as he could remember. Apparently he was one of those men who took his bodily functioning, his health, entirely for granted, having only a very rudimentary knowledge of the anatomy and physiology of the human body.

Abby filled in a requisition form for a chest X-ray, to be done that day in the hospital. If she didn’t get it done now he might never come back, especially if he got scared—any more scared than he was now. She did not want to give him a hint that he might have lung cancer, the possible diagnosis that was uppermost in her mind. He could also have chronic emphysema, a lung disease brought on by repeated chest infections, as well as by smoking. This disease also affected the heart.

She also filled in requisition forms for some basic blood work, to be done in the hospital labs. Chronic smokers were often anemic, as well as suffering from various vitamin deficiencies, as they were frequently poorly nourished. Smoking tended to dull the appetite and become a substitute for food.

‘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.