The Perfect Treatment

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.