Authors: Mark A. Jacobson
M
ARCO WAS ALREADY SETTING
up gels in the laboratory before Kevin left for work. He took a break at noon, set down a stack of data printouts in his nook of a carrel, and had lunchâa thermos of strong coffee and a peanut butter and jelly sandwich. While eating, he gazed at the shelf of bound notebooks he had filled during his three years here. His heels bounced on the floor. He was so close to confirming a radical, new hypothesis, it was hard to stay calm.
Since moving to Berkeley, Marco had only chipped away at creating new knowledge. Once his current experiments were finished and the revised manuscript accepted for publication, his apprenticeship with Professor Goldstein would officially end. He would be promoted to full membership in the team attempting to create clones of genetically identical mice from stem cells. Everyone in the lab believed comparing clones of mice that had a single altered gene to clones of unaltered mice was going to become the gold standard for proving what any particular gene did, at least in mice. And because mouse and human genes were so similar, their experiments would create new paradigms for understanding human diseases.
His eyes strayed to a photo of Kevin with a turquoise lake and snowcapped mountains in the background. Kevin had a rare, contented smile. Marco's neck muscles relaxed. He had taken the picture last summer in the high Sierras. They had backpacked for a week through alpine meadows dotted with marigold, paintbrush, and penstemon. Each morning they scrambled up boulder fields to find the loneliest outposts of life where only one or two flowers could survive. Marco took photos and kept a meticulous log. At their camp, Kevin gathered wood, made fires, and cooked. The modest effort required to survive in such an austere, exquisite place made him glow with satisfaction.
Marco's attention wandered to the data printouts. He reached for a pencil but moved past it, picked up the telephone, and dialed Kevin's pager.
After his morning clinic, Kevin boarded a shuttle to the Hill, the university complex of hospitals, health science schools, and research institutes towering over Golden Gate Park. As he entered a classroom, his pager vibrated and displayed the phone number of Marco's lab. The instructor was explaining the difference between a t-test and a Chi-square test. Kevin wanted to hear this and made a mental note to call Marco later.
He had begun auditing this introductory biostatistics course once he accepted the handwriting on the wall. To have job security, he had to obtain grants. As a physician who didn't perform expensive procedures like bronchoscopy, he had no other income-generating options. A grasp of the methods used in biostatistical analysis was one of the skills he needed to submit competitive proposals.
Yet Kevin was still ambivalent about research. Not only had he failed in Flagler's lab, he had also been burned when he tried to publish a report of the first three Pneumocystis patients they had seen at City Hospital. Herb and he had hypothesized a combination of drug use and multiple bouts of syphilis and gonorrhea infection, features common to all their cases, might have irreversibly damaged the immune system. While typing his final draft, a phone call came from Atlanta. The CDC had investigated five Pneumocystis cases in Los Angeles, all in gay men with a history of many sexually transmitted infections. Their results would be published before Kevin could get his manuscript submitted. The CDC asked him to collaborate. They offered to include the details of his cases in their national dataset, for
their
statisticians to analyze. Eventually, his name would be on some papers, but not as first author.
He couldn't have refused even if he wanted. Though he had been slapped in the face by fate, his mood soon improved. He was actually glad to not be alone in dealing with this disease. Nevertheless, the academic clock was ticking. He desperately needed funding, and a first-author publication would have been a foot in the door, giving him scientific credibility to grant review committees. He was back at square one.
Kevin's pager buzzed again while he stood outside in the drizzle waiting for a shuttle bus. He saw Marco's number, but there was no phone nearby. He couldn't respond until he got to City Hospital.
Over the ocean, a dark curtain of rain was moving inland. Being exposed to inclement weather on the Hill, to forces beyond his control, evoked memories of his ward assignments in the university hospital across the street. He had hated those months, the arrogance of the attending physicians, the lack of resident autonomy, the ambience of social Darwinism. The approaching shuttle reminded him of the deliverance he had felt at moving on to rotations at the Veterans Administration and public hospitals where the mean-spirited competition that house staff exhibited on the Hill softened into collegiality. How strange life's zigzags are, Kevin thought, as he compared those memories to his new appreciation of the Hill's scientific resources.
He was still ahead of the storm sweeping across the city when he got off the shuttle. He walked toward his office in one of the original red-brick buildings constructed after the 1906 earthquake. Its bronze gargoyles, weathered green, were set against a blackening sky. He remembered he should check on his inpatients before meeting Herb at four-thirty. Kevin turned back and passed through motion-triggered, sliding-glass doors into the modern hospital. He had forgotten Marco's page.
K
EVIN WENT TO SEE
Miller last. Flipping through the chart revealed nothing had changed since the morning. He consoled himself with the fact that at least the antifungal infusions hadn't harmed Miller's kidneys yet.
“Give me an order sheet from the chart.”
Dana stood before him, a hand outstretched, her lips pressed tight.
“Why the foul mood?”
“Well, Gail tapped him again this morning, and his pressure was still high. So neurology told us to keep hyperventilating him. Which means we have to continue sedating and paralyzing him so he won't buck the ventilator. Which means we can't assess whether his neurologic status is getting better or worse. Which means I have to say I don't know to all the people who are asking about his prognosis.”
“Who's asking?”
“The chief of medicine, the health department director, the hospital administrator, a nosy reporter I refused to talk to.”
“Wonderful,” Kevin groaned. “Any more city pols come by?”
“No,” said Dana, grinning mischievously. “What, you don't like being a celebrity? The famous immune deficiency doctor?”
Kevin grimaced.
“Just kidding.”
Dana's pager beeped. She looked irritated on seeing the number displayed and went to the nurse's station to make a phone call. She returned ashen.
“My father's in an ER back east with crushing chest pain and EKG changes. I need to get out of here.”
Ten minutes later, Gwen, the back-up resident for the month, came into the ICU. She had been paged by the chief resident who told her the bad newsâshe would have to drop her pulmonary elective and cover for Dana
whose team also happened to be on call today. They had four new admissions so far, and two were unstable. Dana gave Gwen her set of index cards, to-do lists for each of her team's patients.
As she walked out the door, Kevin gave a condolence frown to Gwen.
“It's OK,” she said with a shrug.
Dana's interns and student arrived, and Gwen spread Dana's cards on the conference table. She sent one intern to the ER to take care of a sixty-five year old Salvadoran woman who had a dangerously rapid heart rhythm.
“Massage her carotid artery,” she instructed him. “If that doesn't work dunk her face in a bucket of ice water. If she's still in atrial fibrillation, push digoxin until her pulse slows down.”
She assigned the other intern to manage the admission with a bleeding stomach ulcer.
“Make sure he's got two large bore IV's running wide open,” Gwen advised. “If his blood pressure drops, grab the IV bag and squeeze it,
hard
. Draw a hematocrit every hour and spin it yourself. Dana ordered four units of packed cells half an hour ago. Ride herd on the blood bank if there aren't at least two units already there when you get to the ICU.”
She gave the other two admissions to the medical student and phoned Proctor, leaving a message for Rick that she wouldn't be home until tomorrow night.
“Wow,” said Kevin, “Superwoman takes charge.”
Gwen wondered if she heard a gentle edge of mockery. She could never quite pin that down with Kevin, one of the many entertaining aspects of being his friend. It took her a moment to be sure it was there, an undercurrent in his admiration. Despite an effort to keep from smiling, the corners of her mouth rose.
“I can help with Miller,” Kevin offered.
“That'd be nice. Thanks.”
Kevin searched her face and asked, “You sure you're OK?”
“I'm fine. It's no big deal. Rick is used to this.”
“It must be hard on Eva.”
“You've got to be kidding. If I disappeared completely from her life, she'd be ecstatic.”
Kevin wrinkled his brow.
“Believe me, she is not longing for any more attention than she's getting from me. And she'd be happier with less.”
“You really think she doesn't mind all the time you're away?”
“Did you want to spend time with either of your parents when you were twelve?”
Kevin tried to recall being twelve.
“Wrong question. You were a boy. Have to add two years. Did you want your parents interfering in your life when you were fourteen?”
“God, no.”
“See what I mean.”
That would be a major downside of having children, thought Kevin. They grow up and become difficult. He and Marco had talked of adopting. They were mutually relieved to discover the other had fantasized about the possibility and was nowhere close to considering it seriously yet.
“You think conflict with your child is inevitable?”
“Unfortunately, I'm afraid most of us do have to reject our parents in order to believe we're individuals in charge of our own fate. Though maybe if I were more psychologically minded, more astute at parenting, I could avoid some of the nastier battles.”
“It sounds hard,” said Kevin.
“Not any harder than what we do here, once you know the ropes.”
“How so?”
“Understanding what motivates someone's bad behavior, figuring out how not to take it personally. Sound familiar?”
“Yeahâ¦but she's your daughter. How could you not take it personally?”
“You're a smart cookie, Kevin. That is precisely the problem. Most of the time I do take it personally.”
Holding the bell of his stethoscope to his mouth, Kevin imitated a newsreel reporter from the 1930s.
“Can you believe it folks? She can do all this and still be the mother of a teenage girl. Only her daughter's kryptonite can stop this woman.”
Gwen laughed as Kevin headed off to find Miller's chart.
She had never had a male friend like Kevin, adoring her in an utterly asexual way. I've always had pals at work I could be comfortable with, she thought, but no man, other than a lover, has ever shown me this much appreciation. Wrong, she corrected herself, except for my father.
The summer after Gwen's brother joined the army, her father came out from New York. Her mother, now a dentist's receptionist, had saved enough money for a week vacation at a desert spa. Children were not allowed. Gwen had no choice but to accompany her father on a fishing trip.
Driving east through the empty desert, she was sullen while he remained doggedly cheerful. He let her pick radio stations and control the volume. She was surprised to find he didn't mind listening to loud rock and roll. Turning north, they drove along the eastern slope of the Sierras, stopping at rustic, lakeside lodges to fish and stay the night. She hadn't seen air this clear before. The sky's rich blue color and the steep rock walls above tree line entranced her. Each day they cast lures from a rowboat beneath snow-capped peaks. Her father complimented her repeatedly on her skill at casting.
Gwen's first two catches were too small to keep. Tossing the quivering, iridescent creatures back to freedom thrilled her. On the second day, she caught a trout big enough to eat. As her father was about to impale its jaw on a stringer, Gwen yelled, “Don't!” She held out her hands, demanding the fish. He chuckled at her audacity and let her drop it in the water.
Every evening, he had a single beer, which made Gwen wary, though its only discernible effect was to make him more agreeable. By the end of the trip, it was difficult for her to be angry with him. Still, on principle, she refused to kiss him good-bye. He was disappointed but not put off. He asked her if she'd like to see New York. Unable to hide her excitement, Gwen said yes.
The following summer, she rode east in an air-conditioned bus, studying her transcontinental highway map and calculating distances when not engrossed in the new landscapes. On a moonless night, the coach crossed the eastern Colorado plains. Gwen saw a carpet of stars falling to the horizonâa sixty mile radius away in all directions, the driver told her. The only terrestrial light was from a lone, distant farm house.
She imagined a family with a girl her age living there. She worried the isolation might make them lonely. No, she decided, they were contented, humble people, grateful to live at the center of such a peaceful world. But the girl would need to leave home soon to seek her fortune in a great metropolis.
Her father's apartment was on the thirty-eighth floor of a building in mid-town Manhattan. He let Gwen have his bedroom and slept on the couch. He bought her a subway pass and urged her to see the city while he was at work. She spent the first two weeks exploring neighborhoods from the Battery to Washington Heights and the rest of the trip inside museums.
At the Metropolitan Museum of Art, Gwen was drawn to the ancient marble sculptures. Her favorites were Jupiter astride an eagle and a nude Aphrodite. Perfect human forms carved over two thousand years ago, they defied life's impermanence. She was equally intrigued by the Cloisters, a castle filled with medieval art perched on a bluff above the Hudson River. She went there for the ambience, not the tapestries or sculptures, and pretended to be a princess in fifteenth century France, safe behind the parapets while wars raged below.
On her last evening in New York, her father took her out to a fancy Italian restaurant. He drank two cocktails before dinner and turned gloomy.
“I'm going to miss you,” he said.
Gwen flushed. She fended off her own conflicting emotions and tried to understand what he meant. His sentiment sounded genuine, but she wondered if he had some other agenda. Was he hoping she would take care of him when he became old and feeble?
“Are you lonely?” she asked.
That question flustered him.
“Sometimes,” he acknowledged.
“Why don't you get married again?”
“I don't think so. One alimony is enough.”
“Huh?”
“Honey,” he explained sadly, “All the women I've met here are just like your mother. They want a man to take care of them. That's ultimately a no-win proposition. They end up resenting their dependence. It's a vicious circle.”
Gwen was offended. He had no right to insult her mother. Nevertheless, she recognized the truth in what he said.
“You're strong, Gwen, and smart enough to make your own way in the world. You'll go to college, won't you? I'll give you all the help I can. I promise.”
“College,” she said softly, exhilarated by his confidence in her potential.
“You could do it, Gwen. Finish college and get a good job before you settle down with someone. It's best to have an exit strategy.”
On the ride back to California, she was on the lookout for lone farmhouses, especially at sunset. She didn't find one that had moved her, though in Utah a crow perched atop a dying fir caught her attention. Its glassy black eyes tracked her bus for miles. Gwen felt its steely tenacity stirring inside her.