A Big Decision

By , June 29, 2010 11:13 am

The woman looks at her son.  Then she looks at me, then across to her own mother, and then back at me.

“Oh,” she says finally, wringing her hands like she’s on a quiz show, “I really don’t know.  It’s such a big decision.”  I take a breath, quietly.  “I mean – you’re the doctor.  You tell me what to do.”

“Okay,” I say, “let’s go through it again.”  She nods in agreement.  “Jonah has enlarged lymph nodes in his neck, yes?”  I point across at Jonah, his neck as wide as a bullfrog.  He waves at me comically.

“Yes.”

“And he’s been treated with antibiotics for over a week, with no change.”

“There has been a change,” corrects Grandma.

“Okay, there’s been a little change,” I concede, “but not a lot?”

“Not a lot,” she agrees.

“Your GP sent you to the paediatrician for a second opinion.  He did some blood tests, a screen for glandular fever, and a blood count that came back looking perfect.

“Perfect?” Mums asks.

“The white cells were normal.  We look at these for signs of infection, and…for other nasty things.”

“Nasty things?”

“Like leukaemia,” I say, not wanting to get bogged again.

“Leukaemia?” Grandma pipes.

“Yes, one of the things we look for with this is leukaemia.  And there was no sign of leukaemia.”

“So it’s not cancer?” Mum asks.

“No,” I hear myself saying as a reflex.

“And it’s not an infection?”

“No, it probably is.”

“But you said that the blood test showed no infection?”

“The white cells were all normal…”

“…Which you said meant no infection.”

I pause for a moment, counting sheep.

“This blood test was done two weeks ago.  At that stage, his neutrophils were in the normal range.  I don’t know about today without a repeat test…”

“…If we agree to that test,” Grandma says, shaking her head.

“That’s right.”

“But you said that he looked fine, and that he wouldn’t need antibiotics?” Mum says.

“I said that if this a viral thing, then antibiotics wouldn’t make any difference.”

“And you think this is a viral thing?”  They say it together.

Looking at them, they’re like twins, except that one of them has been kept in a time capsule for twenty years.  Wrinkles aside, they are the same person -  same disposition, same head tilt, same cross-examination technique.

“It probably is.”

“Why?”  Again together.

“Because…”  I pause to gather my thoughts.  “Because he looks so well.  Because he’s never had a fever.  Because he has green snot coming out of his nostrils, and a slightly reddened throat.  And because if this was a bacterial lymphadenitis, he wouldn’t be able to turn his head, his glands would be hot and tender, and he’d be as sick as a dog.”

“But glandular fever is a virus?” says Grandma.

“Yes.”

“And it’s not that?” Mums chimes.

“Well, it may be.”

“But the test was negative.”  Grandma’s turn.  “I thought this was the one thing we did know.”

“The screen was negative, but it’s an imperfect test.  We’d need to do serology for a more accurate test.”

“Why can’t you people give a straight answer for anything?”

“Because unfortunately, medicine isn’t straight.”

They look at me like I’m mad.  Maybe I am.

Through all of this, Jonah has been watching, slightly amused.  I look directly at him and he grins widely, like he’s watching a spectator sport.  I get the feeling that I’m not the only male to get this kind of grilling.

“Oh, oh, I really don’t know about this,” Mum says, “I think I need to talk to Greg.”

“Sure, go for it,” I say.

“You know Greg?”  I look at her, confused.

“So he doesn’t have to be admitted?” Grandma asks, hijacking the conversation.

“You don’t have to do anything,” I say, slightly exasperated.  “It’s a free country.”

“It’s just that Greg is a naturopath, and I think he’d want to know if we were going to pump him full of antibiotics.”

There is a halt in proceedings.

“But he’s already getting antibiotics,” I say finally, confused.

“Yeah, he’s swallowing them,” Mums says, adjusting her woollen headscarf, “he’s not being pumped full of them!”

“Right,” I say, pretending to understand.  “I’ll let you guys talk to Greg, and then have a think.”

* * * * *

I head back in, fifteen minutes later.

“We’ve decided we want the blood test, but not the drip,” says Grandma.

“We want to go home after, and we want the paediatrician to follow us up if it’s not getting better.”

“And at that point, if it’s no better, he’ll come back for further investigation?” I ask, trying to clarify.

“We’re just trying to avoid the trauma.”

I find these people genuinely confusing.

“Which trauma?”

“Of staying in hospital.”

“Oh, that trauma,” I say, a little too candidly.

“It’s no laughing matter,” Grandma says shortly.

“No, fair enough,” I say.  “I guess…most people are worried about needles.  That’s the trauma people are usually scared of…”

“…Oh, we’re fine with that,” Mum says.  I look at Jonah, who does in fact, seem fine with that.  With everything, really.

“If we’re getting the blood tests, we often leave the drip in, in case anything else needs doing, so we don’t have to use another needle…”

“…We don’t want the drip.  We don’t want it to stay in…”

“Okay,” I say conceding.  “Let’s do the bloods, and a chest X-ray, and then we’ll see what they show.”

“And then we can go home?”

“And then you can go home.”  These people have a knack for getting me to say what they want to hear.  “But if things still aren’t improving in five days, you’ll come back in for the drip then?”

“Yep,” they say together.  “And Greg agrees, too,” says Mum.

“Great to have Greg on board,” I say.  “We’ll do the glandular fever test…”

“…I thought we did that one?” Grandma asks.

“Shut up Mum.”

“…And we’ll do one for CMV, and Cat scratch disease and a couple of other infections.”

“Sure.”

“And we’ll just get that chest X-ray as the last thing before you go, hey?”

“No problem.”

* * * * *

Jonah is a delight throughout the blood test.  He’s a special kind of kid.  A bubble of mucus plays at the edge of his nostril as he happily chats about his holidays, not even noticing as the needle goes in.  He then heads off to radiology, excited by a new adventure.  Even Grandma manages a smile, basking in the rays of this joyful child.

I’ve already printed their discharge letter by the time they return from Radiology.  I’m keen to get them out, happy for the paediatrician to sort this out another day, my own head throbbing from diplomacy.

“I’m back from getting my X-ray, Dr Mark!” Jonah yells on return.  I salute him, which he returns with a giggle of innocence that only goes with being eight years old.  His mother smiles, rubbing at his hair, knowing it won’t last forever.

I log into the computer to check the bloods.  The FBE is pristine.  The other tests sit there pending, not due to return till another day.

I minimise that screen, logging into the radiology program.  I punch in numbers, checking them against the name that pops up.  I click on it, and immediately pops up a black and white image.  A Rorschach ink blot.

My heart falls through the floor.   I feel sick.

I drop my head in my hands.

* * * * *

“Hey,” I say.

“Hey,” they all say together.

“Jinx!” Jonah shoots back, clapping his hands in delight.

“What is that?” I ask, pointing at the half-eaten chocolate bun, sitting on a plate beside Jonah.

“Dessert,” Grandma sighs.

“Leah and Trina,” I say, keeping my voice light, “can I just have a chat to you for a second?”

“Sure.”  They both rise and follow me.  “We’ll be back in a jiffy,” Mums says.  Jonah smiles, biting down on his treat.

They follow me into another room, another cubicle;  this one with a door.  There are three mismatched chairs laid out for interview: one covered in red vinyl, strings of cotton coming from it’s edges, one an anaemic green in hard plastic, and a third made of wood, designed for a toddler.  I’ve pre-arranged them so the two adult chairs face the baby one.

“You two take those ones,” I say, “I’ll take this one.”

“Are you sure?” they both ask.

“Quite sure,” I say.

We sit, the silence of the room suddenly very loud.  Those two seconds of deathly stillness sit in the pit of my stomach for a very long time.  Still now.

I take a breath, about to start.

“This doesn’t seem good,” Leah says, laughing nervously, looking across at her mother.

“It’s not,” I say.  Leah looks at me;  her head tilting and her brow knitting.  Trina looks up, mid-ruffling through her handbag.  I take another breath.  “When we did the X-ray, we saw a mass in Jonah’s chest.  Something that will be related to the lumps in his neck.”  They look at me, their eyes yet to register.  “We’ve seen a growth, sitting above his heart.”  I find myself touching my own chest, like I’m playing a piano chord on my chestbone.  “Right here.”

Leah lets out a little sigh, like a cough, like she’s just been winded.

“A growth?”  I see her eyes dancing, searching.  I say nothing, waiting for her to comprehend.  “What do you mean?”

I pause for a moment.  “We don’t know exactly, but I’ve been talking to the oncology team…”

“…Oh, Jesus,” Trina says.

“And we want to admit Jonah, so that we can investigate further.”  There is another silence.

“Is this cancer?” Leah asks.

I feel the acid in my mouth.  I can see my sadness reflected in her eyes.

“It could be.  We’re worried that this is lymphoma.”

Leah stands bolt upright, putting her hand to her forehead.

“No!  No!  No!” she barks, each word getting louder.  She walks around in a tight circle.  “Oh, Jesus.  Oh, Jesus, oh, Jesus,” she breathes.  She sits again, and then looks up.  “But it could be okay?  This might be nothing?”

“We really just need to bring him in to do some more tests,” I say.  “Maybe to get a bone marrow and a needle sample from the node.”

“This is not happening,” Trina says, as she dissolves into tears.  We all listen to her sobs for a while.

“How big is it?” Leah asks finally.

“About eight centimetres,” I say, measuring between my thumb and forefinger.  Trina continues to sob.  Leah is quiet and still.

“Who ordered the X-ray?” she asks.

“I did.”

“Thank you.”  I feel my own lip wavering, tears at the edge of my eyes.

“I’m sorry about before.  I really am.”

Leah moves forward, and takes me into a hug.  It leaves me totally thrown.

“It doesn’t matter,” she says, her voice now monotone.  “Nothing matters now.  All that worry about doing the right thing?  Thinking everything else is such a big decision?  It all just fades to bullshit, when this happens, doesn’t it?”

I frown, nodding.

“So he’ll need to come in now,” I say, eventually, quietly.

“Of course.  Of course,” she whispers.

She stands again, her hand returning to her head.  “I’m in a nightmare.  I’m in a fucking nightmare.  Somebody wake me up.  Please, somebody wake me up,” she groans.  “My poor boy.  My poor boy.  It couldn’t have happened to a better kid.”

I hear those words.  I think of Jonah, of his laughter, and his innocence, and I really hear those words.

I look back at Leah, a study in grief reaction.  In less than two minutes, I’ve seen her go through denial, anger, bargaining, and now depression.  She finally lifts her head and looks straight at me, her eyebrows folding at their edges.

“Why, Mark, why?”

I feel myself frown, trying to remain calm and professional.  But I can’t.

“I don’t know, Leah,” I say, finally, my voice cracking.  “I…I don’t know.”

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2 Responses to “A Big Decision”

  1. Susan Nethercote says:

    Oh my god, that made me cry!

  2. This story is very tragic and your writing of it made me feel like I was in the room right there with you as broke the devastating news.
    You’re a talented writer and physician. Thank you for doing what you do.

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