Miracle Cure (19 page)

“Thank you for saying that.”

“I … I’ll be back in Boston in three days. If it’s
okay, I’d like to call you before I come. Perhaps we could have dinner together.”

Brian felt his pulse stop, flip-flop, then start up again.

“Sure,” he said, trying for some measure of aloofness. “I’d like that very much.”

He grinned at her, turned, and walked into the chambermaid’s linen cart.

B
RIAN BEGAN HIS FOUR HOURS IN THE
V
ASCLEAR CLINIC
by removing three days’ worth of the drug for Jack—two from a new backup supply, and one from a long-term beta patient named Jessie Pullman, due in for treatment at six. He also had a single dose tucked away in the refrigerator at home in Reading in case, for whatever reason, the clinic supply became inaccessible to him. Two weeks. Assuming the drug began working for Jack, in two weeks they would be able to pop over to the local pharmacy and pick up a month’s supply.

With thoughts of Jack, Vasclear, recovery, Teri, Freeman, the FDA, and the long night on-call competing for control of his head, Brian picked up the first Vasclear patient’s chart. It was Wilhelm Elovitz, the seventy-four-year-old who had walked away from an encounter with the high-voltage subway rail. A Phase One patient, Elovitz had started on Vasclear before the double-blind
study was begun, and had now received two years of treatment with the drug.

“Mr. Elovitz, it’s good to see you again,” Brian said. “I’m Dr. Holbrook.”

“Bill,” Elovitz reminded him. “Everyone calls me Bill.”

His silver hair was as uncontrolled as before, his smile just as engaging. Brian glanced at the cast on his left wrist, then noticed the row of blue numbers tattooed inside Elovitz’s right wrist. He was a Holocaust survivor.

Distracted by the numbers and by his own concerns, Brian wasn’t as sharp and observant as he usually was when approaching a patient. As a result, he was already seated at the small desk when he first appreciated the swelling in Elovitz’s ankles. Then he remembered the shortness of breath he and Phil had observed in the ER. The dyspnea wasn’t as easily discernible today as it had been then, but it was definitely still there. The man was almost certainly in some degree of gradually developing heart failure.

“If you could just give me a minute, Bill,” Brian said, “I’d like to brush up on your medical history.”

He opened the hospital record and flipped through it expertly. Elovitz, a Charlestown resident and one-time butcher, was referred to Carolyn Jessup by his GP because of typical cardiac chest pain. He was placed on Vasclear immediately, and it looked as if, for a time, he experienced some improvement in his symptoms, with much less pain and much more exercise tolerance. Then, week by week, month by month, his cardiac condition worsened again.

Eight months ago, he was hospitalized for two days for what appeared to be a small coronary. Since then, he had been coming monthly to the clinic for his Vasclear treatment, but the notes, mostly by various medical residents,
nurse practitioners, and cardiology fellows, were rather sketchy. From what Brian could tell, there hadn’t been a chest X ray or complete set of blood tests in over six months. Every one of his caregivers was treating Elovitz for congestive heart failure—a very common loss of heart-muscle pumping ability, usually caused by arteriosclerosis. It seemed that sometime along the way one physician had made that diagnosis, and everyone else had just assumed that it was correct. A bit sloppy for a place like BHI, Brian thought. Probably right about the diagnosis, though.

“So,” Brian said.

“So?”

“So, how are you doing?”

“Ah,
that
‘so.’ ” Elovitz paused for a breath. “Well, the truth is, Dr. Holbrook, not so hot.”

“Tell me why.”

Elovitz patted his chest.

“It’s my breathing. It never feels right.”

“Do you sleep flat at night?”

“Oh, no. I feel like I’m suffocating when I do that. I sleep on three pillows. My wife doesn’t use any.”

“Can you make it up a flight of stairs?”

“I can, our home is up one, but I might have to stop once.”

Brian scanned Elovitz’s list of medications, which had been growing over the past six months; all were directed at arteriosclerosis and congestive heart failure. Digitalis, long-acting nitroglycerin, a vasodilator, aspirin as a blood thinner, a fairly powerful diuretic.

“When did your ankles start to swell like that?” he asked.

Elovitz shrugged. “When does anything really start?” he asked, stopping between sentences for some extra breaths. “It comes, it goes, you really don’t notice it
much.… It comes, it lasts a little longer, you still don’t think much of it.… Then, one day, you realize it’s come, but it hasn’t gone away. It was like that with the ankles swelling, it was like that with the shortness of breath.… I’ve been through a great deal in my life, Dr. Holbrook,” he said, nodding at the tattoo, “much of it unpleasant. If something doesn’t really bother me, I usually wait until it goes away.”

“But this breathing problem and the shortness of breath aren’t going away?”

“No,” Elovitz said sadly. “I’m afraid they aren’t.”

Brian glanced out the door and down the hall of the clinic. He knew he was behind schedule. He knew patients were waiting for his once-over so that they could be given their Vasclear and make way for the next hour’s arrivals. But this man, who had endured so much, who had paid such unimaginable dues in his life, needed more than a once-over. He needed meticulous evaluation, and treatment that was carefully directed toward the underlying cause of his heart failure. The diagnosis of all the residents, nurse practitioners, and fellows was probably right, but the rather perfunctory care the man was receiving was not.

He moved Elovitz from the Vasclear-administration room with its contoured chair to one of the two rooms with a flat examining table. Then he asked Lucy Kendall to pick up two extra patients that hour.

“I’ll make it up to you,” he said, ashamed of himself for emphasizing the double entendre with a wink.

“When?” she replied.

Brian began Elovitz’s workup with a careful vascular exam—blood pressures, lying and standing, in each arm; ophthalmoscopic examination of the arteries and veins along the surfaces of both retinas; careful inspection of the jugular-vein pulse pattern in the neck; and palpation of
the arterial pulses in the neck, arms, groin, posterior knee, ankles, and feet. Finally, after a lung and abdomen exam, he turned his attention to Elovitz’s heart.

Except for the difficulty he experienced lying flat for any extended period of time, Bill Elovitz was a perfect patient. For one minute, two, five, Brian listened, turning him on his left side, then his right, sitting him up, laying him down, then sitting him up again. As a medical student, Brian had learned the names and significance of the various normal and pathological heart sounds. As an intern and resident, he had begun to distinguish them. But it wasn’t until his years of cardiac fellowship that his ear truly became trained. Now, as he completed his examination of Bill Elovitz and worked his stethoscope from his ears, he flashed on an exchange with the chief of pediatric cardiology during the very first day of his rotation through the man’s service.

“Excuse me, sir,” Brian had asked, “but I don’t see how you can hear all that you just described when this baby’s heart is going at one hundred and forty beats a minute.”

“Son,” the professor had replied patiently, “by the time you get finished with your training in this department, your ear is going to be so attuned that you’re going to hear lub in a little one’s heartbeat and get bored waiting for dub.”

The cardiac exam of Bill Elovitz had not sounded normal to Brian at all. It included sounds that he would never have picked up even as a resident. An increase in the pulmonic component of the second heart sound. A fourth heart sound from the right ventricle. Soft murmurs suggesting abnormal turbulence through both the pulmonic and tricuspid valves. All this without evidence of much fluid in Bill’s chest.

It was still quite possible that this was just what the
residents had been saying—garden-variety congestive heart failure, caused by increasing hardening of Bill’s coronary arteries. The medical maxim was, When you hear hoofbeats on the plains in Arizona, don’t go searching for zebras. But based on Brian’s cardiac findings, there
was
one possibility other than congestive failure—one zebra.

Congestive failure surely remained the most likely cause of the hoofbeats. But if it wasn’t, then Elovitz’s problem was almost certainly in his lungs, and the heart problems and ankle swelling were secondary to it. The zebra that kept galloping through Brian’s mind was called pulmonary hypertension. PH, thickening of the walls of the arteries in the lung, caused breathing problems and increasing resistance to blood flow that would eventually put an enormous strain on the heart. The condition was very uncommon, initially subtle, and almost invariably fatal. Its causes were many, but included blood clots from the legs and pelvis going to the lungs, various infections, AIDS, certain degenerative lung diseases, and several different toxins and medications.

There was also an extremely rare version of PH called PPH—primary pulmonary hypertension—which seemed to have no detectable underlying cause at all.

Could this Vasclear patient have pulmonary hypertension as an explanation for his symptoms? It would be extremely taxing to find out. And it would be almost impossible to determine if the cause of the problem was an underlying lung disease, toxicity from some other substance, or a side effect of Vasclear. But it seemed crucial that he try.

“Bill, who came with you?” Brian asked.

“My wife. She went down to get a cup of coffee.”

“Well, maybe I should wait until she gets back to tell you what I think.”

“No,” Elovitz said with some force. “That won’t be
necessary.… Devorah has a lot of trouble with her nerves. She’s on medication.… I have no desire to upset her.… Whatever you have to say, you can say to me.”

Brian shrugged.

“Okay,” he said. “The doctors who have taken care of you here in the past think you have a condition called congestive heart failure. And they may well be right. But I find myself wondering if instead you may have a rather unusual lung problem called pulmonary hypertension. We call it PH. But I want to stress that PH is by no means a certainty in you. Because it is so difficult to make that diagnosis, and involves a fair number of tests, I would like to suggest strongly that you let me admit you to the BHI clinical-research ward for a few days.”

The color instantly drained from Bill Elovitz’s craggy face. He shook his head, at first a little, then more vigorously.

“You will have to find another way, Dr. Holbrook,” he said.

“But why?”

Elovitz displayed his tattoo.

“That
is why. That and concern about my wife.… I have no objection to coming in for tests, but in the Buchenwald camp there was a hospital.… It was a place as base, as depraved as you could ever imagine.… My friends, family, and I were taken there many times.… In fifty years since then, I have stayed overnight in a hospital only once, for two days when I had my heart attack.… Do your tests, Dr. Holbrook. Do whatever you want.… But do not put me in the hospital … unless it is something I would die without.”

“At the moment, you’re not in that kind of danger,” Brian said. “But you’ll need to come in several times to get all these studies done.”

“It shouldn’t surprise you that I have nothing else demanding my time.… Just tell me what to do.”

Brian wrote out a stack of laboratory and X-ray requisitions: EKG, chest X ray, echocardiogram, ventilation/perfusion lung scan, arterial blood gas levels, blood chemistries, and a complete blood count. Once all the results of these studies were in, he would determine if the most invasive test, a pulmonary arteriogram, was also indicated.

“The secretary will schedule these tests for us, Bill,” he said. “Most of the blood work can be done now. Meanwhile, I’m going to adjust your medications a bit.”

“What about my Vasclear?”

“Excuse me?”

Elovitz grinned.

“My Vasclear.… That
is
one of the reasons why I came in tonight.”

“Oh, yes. Well, Bill, with all that’s going on, and given how long you’ve been part of the study, I think it would be better to hold off on your Vasclear until after the tests are back. Come, I’ll help you get them scheduled.”

As Brian walked Bill down the hall, he reflected on a massive outbreak of pulmonary hypertension in Spain in the eighties caused by tainted cooking oil, and another a few years later in New Mexico linked to the ingestion of L-tryptophan in an over-the-counter sleep medication. Then, more recently, there was the striking increase in PH associated with certain appetite suppressants. But except for those outbreaks, the condition was as rare as … as zebras on the plains in Arizona. And since his arrival at BHI, he had heard absolutely nothing about PH as a side effect of Vasclear, nothing at all.

It was entirely likely that he was orbiting Saturn on this one. And even if Bill Elovitz did have PH, his was a single, isolated case. There was no way to prove, or even infer, that Vasclear had anything to do with it. Still, Bill
Elovitz was sick and getting sicker. Except for a little inconvenience to him and a modest financial hit for his insurance carrier, there really was no reason not to proceed with the workup. If he had PH, the quality and to some degree the quantity of his life could be improved, although the course of the disease would still be inexorably downhill.

As they turned the corner heading for the reception area, Brian saw a half-dozen huge balloons floating on ribbons over the secretary’s desk. Getting closer, he realized there was a decorated sheet cake on the desk, large enough to feed a platoon.

“Hurry up,” Lucy Kendall called excitedly. “We’re all starving.”

Brian was still several yards away when he was able to read the frosting inscription:
Thank You, Dr. Holbrook
.