Of Flesh and Blood (17 page)

Absorbed in her coloring, she replied without even looking up. “You sure talk boring sometimes, Dr. M.”

“Keisha!” Maya looked embarrassed.

“You can’t argue with her, Mom.” Tyler chuckled, turning back to her parents. “You see, leukemia cells don’t look the same as normal white blood cells. On their surface, they have an abundance of molecular cell markers, which are kind of like the unique spots on a leopard. Except the cancer cells tend to overexpress—or make too many copies of—those markers.”

“Like a leopard with too many spots?” Keisha suggested in mid–marker stroke.

“Exactly! Hey, I didn’t think you were even paying attention, smarty!” Tyler said, drawing a wide grin from Keisha that showed the gaping space where her two front adult teeth had yet to grow in.

“About those cell markers, Dr. McGrath,” Jonah encouraged.

Tyler nodded. “One marker in particular that is overexpressed on the surface of leukemic cells is a receptor called CD thirty-three.”

Maya held up her hand, as if wanting to ask a question in class. “Is that why they call it ‘targeted therapy’? Because the drugs attack those tumor markers?”

Tyler nodded. “Up until recently, we didn’t have drugs that could distinguish between the ‘good’ and the ‘bad’ cells. Most chemotherapy drugs attack them all, and we just hope the cancer cells are selectively destroyed because they multiply so quickly and that’s when cells are most vulnerable.” He smiled at Maya. “But a few years ago scientists infected mice with human leukemia cells. They were able to grow and isolate antibodies that specifically attack certain tumor markers. Thus creating drugs like Vintazomab.” He made a fist with one hand and clamped his other over it like a Venus flytrap closing over its prey. “Vintazomab binds to the CD thirty-three receptors on the cells which have the most markers—in other words, the leukemic cells—and selectively destroys them.”

Both parents nodded their understanding. Jonah held out his hand. “So this Vintazomab won’t harm Keisha’s good blood cells?”

“Well . . . some normal blood cells also have the CD thirty-three markers on their surface, but not nearly as many as the leukemia cells,” Tyler hedged. He remembered the case reports of the three children, out of the roughly three hundred already treated with Vintazomab, who had died during early treatment. As with other chemotherapy-related deaths, no one knew for certain if the drugs or the cancer was to blame. However, one
death per hundred patients treated made the drug less toxic than many other chemotherapy agents. “In early clinical trials, there have been a few serious side effects, but most patients have tolerated the drug well.”

Still holding each other’s hands tightly, Maya and Jonah shared a quick glance in which Tyler recognized a trace of the raw vulnerability that such decisions always elicited. But it didn’t last. Jonah reached over and squeezed his daughter’s shoulder affectionately. “When can Keisha begin the Vintazomab treatment, Dr. McGrath?”

“In the next two or three days, I hope.”

Keisha wriggled free of her father’s hand. “Daddy, I can’t draw with you harnessing me!” she squealed.

“You mean
harassing
, hon,” her mother, the teacher, corrected.

Keisha shrugged. “I’m drawing you a pony, Dr. M,” she said without looking up.

Tyler studied the page. Earlier, he had mistaken the brown creature for a cow, but he realized that it could pass for a horse, too. “It will be perfect for the wall behind my desk,” he said.

“I think I’ll draw you riding him,” Keisha said. “You ever ridden a pony?”

“Not for a long time.” Tyler had a flashback to his father’s birthday card with the loose photo inside of him mounted on a horse—a three-year-old cowboy. “How about you, Keisha?”

“I like to ride ponies,” Keisha said. “Not horses, though. They are too high. And I don’t want to fall, because Mommy and Daddy say I bruise too easy now.”

Keisha drew on happily for several moments. When she finished, she held the sketch up coyly for his assessment. It still looked more like a cow, now with a broom straddling it, but he was touched by the effort. He reached up and pantomimed tipping an imaginary hat. “Perfect. I’m mighty obliged, ma’am.”

Keisha giggled. Then she lowered the sketch to her lap. The smile left her lips. “Dr. M, are you going to have to put another needle in my back when you give me this Vintazo stuff?”

Tyler swallowed, realizing Keisha had been paying attention to every word of the drug’s description. He nodded. “Remember last time, Keisha? We’re going to put that magical numbing medicine on your back again. Did you feel it then?”

She shook her head minimally.

“You won’t this time, either.” He pulled off the imaginary hat and pretended to hold it over his heart. “I’ll cowboy swear on that!”

The door opened and Nikki Salazar poked her head through. Her face was uncharacteristically pale. “Dr. McGrath, I’m sorry to bother you, but may I have a word?”

Reading the urgency in her features, Tyler excused himself and hurried out to join Nikki in the hallway.

Nikki stared hard into his eyes. “It’s Nate,” she said quietly. “They’ve moved him to the ICU.”

Tyler’s heart sank, but he wasn’t entirely surprised. An hour earlier, Nate Stafford had spiked a fever. With the immunocompromised patients, infections often struck with the speed of a cobra. Tyler knew Nate must have had pneumonia because the boy had started to cough as soon as his temperature rose. “Is he intubated?”

Nikki nodded. “They had to put him on the ventilator. He could hardly breathe.”

Tyler turned and rushed toward the staircase at the end of the hallway. Nikki stuck by his side. “If we’re going to try him on Vintazomab then we shouldn’t wait for his pneumonia to be treated,” he said.

“So let’s start treating him in the ICU.”

“Yeah, we better.”

“I’ll get the supplies and meet you up there,” she said as they reached the door to the stairwell.

“Okay.” Tyler opened the door, stepped into the stairwell, and raced up the stairs.

Outside Nate’s ICU room, Tyler slipped into the full sterile gear. Though he was expecting the sight, his heart still ached when he stepped inside and saw the boy with a breathing tube sticking between his lips and multiple lines hanging over him like a nightmarish cobweb. An ICU nurse attended to the infusion pumps on the near side of Nate’s bed, while his parents hovered over their son from the other side.

Craig Stafford’s masked head snapped up in Tyler’s direction, but Laura could not tear her eyes away from her boy. Nate’s face was even grayer than the tubing that ran from his mouth and led to the life-support system. His glassy, half-shut eyes drifted over to view the new visitor.

“What do we do now?” Craig demanded before Tyler even reached the bedside.

Tyler didn’t say a word until he made it to the bed. “Hi, Nate,” he said in his most reassuring tone as he laid a hand on the boy’s shoulder. “Everyone misses you downstairs, so let’s make this a short stay here, okay?” He forced a smile. “Trust me, Nate, you’ve sailed through tougher binds than this one.”

The child’s mouth moved around the tube but no sound emerged except the whooshing noise of the ventilator that now breathed for him.

“Don’t try to talk, Nate. You’ve got to rest.” Tyler turned to his parents. “Craig, the plan has always been to start the new treatment today. And that’s exactly what we’re going to do.”

“But his pneumonia!” Laura croaked.

“The ICU team is treating it,” Tyler said. “We need to jump-start Nate’s immune system. The only way I know how to do that is to start him on targeted therapy.”

Laura stared at him a long moment but then she nodded. “Okay.”

Craig looked far more hesitant, but he, too, nodded his consent.

Tyler turned back to his patient. “Nate, I know you can’t speak, but I want you to understand that we have to get this new medicine going.”

Nate’s eyelids widened momentarily. Tyler recognized the fear despite the boy’s sedation. He squeezed his shoulder a little harder. “Remember, Nate? I promised we wouldn’t hurt you. In fact, we’re going to make you sleep through the whole thing.”

Nate blinked once, and his mouth appeared to relax around the tube.

Tyler took a deep breath. Nate was so sick and his cancer so advanced that he knew the chance of any intervention helping was unlikely. They were verging on “a wing and a prayer” territory, but he forced those thoughts out of his head and focused on the immediate steps.

Tyler walked Nate and his parents through the intravenous infusions of Vintazomab that they would need to run and the lumbar puncture—known by some as simply “LP” or “spinal tap”—he had to perform to ensure the medicine reached the leukemic cells near Nate’s brain.

Craig snapped his fingers in frustration. “How is the medicine going to reach Nate’s brain if you only stick it in his back?”

“We thread a hollow needle between the backbones, or vertebrae,” Tyler explained patiently. “The medicine flows directly into a layer—what we call
the subdural space—that goes all the way up the spine. It runs into the space at the base of the skull—the intrathecal sac—and then into the fluid surrounding the brain.”

“Like a drainpipe,” Craig grunted.

“Exactly.” Tyler went on to explain the potential complications and side effects associated with the drugs. However, he opted not to tell them that the only fatalities in the Vintazomab treatment group had occurred in the smaller subset of patients who, like Nate, needed to have the medicine injected directly into their spinal fluid. This drug was the patient’s last hope, and Tyler saw no point in adding to Craig and Laura’s overwhelming burden.

Almost half an hour passed before the pharmacy sent up all the necessary bottles and vials of medication. Tyler used the time to prepare his LP tray while Nikki assembled the lines and extra tubing required to run in the drugs. Against the wall behind them, she lined up a series of IV poles holding the tinted glass bottles of Vintazomab they planned to infuse into Nate’s bloodstream and spinal fluid.

Tyler had offered Nate’s parents the opportunity to stay in the room but, understanding that their son would be under a general anesthetic, neither of them wanted to watch him endure the invasive procedure.

A chunky young anesthesiologist, Dr. Jane Lomas, soon joined them in the room. Sitting at the head of Nate’s bed, she plugged a syringe loaded with a foamy, white general anesthetic agent into one of the tubes. She glanced over to Tyler, who nodded his consent for her to begin.

“We’re going to start now. All right, Nathan?” Lomas pushed down on the syringe’s plunger. “Count down from twenty in your head.”

“You won’t even make it to ten,” Tyler said from the far side of the bed. “Have a good sleep, buddy. Dream of all those ball games you’ve stolen for your team.”

Within fifteen seconds Nate’s eyes fluttered and then closed. Nikki came around to the near side of the bed, uncovered his emaciated body, and rolled him with ease onto his side, his back facing Tyler. She repositioned the boy’s legs so that his bony knees and hips were bent and he was curled into the fetal position.

Tyler sat down at the stool facing Nate’s back. As a pediatric oncologist, he had performed countless LPs. The procedure was second nature to him,
but as he reached for the alcohol-soaked sponges and began to sterilize the central back where he intended to insert the needle, his heart thumped harder. He couldn’t shake the sudden sense of foreboding.

With other patients, he would have needed to feel along the spine for the bony prominences to find the right spot (between the third and fourth lumbar vertebrae) to puncture with the spinal needle. But Nate was so skeletal that Tyler could spot his entrance point from across the room. He reached for the local anesthetic syringe and stuck the needle through the skin, raising a weal of tissue at the site of insertion. Nate didn’t flinch, which indicated he was sufficiently anesthetized. Tyler inserted the needle farther and froze what little deep tissue Nate had between his skin and spine, so that the boy would not feel any procedural pain when he awoke.

The smell of the alcohol-based skin cleanser drifted to Tyler. He had grown to despise the bitter scent, which he associated with all the painful taps and biopsies he had to inflict on so many young patients. Still feeling inexplicably uneasy, he grabbed the long, skinny spinal needle off the surgical tray. Tyler applied the tip of the spinal needle against the skin. Satisfied that his alignment was perfectly straight and in line with the rest of the spine, he applied steady pressure, piercing the skin and slowly advancing the needle.

He felt the familiar pop as the needle penetrated into the subdural space of the spinal canal and was sucked inside by a vacuum force. Leaving the larger hollow needle in place, Tyler withdrew the sharp stylet introducer from its center. As soon as the stylet came free, spinal fluid—looking as clear and harmless as tap water—dripped from the near end of the needle like a faucet with a very slow leak.

Sweating now, Tyler reached for the dangling end of the tubing that Nikki passed him and then hooked it up to the free end of the spinal needle. He waited for a moment as Nikki adjusted the flow into the tube. She nodded once. The connection was good.

Tyler reached for the IV poles behind him. With a quick scan of the bottles’ labels, he pulled the third one toward him. He read the wording on the bottle twice. As per protocol—because of past medicolegal tragedies that had occurred in other hospitals when the wrong medicine was infused into the spinal space—he waited for Nikki to read it as well before proceeding.

“Vintazomab,” she confirmed aloud.

Satisfied, he plugged the free end of the medicine, “piggyback” style, into the tubing that led to the spinal needle in Nate’s back. With a thumb, Tyler released its roll dial and tapped a button on the electronic flow meter. The fluid began to run. He watched as the medicine coursed freely along the tube and into Nate’s back through the spinal needle.

With nothing left to do but watch now, Tyler leaned back in his seat. His own worries—like his marital strife and conflicted relationship with his father, and even Nikki—all seemed so trivial and petty in relation to the near-hopeless battle Nate was waging.