Terminal

Before Sean called anybody, he approached Carla Valentine, the head nurse. “You guys looking for me?” he asked expectantly. He was hoping they were because then the page would involve some easily performed scut work. What Sean feared was that the page was coming from either admitting or the ER.

“You’re all clear for the moment,” Carla said.

Sean then dialed the operator and got the bad news. It was the ER with an admission.

Knowing the sooner he got the history and physical done, the better off he’d be, Sean bid farewell to Peter, who was still on the phone, and went downstairs.

Under normal circumstances Sean liked the ER and its constant sense of excitement and urgency. But on the afternoon of his last day on his medicine rotation, he didn’t want another case. The typical Harvard medical student’s workup took hours and filled between four and ten pages of tightly written notes.

“It’s an interesting case,” George said when Sean arrived. George was on hold on the phone with radiology.

“That’s what you always say,” Sean said.

“Truly,” George said. “Have you ever seen papilledema?”

Sean shook his head.

“Grab an ophthalmoscope and look at the guy’s nerve heads in both eyes. They’ll look like miniature mountains. It means the intracranial pressure is elevated.” George slid the ER clipboard along the countertop toward Sean.

“What’s he got?” Sean asked.

“My guess is a brain tumor,” George said. “He had a seizure at work.”

At that moment someone came on the phone line from radiology, and George’s attention was directed at scheduling an emergency CAT scan.

Sean took the ophthalmoscope and went in to see Mr. Martin. Sean was far from adept at using the instrument, but after persistence on his part and patience on Louis’s part, he was able to catch fleeting glimpses of the mounded nerve heads.

Doing a medical student history and physical was a laborious task under the best of circumstances, and doing it in the emergency room and then up in X-ray while waiting for a CAT scan made it ten times more difficult. Sean persisted, asking as many questions as he could think of, especially about the current illness. What Sean learned that no one else had was that Louis Martin had had some transient headache, fever, and nausea and vomiting about a week after his prostate surgery in early January. Sean had stumbled onto this information just before Louis began his enhanced CAT scan. The technician had to order Sean out of the CAT scanner room and into the control room moments before the study commenced.

Besides the technician running the CAT scanner, there were a number of other people in the control room including Dr. Clarence Handlin, Louis Martin’s internist, George Carver, the medical resident, and Harry O’Brian, the on-call neurology resident. They were all grouped around the CRT screen, waiting for the first “cuts” to appear.

Sean pulled George aside and told him about the earlier headache, fever, and nausea.

“A good pickup,” George said while he pulled pensively at the skin at the edge of his jaw. He was obviously trying to relate these earlier symptoms to the current problem. “The fever is the curious part,” he said. “Did he say it was a high fever?”

“Moderate,” Sean said. “102 to 103. He said it was like having a cold or mild flu. Whatever it was, it went away completely.”

“It might be related,” George said. “At any rate this guy is a ‘sickie.’ The preliminary CAT scan showed two tumors. Remember Helen Cabot upstairs?”

“How can I forget?” Sean said. “She’s still my patient.”

“This guy’s tumors look very similar to hers,” George said.

The group of doctors around the CRT screen began talking excitedly. The first cuts were coming out. Sean and George stepped behind them and peered over their shoulders.

“Here they are again,” Harry said, pointing with the tip of his percussion hammer. “They’re definitely tumors. No doubt at all. And here’s another small one.”

Sean strained to see.

“Most likely metastases,” Harry said. “Multiple tumors like this have to come from someplace else. Was his prostate benign?”

“Completely,” Dr. Handlin said. “He’s been in good health all his life.”

“Smoke?” Harry asked.

“No,” Sean said. The people in front moved to give Sean a better view of the CRT screen.

“We’ll have to do a full metastatic workup,” Harry said.

Sean bent over close to the CRT screen. The areas of reduced uptake were apparent even to his inexperienced eye. But what really caught his attention was how much they resembled Helen Cabot’s tumors, as George had said. And like hers, they were all in the cerebrum. That had been a point of particular interest with Helen Cabot, since medulloblastomas generally occurred in the cerebellum, not the cerebrum.

“I know statistically you have to think of a metastasis from lung, colon, or prostate,” George said. “But what are the chances we’re seeing a tumor similar to Helen Cabot’s? In other words, multifocal primary brain cancer like medulloblastoma.”