Read an Excerpt

Chapter One

Wednesday morning in September. A brisk fall morning sends sunlight flickering through the blinds. I wake to the sweet stirrings of an old alarm clock. I am a doctor, thirty-one years old, just graduated from residency and the newest employee in my father's dermatology practice in Bay Ridge, Brooklyn. I awake, I'm not ashamed to say, with youthful vigor — life is good. My first stop is Downstate Medical School for a conference.

In the Outpatient Dermatology Clinic, patients wait in each examining room. They will be asked questions and examined by nearly thirty physicians. Later their cases will be discussed in the conference hall. The familiar faces of my residency are assembled outside the clinic. I am now an assistant professor. Dressed in a new suit, I am expected to answer rather than ask questions. The change in status is exhilarating.

There are several fascinating cases being presented today. One resident has brought in a young girl with ichthyosis, a condition named after the Greek word for fish; the girl's skin is covered with gray, adherent scales. Another patient with generalized blisters has pemphigus ("bubbles" in our Hellenized medical lingo). There is also an AIDS patient whose face is studded with numerous pimples that could easily be mistaken for acne — only he has a fungal infection called histoplasmosis that will inevitably kill him.

"David, come see my case," says an enthusiastic young resident. "It's an unknown. Tell me what you think." He refers to a patient who carries no diagnosis, a diagnostic dilemma that the department will attempt to solve collectively. As I look at the lesions on the elderly man's face, I suddenly feel a strange sensation sweep across my right eye. It's as if someone were shining a flashlight at me. It passes.

"Are you okay?" inquires the resident.

"Fine," I answer. "I just felt this weird . . . Nah, it's nothing."

Nothing. A minor disturbance, I decide, despite the fact that it continues to come and go all day. Still, it doesn't prevent me from contributing my opinion about the "unknown" case. Nor am I unable to perform my scheduled surgeries at the office later on in the afternoon. My vision remains intact, as we say in the medical profession.

On the way home that evening, I stop at my friend Tom's house. He is an ophthalmologist at a similarly early stage in his career. We play with Tom's two-month-old baby and debate which managed-care plans to join. As I am about to leave, Tom offers to examine my eyes. I resist. I'm a doctor, after all. Trained to detect signs and interpret symptoms in others, we doctors tend to dismiss our own complaints. I learned that from my father. Tom insists.

His office is in the basement of his house. I sit upright in the examining chair and read the letters on the wall, first covering my right eye, then my left. "Vision's twenty/thirty. Good. Now let's take a look inside." Tom swings around the crescent-shaped slit lamp into proper position. "Left eye looks fine." I hear his slow, heavy breathing; his face is less than an inch away from mine. "Right eye looks . . . Shit. There . . . there . . . there seems to be a problem."

A major one. The veins of my right eye are engorged and blood is spilling out into the space in front of the retina, signs of a blockage or clot in the central retinal vein. But thromboses — the medical term — don't usually happen in young, healthy adults. They occur in older patients who have abnormalities with their circulation.

Tom, who rarely loses his calm, is visibly nervous. He calls his mother, also an ophthalmologist. She is even more nervous. Tom phones the chairman of his department at Downstate Medical School. Dr. Wolintz thankfully defuses some of the alarm. He claims that, while uncommon, young people can develop thromboses like mine; he's seen it happen before. And unlike older patients, they tend to have a much better course. Nevertheless, he wants to see me tomorrow morning.

Should I be scared? I'm not sure. What do I know about the eye? I skipped that part of the body in medical school. And other than a fleeting, barely perceptible sensation, I feel great. I decide to be as confident as the expert and try to convey this to my wife, Daniella, when I tell her to cancel our dinner plans at the famous Bouley restaurant. We had waited two months for the reservation so that we could celebrate our fourth wedding anniversary in style. Tomorrow. September 14, 1995. A day of consequence. She agrees to cancel only if I promise a rain check. No problem.

The next morning, I am examined by Dr. Wolintz, who repeats the benign prognosis. There is no need for concern. Chances are, the condition will persist for several months and leave no permanent damage. It is also most likely an isolated problem; he doubts there is anything else wrong with me. To be sure, though, he sends me for a few blood tests. In rare cases, a thrombosis can be caused by a hereditary clotting disorder, an autoimmune disease (like lupus erythematosus), or even the dreaded scourge of the previous century, syphilis. I won't mention the last possibility to Daniella.

Before leaving, a host of residents are called in to see my case. They are told it is a classic that few will encounter a second time in their professional lives. One of them will undoubtedly be persuaded to present me at an ophthalmology conference. Now I am the curiosity on display.







At least I'm a relatively healthy curiosity. I go for the tests that afternoon, remaining confident they will turn out negative. A nuisance, that'll be the extent of it. Just as I had concluded in my own initial assessment. A little scary. Not the end of the world.

Thursday evenings at the office are busy sessions for me. I'm glad to be seeing patients. After my brief glimpse of patienthood, I am unusually exuberant in my white coat.

"Those pimples are clearing up, Jenny. You're looking great. Keep up the good work."

"Warts are a funny business, Mrs. Jones. And little Michael seems to have particularly stubborn ones. Not to worry, we'll get 'em this time. Michael, a little freezing, that's all. Won't hurt a bit." I aim my liquid nitrogen gun at Michael's verucca and fire.

My next patient is Shoshanna Rubenstein, a twenty-three-year-old girl who has a severe form of alopecia areata, a mysterious disease that results in hair loss. Shoshanna has only a few clumps of hair remaining on her scalp, which she meticulously conceals with a wig. Ashamed, insecure and desperate, she wants eyebrows again; makeup isn't doing the trick. I want to help. Just as I'm about to inject the area with steroids, the nurse calls me to the phone.

"Dr. Biro?"

"Yes."

"This is Jody from Sherman Labs. Hope I'm not interrupting. Thought you might like to hear the results of your blood tests."

"Oh yeah. I completely forgot."

"Should I read the abnormal values first?"

The abnormal values?

"White count, 2.8. Hemoglobin, 10.3. Platelets, 47,000. The other tests are pending."

My insides drop, my entire body plummets downward. A sharp, rapidly expanding pain grips my spine, wraps around my throat and closes off the windpipe. For a second, I can't breathe. I need time to recover from the shock. Nothing makes sense. None of the values are normal. It's not possible. I feel fine. The needle-stick five years ago during my surgery rotation at Columbia flashes before my mind. Could it be AIDS? No, that's ridiculous. In fact, the whole thing is ridiculous. It must be a mistake. I gather myself and march back into the examining room, determined to go on seeing patients.

"Okay, Shoshanna. This won't hurt a bit." I pick up the syringe. Moving toward her eyebrows, my hand begins to shake. Maybe this isn't such a good idea after all. Embarrassed, I steady the syringe against my left hand and push the plunger forward, causing more discomfort than necessary. At that moment, I do not see Shoshanna. I am unaware of her pain. It's time to stop.

Fortunately, my father's associate is in the office and agrees to cover for me. I call home. My father takes the news with customary calm. He suggests we drive down to the local hospital and repeat the test. No use getting worked up unless we're sure of the facts.

The blood counts at Victory Memorial Hospital come back the same. There's definitely something wrong. We are sure now.

It's clear — relatively clear, although all this unexpected news is making thought increasingly difficult — that the most likely source of the problem is in the blood. My counts are blatantly abnormal. We drive back to the office and make calls, my father on one line, I on another. A friend from internship gives me the name of a hematologist at New York University. Dr. Raphael is not only an astute clinician, she assures me, he's also one of the nicest attendings on staff. Yes, I remember rounding with him when I was an intern at NYU a couple of years ago.

"Dr. Raphael," I say when the page operator finally connects me. "I hope I'm not bothering you." It is 9:45 p.m. "You probably don't remember me, but I have a problem and didn't know where else to turn."

"What's up?"

I tell him about my eye. I tell him about my blood tests.

There's a pause on the line.

Then he asks, "How have you been feeling lately?"

"Fine."

"Then there's only one way to find out what's going on. We have to do a bone marrow biopsy. How's first thing tomorrow morning? Can you be at my office at eight-thirty?"

"Of course. I really appreciate this, Dr. Raphael."

"That's quite all right. Just get a good night's rest. There's nothing we can do right now. We'll know soon enough."

Know what?

Do I want to know?

A good night's rest?

What will I tell Daniella?

Nothing yet. I am determined to hold my breath for the next twelve hours.