STRANGE,but two weeks later my life was again normal: I saw my patients, did my angiograms, shopped with Claudia, saw Mick and his well-functioning parts on consecutive Thursdays. One of these Thursdays was the day after my birthday, and Mick gave me a pair of sea-glass earrings.
It was a Friday and I was sitting in my office going through charts when a hand with blue-polished nails slapped a slip of paper on my desk. “Can you maybe call this guy pronto?” Lindy said. “He’s been bothering us since we turned on the phones. Says you’re a”—her voice took on a whine—“personal friend. Coach Crabbe. Coach Crabby, in my opinion.”
I frowned at the paper, with its notations of Mick’s cellphone number, his pager number, his office number, the number of his phone at home. The home phone number I didn’t recognize. “Urgent” was scrawled across the top of the paper, with a listing of the times Mick had called. “Why didn’t you page me?” I asked Lindy, reaching for the phone.
“He’s not a patient! Not even related to a patient. Listen, this guy is a case and a half. Coach Crabbe, Coach Crabbe. What’s he a coach for, roller hockey?”
“Mick?” I waved Lindy away, beckoning her to close the door behind her. “Are you okay?”
His daughter, Jessica, twenty-two years old, was having chest pain. Had been having it off and on for weeks. She couldn’t push a stroller up a hill without getting short of breath and hurting. Mick’s wife was the one who first noticed it. “Karn said Jessica got white and beads of sweat popped out all over her forehead. Karn was afraid she’d die on her right there.”
“Did she go to the emergency room? Call her doctor?”
“She doesn’t have a doctor except for her OB. She’s scared of doctors, see? Always has been, probably gets that from me.” Mick moved over those last words so quickly I barely registered them until later. “So I talked to her for like an hour last night and she finally agreed to see you. Because there’s a connection. Because I told her she can trust you.”
I was speechless. Mick’s daughter! I could think of a thousand reasons I didn’t want to have Mick’s daughter as a patient.
Mick said, “I told her you were Marcus’s girlfriend.”
I made a laugh that sounded like a honk. What was happening to me? Why was I making these bizarre noises? “But my office is a long way from your house, Mick,” I said. “If she needs to be hospitalized or a procedure done—not that that’s likely, not at her age—are you sure you want to do it here?”
“We go where my friends are,” Mick said. “Friends help out.”
I WAS UP HALF the nights all that weekend. What if Karn insisted on driving her daughter to see me, on sitting in the waiting room until I emerged with my opinion, or—this was the worst—marching herself right into my exam room? But Jessica was an adult; she surely would be coming on her own. Or perhaps not, since she still lived in her parents’ home. She had a job at a children’s clothing store owned by a Turkman State alum (friends help out). I suspected, although I hadn’t asked about this explicitly, that Mick paid for all the diapers and toys that Jessica needed for her baby.
“Your new patient’s here,” LeeAnn said Monday, tapping the chart in the container outside the exam room door.
“Miss Crabbe?” I said, peeking around the door, and there was—thank God!—only one person in the room, a pretty young woman with straight light brown hair.
“Dr. Toledo?” she said from her perch at the end of the exam table, holding out her hand. Mick around her eyes, I noticed. A friendly face, a lap that was a little abundant. A good diet-and-exercise person, I thought, relieved. Someone who’d be grateful for some lifestyle advice. “Thanks for seeing me,” the young woman said. “I don’t like doctors, no offense, but how could I not like a friend of Marcus’s?”
I can’t tell you how relieved I was, how proud I was of Mick for having this polite and pleasant daughter. All my thoughts of the day before (scared of doctors, eh? well, she was probably hysterical, had that panic attack chest pain that always required multiple negative tests and countless office visits to allay) popped like a balloon. I could see that Jessica was not a person to make up chest pain. Jessica would have something wrong. It would be something minor—esophagitis or a prolapsed heart valve—and I’d find it and treat it and everyone would be happy.
“Oh, no problem,” I said. “I’m glad to see you.” I wish Mick could meet Claudia, I thought. He’d like Claudia.
I sat and we settled down to business. I asked questions and listened, inspecting the form Jessica had filled out in the waiting room, wondering what Claudia would think of Mick, how she would behave toward him (I hoped she wouldn’t clam up and stare), and within minutes I was filled with such anxiety I didn’t trust myself to speak, because Jessica’s story sounded exactly like angina, the classic symptom of a blocked artery in the heart, and a blocked artery was something I wanted to suspect only in an older person, not in a young woman like Jessica.
“. . . and I sat myself and the stroller on the edge of the road for about five minutes,” Jessica was saying, “and then I could go on.”
Difficult to picture Jessica as a mother. Like Claudia, she looked dewy as a child herself, barely older than a junior high school student, and her lips were puffed and rounded like her father’s, and the thought of slipping a catheter into her groin, of running its tip up through her abdomen into her chest and her cardiac vessels, of possibly finding a blockage, of opening that blockage with a balloon, was impossible. I didn’t often think of what I did as an invasion, but of course it was. I can’t handle this, I thought. I can’t do this. “Any recent stress?” I asked, the next question on my list.
“Have you ever met my mom?” Jessica said. She laughed in an exasperated way, and I hurriedly shook my head, startled at the mention of Karn. “I live at my parents’. That can be a little stressful.”
I was careful to keep my face neutral. “Is your chest pain ever triggered by stress?”
“See”—Jessica tapped her head with her index finger—“I’m figuring her out. I finally realized that she’s the above-the-title star of our household, and if you treat her that way, if you think of everything you do as supporting her performance, then things can go pretty well. But if you make her look bad, or if you want a breakout role for yourself, well . . .” She laughed a shade too heartily. “That’s when the shit hits the fan.”
She swore. Mick’s daughter swore. And his wife was a witch. Why would a normal man put up with the sort of drama-queen spouse that Jessica was describing? I had trusted, I realized, that Mick’s wife was a pleasant, harmless person, a woman he stayed with out of loyalty and guilt, not out of some crazy need. I felt like I’d been thrust under murky water, and I was watching my opinion of Mick sink like a stone.
“You need a stress test,” I finally said. “You’re way too young and healthy to have coronary artery disease, but sometimes strange things happen. You could even have a congenital narrowing in an artery. I know you drove a long way to get here. Let’s see if I can arrange something right now.” I wandered out to the front desk, where Howard, chattering away with a patient at the window, was massaging Lindy’s shoulders. I’m not handing her over to him, I thought, thinking of his reading of Mrs. Griffiths’s scan. I walked back to my office and closed the door.
“Of course!” Lenny the nuclear-medicine doc said over the phone, the eagerness in his voice making me queasy. “Send her over and we’ll do her right away.”
I see what’s coming, I thought, sitting at my desk and chewing on my right thumbnail. The scan will be abnormal and I’ll have to cath her. When I took my thumb from my mouth there were dents in the polish of my nail.
MY WHOLE FAMILY CAME,” Jessica said, smiling from her hospital bed the next morning. And indeed there they were, lined up on chairs against the wall of her room like a panel of judges: Mick, Karn, the sons Bobby and Eric, Eric’s wife Delilah. A toddler was standing pressing buttons on the control panel that moved Jessica’s bed, and when he tilted his head to gaze at me he looked startled.
“You’re not used to a grown-up my size,” I said, and he frowned with something like suspicion before he looked away.
“Dr. Toledo,” Karn said, rising, and then both she and Mick were in front of me.
I had never realized Mick was quite so tall. He was huge, he was a mountain, and Karn was almost as big as he was. They looked to me like a pair of giants. They looked to me as if they fit together.
“I’m Jessica’s mother, Karn Crabbe.” Karn gripped my hand and held it. “You’ll take good care of her?” Up close Karn had pale eyebrows and eyelashes clumped with mascara, as well as crow’s-feet and vertical lines around her mouth. Too much sun, I thought, painfully aware of my fingers being jammed together. Pool rats, my father used to call the tanned country club members, although he smiled and preened in their presence. “Marcus speaks so highly of you,” Karn said.
“I’ll do my best,” I said, wondering if I’d ever meet Marcus. Now that I was confronted with Mick’s whole family, it seemed impossible I’d ever met Mick. Our hotel room seemed like a phantasm, or a remembered room in an exotic place—Helsinki, say, or Madagascar—I’d probably never get back to and could scarcely believe I’d been to.
“Thank you for seeing her,” Mick said. “Thank you for finding the problem.” He extended his hand as Karn finally let go. “I’m Mick, by the way. I’m Jessica’s dad.”
I could barely touch him. “Pleased to meet you.” A perfunc tory handshake, and I couldn’t meet his eyes. “I’m not sure what the problem is, really, but the cath should let us know. Your echocardiogram, by the way”—I aimed my words at Jessica—“the heart ultrasound was fine.”
Jessica’s bed was moving higher and higher, to the delight of the toddler at the controls. “Oh, no!” Jessica said as the boy giggled. “Don’t make me hit the ceiling!”
I met the sons. Bobby, a carpet installation supervisor, was shaggy and overfriendly, like a pound dog desperate for a home. Eric was more composed; he wore a shirt and tie and had lacquered, pharmaceutical rep hair, and his darkly exotic wife clung to him like an accessory. I knew that she was Muslim, and that their marriage was a family crisis. Karn had converted to Catholicism when she married Mick, and she didn’t understand why Delilah didn’t do the same. Eric managed the dining room at a country club. He looked more like Mick than his brother did, although both of them had Mick’s blue eyes, and Bobby—this disturbed me, as if he’d stolen something—had his father’s aching arch.
“And here’s Grandma’s cupcake!” Karn said, scooping up the toddler from behind, and for an instant a flash of terror transformed the boy’s face. She calls people by food names just like Mickey does, I thought. “Oooh,” Karn said, squishing the side of her face into her grandson’s, and I realized her eyes were as blue as Mickey’s, that someone could say her sons had her eyes too.
“How’s the patient?” I asked, approaching Jessica’s bedside, now almost at the level of my shoulders. “How’s the reason everyone is here?”
AFTERLENNY CALLED ME with Jessica’s scan report, I’d stayed after office hours talking with Jeremy, then gone online at home with a cardiology chat group. Jeremy had had a twenty-year-old male with three-vessel disease who’d gone to bypass, but he had been from one of those bad-cholesterol families, and his father had died at forty-one. None of the docs online had seen coronary artery disease like this in a twenty-two-year-old female, but each of them knew someone who had, and the consensus opinion was to treat it just like coronary artery disease in someone older (the usual angioplasty and stent, or the occasional laser, or referral to bypass for severe disease). Of course, they all admitted, treating someone that young made you nervous. No one envied me.
I almost crawled under my deck that night reaching for Ginger, but she moved herself to a more distant spot and lay down.
Jessica was my second and final cath that Tuesday. After I’d finished with my first patient’s family in the waiting room, I went to the sinks to rescrub and gown up. A trainee nurse was observing my procedures. “No high cholesterol?” the trainee was saying to Jessica as I passed. “No diabetes?” The naïve believe in pure causation; they don’t think of bad luck.
“Boy, she’s a young one,” Helen, the head nurse with the sick husband, said in a low voice, and I wasn’t sure if she was referring to Jessica or the trainee.
Jessica had been medicated before her stretcher was rolled into the angio suite; she was in the perfect state for a cath, awake but relaxed, floating. The cath lab’s assistant nurse scrubbed Jessica’s right groin, letting the trainee make a swipe or two, and once Jessica was draped I inserted the needle through which I’d pass the guidewire and then the catheter that would snake up Jessica’s aorta to her heart.
“Little bee bite!” the student nurse said. Across from me, behind the trainee’s back, I could see Helen under her mask mimicking those words. She noticed me and winked.
“You okay, hon?” I asked, glancing at Jessica’s face, and Jessica nodded. Hon, darlin’: the cath lab brought out the small-town in me.
Unusual in this place to see such a young leg, firm-fleshed and unveined and hairless. At the end of the table, poking out past the sheeting, was a big toe with a purple polished nail.
I expected to find something, yes, but what I found was worse than I expected: a blockage a full half-inch long at the head of the heart’s main artery, the left anterior descending. It was so narrow the dye, on the viewing screen above the angiogram table, wafted down the artery like a spanning thread of spider’s silk. The rest of Jessica’s vessels looked fine. I didn’t know what to do. If the blockage were farther downstream in any of her vessels, or if the blockage were less narrow, Jessica would be an ideal candidate for an angioplasty followed by a stent. I could slip a guidewire through the narrowed artery, pass and expand a tiny balloon over the wire to smush the clot and plaque against the vessel wall, and follow this, once the artery was opened, with the insertion of a minute mesh tube—a stent—designed to keep the vessel clear. It could be so easy. But with a narrowing this severe, the guidewire, the first thing I’d need to insert, might block the blood flow totally, and then I wouldn’t know where I was. Worse, blocking off with a balloon—even temporarily—a vessel this close to its origin was to run the risk of killing off a tremendous amount of heart tissue. It would be like damming the Mississippi at Minneapolis. Block flow farther down at Memphis or New Orleans, and there would be less territory deprived of flow. “You have a narrowing,” I imagined saying to Jessica. “It’s in a bad spot and to be safe I think you’ll need a bypass.” Bypass: her young chest sliced and held open, a vessel from beneath her rib prised out, the beep of her heart on the monitor disappearing, the whirring chug of the heart-lung machine kicking in. “I hate to say this, but you’re going to need a bypass.” I opened my mouth to say these words but something different came out.
“You’ve got a very tight blockage in a major heart vessel called the left anterior descending,” I said. “I’m going to try to open it.”
Jessica nodded.
I was aware, across the table, of Helen’s unusual stillness. I ignored it. I edged the wire forward down the artery, had Helen inject a bolus of dye. I lifted my eyes to the viewing screen. Nothing. The wire had indeed occluded the artery.
I fiddled with the wire, reinjected: was I imagining it, or did this time a strand of dye go through? “Good,” I said, to no one in particular. “I can open this.”
“You’re doing it?” Helen asked, a hint of sharpness in her tone. “It’s an awfully high . . .” But Helen stopped because it wasn’t her place to question, and besides, it was too late. I was doing it.
Jessica moaned. “Start the IV nitro,” I said.
“Jesus,” Helen murmured, glancing at the monitor, and whatever had driven me into this—self-assurance, or hubris, or the urge to impress Mick (my God, not that!)—I would have to live now with the repercussions: the monitor showed a huge heart attack—a temporary one, I hoped—caused by my inflated balloon, the rising ST segments extending to the far reaches of the heart’s front wall. If I let the balloon down now the artery might not be ready for the stent; if I kept up the balloon too long, a very big chunk of Jessica’s heart muscle would die. I was too committed now for second-guessing, too far in to turn around. For the glory or the agony, for better or for worse, I was committed.
I glanced at Jessica’s pale and beaded face. No question, this must hurt. “Let’s go with some morphine,” I said to Helen. The trainee’s eyes were wide behind her mask, as if this was the most exciting thing she’d seen.
It was almost like sex, I thought later, as I wadded up my gown and mask to toss into the wastebasket: in the middle of a procedure, the rest of the world fell away. Lists of chores, anxieties about Howard, the sound of my pulse in my ears, Claudia, Mick, Karn—all this disappeared. There was only the tree of vessels on the viewing screen, and my fingers, and my equipment, and my brain. I still felt half in a reverie as I walked into the waiting room to talk with Jessica’s family, and that was why it was such a surprise, after I said my few words, to see Karn moving toward me with her arms out, her bobbing breasts coming at me at eye level. “Mickey, get off the damn phone!” Karn was saying. “Mickey, Dr. Toledo has wonderful news!”
The news was not completely wonderful. Their daughter had heart disease—this was news. Their daughter had squeaked through a challenging procedure with no evidence of lasting heart damage—this was news too. But all Karn heard, all anyone seemed to hear, were these two sentences: “We got a really good result. The vessel’s open.”
Later, Karn wouldn’t let go of my hand. “How can we thank you?” she asked. “How can we ever, ever thank you?” She turned to Mick. “We should take Dr. Toledo and Marcus out to dinner.”
Under other circumstances, I would have laughed at Mick’s startled face. “Sure,” he said. “Sure. That’d be nice.”
“Just not very practical,” I said quickly. “I work, like, all the time.”
THREEMINUTES WITHOUT OXYGEN,” I told Jessica twenty minutes later in the recovery room. “That’s about the maximum the heart will forgive.” I hesitated. “We took you to the max.”
Jessica smiled brightly from her gurney, a plastic cup filled with water and ice on the bed tray beside her, and I wondered how much she—how much any of them—understood.
“You’re totally open,” I said. “I just hope you won’t make me do it again.”
“Oh, no!” Jessica was radiant in her innocence, the whites of her eyes and her teeth so bright they reminded me of touched-up senior pictures back in high school. I almost killed her, I thought, and I wondered, not for the last time, why I’d gone through with it, why I hadn’t simply said to Helen, Get the surgeons on the line. I patted Jessica’s foot and headed for my office and the moment the staff (I know this for a fact, they have told me) still talk about: when Dr. Toledo stood in the back hallway crying and shaking, and it took LeeAnn almost half an hour to calm her down.
“So she’s fine?” LeeAnn said. “It worked out?”
“It was too risky. I should never have tried it.”
“You saved her a bypass.”
“I don’t do that sort of thing,” I said. “I’m not a cowboy.” The ER docs who split people’s chests were cowboys, as were the pulmonary docs who stuck needles in their patients’ chests without using an ultrasound for guidance.
“When’s your next angiogram?” LeeAnn asked. “You’ve got Cotter and Perkins both scheduled for tomorrow, right? You okay with that? Of course you’re okay with that. You’re going to get back on that horse, Dr. Toledo. Tomorrow you get on that horse.”
“You opened her?” Jeremy said. “Your baby patient had an LAD lesion that proximal and you opened her? Holy torpedo, it’s Genie Toledo.” And it was not exactly admiration, I knew, that led to his next words: “Nerves of steel, baby. Nerves of steel.”
“Don’t you try it!” Jeremy would tell Howard at our next group meeting. “This stunt should only be attempted by paid professionals!”
Tessa said, “An angel on your shoulder.”
I said, “An angel on Jessica’s shoulder.”
Two days later I walked into our room. “Mickey, what the hell? I come out of the cath lab to tell you about your daughter and you’re on the phone? On the phone? ”
Mick gave a heh-heh-heh sort of laugh. “I was talking to Hugh,” he said. “I wanted you to see I wasn’t worried.”
“Jesus, Mick, you should have worried.” I sat on the edge of the bed. “I almost killed her.”
“But you didn’t, and even if you had you wouldn’t have meant to,” Mick said imperturbably.
“Mick, come on,” I mumbled, startled. “I think that’s a little too much faith.”
“I knew you could make her well.” He opened his arms and beamed. “And to think you do things like that every day. Wow, wow, wow.”
Jessica had left the hospital the previous morning, blowing me a kiss as she walked with her brother Eric and his wife down the hall. “Thanks a lot,” her brother Bobby said, lagging behind them. “I don’t usually like doctors, but you’re great.” Their mother thought so too, Bobby said. She wanted to come upstairs and say goodbye herself, but they were parked illegally and someone had to stay in the car.
The flowers Karn and Mick sent me on Monday barely fit through my office door. Enough blossoms to cover a casket, I thought.
