Sunday, December 1, 2013

Shadows and Light

I stood silently in the cold, dark room, the shadows and light of the X-ray film playing on my face, and I knew that this day would be the border between Before and After in my life, that everything had already changed.

In the summer of 1981 I was beginning my pediatric residency at Lenox Hill Hospital in New York City.  It was a small program, only four residents in each of the three years, so we each spent a great deal of time at other institutions doing specialty rotations.  In August of that year I was at Memorial Sloan-Kettering, then as now, one of the premier cancer hospitals in the country, doing my intern-year pediatric Hematology-Oncology rotation.  I was taking care of kids from all over the world with cancer and leukemia, many of them there because they couldn’t be treated in their home cities.  Memorial, for many, was the hospital of last resort, the place where the mysterious cases were sent and where a few, even kids, came to die.

Each morning our team – the attending physician, the senior resident, myself and the other interns, and the medical students – would go down to the radiology department to look at any X-rays that had been done on our patients in the past 24 hours and discuss them with the radiologist.  We had finished going over all our films when the radiologist said, “Wait a minute.  I know you guys are peds, but I want to show you this one film.  It’s really interesting.”  He sifted through a pile of X-rays on the desk in front of us, held up a film, and slapped it up on the backlit viewbox.  “Take a look at this.  What do you think?”

We all stood in perplexed silence for a moment.  I looked at the chest X-ray on the box in front of me and systematically began to analyze it.  Based on the size of the chest it looked like an adult, probably male since no breast shadows were evident.  Good quality film, no rotation.  Heart normal size.  Lungs…  Something about the lungs.  They were clear for the most part: Black fields indicating that the X-rays were going clear through the mostly-air of the lungs to expose the film behind, blocked at regular intervals by the gentle white arcs of ribs bordering and encircling the chest.  But in the blackness where there should be nothing – more white, something, some things, in the lungs blocking the X-rays, things that looked like huge cotton balls.  “Fluffy infiltrates” is the term radiologists use for lesions such as these.  I thought I could rattle off a few things that did this, but it would help to know more about this patient.  I knew my place so the resident was the one who asked the question.

“What’s the history?”

“27-year-old white male,” the radiologist answered, and as he said it, I thought, 27?  Makes no sense.  These sorts of infiltrates are usually seen in fungal infections in really old people.  But 27?  He was still talking.  “He’s been coughing for a couple of months, losing weight, no energy.  Anyone want to guess what this is?”  The attending mentioned fungal pneumonia.  Cool, I thought.  Nailed that one!

“No,” the radiologist answered, clearly pleased at having stumped a clinician.  “Anyone else?”  Silence.  After a moment he looked over the crowd and said, with a sly smile, “Pneumocystis carinii pneumonia.”  His audience didn’t disappoint.  This revelation actually brought a gasp from the attending.  For myself, I thought: That’s impossible. Pneumocystis carinii was thought to be a protozoan and a very rare cause of disease in healthy humans.  My only past experience with Pneumocystis pneumonia had been the year before during an internal medicine rotation when I had taken care of an extremely ill, immunosuppressed woman in her late 80’s.  For Pneumocystis pneumonia to be present in an otherwise healthy man in his 20’s was almost inconceivable.  My thoughts were being echoed by the attending who was asking the radiologist about this case.  “How do you know that’s it?” he asked.

“Pulmonary did a biopsy,” he said.  “But shouldn’t your next question be, what’s a pneumonia doing at Memorial?”  We looked at each other.  Yes, it should.  Why indeed would someone with an infectious pneumonia be admitted to a cancer hospital?

Scanning the crowd, the radiologist finally said, “Because the patient was originally referred here for Kaposi’s sarcoma.”  Again, his audience was thunderstruck.  I’d read about Kaposi’s sarcoma but had never actually seen it.  It was a form of skin cancer that looked like a bluish-purple bruise.  Indeed, it was often assumed to be a bruise for weeks until the patient noticed that it hadn’t gone away.  But again, it was only seen in very old, very frail people whose immune systems were not working.  What was going on with this 27-year-old?

“Here’s the thing,” the radiologist continued, answering our unspoken question. “This young man gets referred here for Kaposi’s by his private doc, and then they find out he’s been coughing and losing weight so they get this chest X-ray and see this and call in pulmonary to get a biopsy.”  I looked at the date on the X-ray film and saw that it had been done almost two weeks earlier.  “So the pulmonologists are stumped, and they start talking to other docs around town.  Turns out this guy’s not the only one with this stuff going on.”  He paused for a moment.  “There’ve been about 5 or 6 cases pretty much like this, healthy young men who suddenly get sick with diseases that only older, immunosuppressed people get.  And you know what they all have in common?”  Again he paused.  “They’re all homosexual.”

I don’t remember if I broke into a sweat.  I do know that my face flushed, and I could feel my heart pounding like one of the jackhammers out on York Avenue.  I looked at the film again, for something, what?

“Wait a minute,” the attending said.  “I think I read something about this in Morbidity and Mortality Weekly Report.  Clusters of homosexual men coming down with these weird diseases.  Here, San Francisco, Atlanta…”

“This is one of them,” the radiologist said triumphantly, as if he were displaying a rare white tiger.

Fluffy infiltrates, Kaposi’s sarcoma, Pneumocystis.  Words I’d heard.  Things I’d seen, but in the pit of my stomach I knew that I would hear these words over and over and over again, in hospitals, in bars, in community meetings, from friends, on TV.  Something bad was happening…  This X-ray, this guy I’d never met:  He could be me.  Someday, I wondered, would I be him?

I don’t remember much more of the discussion that followed as the attendings, resident, other interns, and students talked about what they did and didn’t know, what they’d heard and hadn’t heard, about this cluster of cases.  Someone said something about sexual spread, someone else a tentative name she’d heard for it called gay lung disease, another made a wisecrack.  I was silent, staring at patterns of shadow and light.

Once we got back to the inpatient floor, there were a lot of sick kids to take care of, and I didn’t have much time to think about the X-ray or the man with – what?  This thing with no name.   It wasn’t until much later, as I walked the 15 blocks to my apartment on 2nd Avenue between 80th and 81st in the dark, still-hot August evening,  that the unease of the morning returned. 

I got home late that night.  Bob was there.  He’d already eaten.  “I saved you some,” he said, fixing a plate for me.  We’d been together for over a year but had just moved in together two months before.  “Long day, huh?”

“Yeah,” I said quietly, looking up at him as I poked at my food, almost examining him.  “Yeah, long day.”

In bed that night I held Bob as he slept, listening to his breathing – his strong healthy breathing – and I wondered about the future.  I wanted this moment to last forever.  I didn’t know then that Bob and I would split up three years later, that we would become best friends very quickly afterwards, and that we would remain best friends until he died at the age of 36 on Thanksgiving weekend 1994.  I didn’t know then that he would come to me in a dream in 1997 to tell me that death is nothing to fear and that he would always be with me.  I didn’t know then that – though I would be spared the virus – this day would give my life focus and that I would be one of the survivors to tell the story of my people in the time of plague. 

I didn’t know any of this on that night in 1981, holding my lover in the August heat as he slept, or earlier that morning standing frozen in the dark, staring at the chest X-ray of a nameless 27-year-old gay man, but I did know as I finally fell into a troubled sleep that life as I knew it had changed forever.

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