I SAW THE CANCER immediately. It was right there in front of me. As always, I found myself taking a sharp intake of breath as the realization hit: I am looking at the beginning of the end.
The cancer was shaped like a dandelion. Sometimes this sort of tumor looks like a cheap Christmas decoration—a five-and-dime star with ragged edges. But this specific one was more like a minor-looking flower that had been denuded, stripped down to its seeds, but with an insidious, needle-like structure. What radiologists call a “spiculated structure.”
Spiculated. When I heard that word for the first time I had to look it up. Discovered its origins were actually zoological: a spicule being “a small needle-like structure, in particular any of those making up the skeleton of a sponge” (I’d never realized that sponges have skeletons). But there was an astronomical meaning as well: a short-lived jet of gas in the sun’s corona.
This last definition nagged at me for weeks. Because it struck me as so horribly apt. A spiculated cancer, like the one I was looking at right now, may have commenced its existence years, decades earlier. But only after it makes its presence known does it become something akin to the burst of flame that lights everything in its path, demanding total attention. If the flame hasn’t been spotted and extinguished early enough, it will then decide that it isn’t a mere fiery jet stream, but rather a mini supernova which, in its final show of pyrotechnic force, will destroy the universe that contains it.
Certainly the spiculated species I was now looking at was well on its way to explode—and, in doing so, end the life of the person within whose lung it was now so lethally embedded.
Another horror to add to the ongoing catalog of horrors that is, in so many ways, the primary decor of my nine-to-five life.
And this day was turning out to be a doozy. Because, an hour before the spiculated cancer appeared on the screen in front of me, I had run a CT scan on a nine-year-old girl named Jessica Ward. According to her chart she’d been having a series of paralyzing headaches. Her physician had sent her to us in order to rule out any “neurological concerns” . . . which was doctor shorthand for “brain tumor.” Jessica’s dad was named Chuck—a quiet, hangdog man in his midthirties, with sad eyes and the sort of yellowing teeth that hint at a serious cigarette habit. He said he was a welder at the Bath Iron Works.
“Jessie’s ma left us two years ago,” he told me as his daughter went into a dressing area we have off the CT scan room to change into a hospital gown.
“She died?” I asked.
“I wish. The bitch—’scuse my French—ran off with a guy she worked with at the Rite Aid Pharmacy in Brunswick. They’re livin’ in some trailer down in Destin. That’s on the Florida Panhandle. Know what a friend of mine told me they call that part of the world down there? The Redneck Riviera. Jessie’s headaches started after her ma vanished. And she’s never once been back to see Jessie. What kind of mother is that?”
“She’s obviously lucky to have a dad like you,” I said, trying to somewhat undercut the terrible distress this man was in—and the way he was working so hard to mask his panic.
“She’s all I got in the world, ma’am.”
“My name’s Laura,” I said.
“And if it turns out that what she has is, like, serious . . . and doctors don’t send young girls in for one of these scans if they think it’s nothing . . .”
“I’m sure your physician is just trying to rule things out,” I said, hearing my practiced neutral tone.
“You’re taught to say stuff like that, aren’t you?” he said, his tone displaying the sort of anger that I’ve so often seen arising to displace a great fear.
“Actually, you’re right. We are trained to try to reassure and not say much. Because I’m a technologist, not a diagnostic radiologist.”
“Now you’re using big words.”
“I’m the person who operates the machinery, takes the pictures. The diagnostic radiologist is the doctor who will then look at the scan and see if there is anything there.”
“So when can I talk to him?”
You can’t was the actual answer, because the diagnostic radiologist is always the behind-the-scenes man, analyzing the scans, the X-rays, the MRIs, the ultrasounds. He rarely ever meets the patient.
“Dr. Harrild will be talking directly to Jessica’s primary-care physician. I’m sure you’ll be informed very quickly if there is—”
“Do they also teach you to talk like a robot?”
As soon as this comment was out of his mouth, the man was all contrite.
“Hey, that was kind of wrong of me, wasn’t it?”
“Don’t worry about it,” I said, maintaining a neutral tone.
“Now you’re all hurt.”
“Not at all. Because I know how stressful and worrying this must be for you.”
“And now you’re reading the script again that they taught you to read.”
At that moment Jessica appeared out of the changing room, looking shy, tense, bewildered.
“This gonna hurt?” she asked me.
“You have to get an injection. It sends an ink into your veins so we’ll be able to see what’s going on inside of you. But the ink is harmless.”
“And the injection?” she asked, looking alarmed.
“Just a little prick in your arm and then it’s behind you.”
“You promise?” she asked, trying too hard to be brave, yet still so much the child who didn’t fully understand why she was here and what these medical procedures were all about.
“You be a real soldier now, Jess,” her father said, “and we’ll get you that Barbie you want on the way home.”
“Now that sounds like a good deal to me,” I said, wondering if I was coming across as too cheerful and also knowing that, even after sixteen years as an RT, I still dreaded all procedures involving children. Because I always feared what I might see before anyone else. And because I so often saw terrible news.
“This is just going to take ten, fifteen minutes, no more,” I told Jessica’s father. “There’s a waiting area just down the walkway with coffee, magazines—”
“I’m goin’ outside for a bit,” he said.
“That’s ’cause you want a cigarette,” Jessica said.
Her father suppressed a sheepish smile.
“My daughter knows me too well.”
“I don’t want my daddy dead of cancer.”
At that moment her father’s face fell, and I could see him desperately trying to control his emotions.
“Let’s let your dad get a little air,” I said, steering Jessica into the scan room, then turning back to her father who had started to cry.
“I know how hard this is,” I said. “But until there is something to be generally concerned about . . .”
He just shook his head and headed for the door, fumbling in his shirt pocket for his cigarettes.
As I turned back inside I saw Jessica looking wide-eyed and afraid in the face of the CT scanner. I could understand her concern. It was a formidable piece of medical machinery, stark, ominous. There was a large hoop, attached to two science fiction–style containers of inky fluid. In front of the hoop was a narrow bed that was a bit like a bier (albeit with a pillow). I’d seen adults panic at the sight of the thing. So I wasn’t surprised that Jessica was daunted by it all.
“I have to go into that?” Jessica said, eyeing the door as if she wanted to make a run for it.
“It’s nothing, really. You lie on the bed there. The machine lifts you up into the hoop. The hoop takes pictures of the things the doctor needs pictures of . . . and that’s it. We’ll be done in a jiffy.”
“And it won’t hurt?”
“Let’s get you lying down first,” I said, leading her to the bed.
“I really want my daddy,” she said.
“You’ll be with your daddy in just a few minutes.”
She got herself onto the bed.
I came over holding a tube attached to the capsule containing all that inky liquid, covering with my hand the intravenous needle still encased in its sterilized packaging. Never show a patient an IV needle. Never.
“All right, Jessica. I’m not going to tell you a big fib and say that getting a needle put into your arm is going to be painless. But it will just last a moment and then it will be behind you. After that, no pain at all.”
“I promise—though you might feel a little hot for a few minutes.”
“But not like I’m burning up.”
“I can assure you you’ll not feel that.”
“I want my daddy . . .”
“The sooner we do this, the sooner you’ll be with him. Now here’s what I want you to do . . . I want you to close your eyes and think of something really wonderful. You have a pet you love, Jessica?”
“I have a dog.”
“Eyes closed now, please.”
She did as instructed.
“What kind of dog is he?”
“A cocker spaniel. Daddy got it for my birthday.”
I swabbed the crook of her arm with a liquid anesthetic.
“The needle going in yet?” she asked.
“Not yet, but you didn’t tell me your dog’s name.”
“And what’s the silliest thing Tuffy ever did?”
“Ate a bowlful of marshmallows.”
“How did he manage to do that?”
“Daddy had left them out on the kitchen table, ’cause he loves roasting them in the fireplace during Christmas. And then, out of nowhere, Tuffy showed up and . . .”
Jessica started to giggle. That’s when I slipped the needle in her arm. She let out a little cry, but I kept her talking about her dog as I used tape to hold it in place. Then, telling her I was going to step out of the room for a few minutes, I asked:
“Now is the needle still hurting?”
“Not really, but I can feel it there.”
“That’s normal. Now I want you to lie very still and take some very deep breaths. And keep your eyes closed and keep thinking about something funny, like Tuffy eating those marshmallows. Will you do that for me, Jessica?”
She nodded, her eyes firmly closed. I left the scan room as quietly and as quickly as I could, moving into what we call the technical room. It’s a booth with a bank of computers and a swivel chair and an extended control panel. Having prepped the patient I was now about to engage in what is always the trickiest aspect of any scan: getting the timing absolutely right. As I programmed in the data necessary to start the scan, I felt the usual moment of tension that, after all these years, accompanies each of these procedures I conduct; a tension that is built around the fact that, from this moment on, timing is everything. In a moment I will hit a button. It will trigger the high-speed injection system that will shoot 80 milligrams of high-contrast iodine into Jessica’s veins. After that I have less than fifty seconds—more like forty-two seconds, given her small size—to start the scan. The timing here is critical. The iodine creates a contrast that allows the scan to present a full, almost circular image of all bone and soft tissue and internal organs. But the iodine first goes to the heart, then enters the pulmonary arteries and the aorta before being disseminated into the rest of the body. Once it is everywhere you have reached the Venus phase of the procedure, when all veins are freshly enhanced with the contrast. Begin the scan a few critical seconds before the Venus phase and you will be scanning ahead of the contrast, which means you will not get the images that the radiologist needs to make a thorough and accurate diagnosis. Scan too late and the contrast might be too great. That’s why this small block of time still fills me with dread, even after the thousands of scans I have conducted. If I fail to get the timing right the patient will have to go through the entire procedure again twelve hours later (at the very minimum), and the radiologist will not be pleased. Which is why there is always a moment of tension and doubt that consumes me in these crucial seconds before every scan. Have I prepped everything correctly? Have I judged the relationship between the diffusion of the iodine and the patient’s physique? Have I left anything to chance?
I fear mistakes in my work. Because they count. Because they hurt people who are already frightened and dealing with the great unknown that is potential illness.
But children . . . children with cancers . . . it still pierces me. Being a mom makes it ten times worse. Because I am always thinking: what if it was Ben or Sally? Even though they are now both in their teens, both beginning to find their way in the world, they will always remain my kids, and, as such, the permanent open wound. That’s the curious thing about my work. Though I present to my patients, my colleagues, my family, an image of professional detachment—Sally once telling a friend who’d come over after school, “My mom looks at tumors all day and somehow always seems cheerful . . . how weird is that?”—recently it has all begun to unsettle me. Whereas in the past I could look at all forms of internal calamity on my screens and push aside the terribleness that was about to befall the person on the table, over the past few months I’ve found it has all started to clog up my head. Just last week I ran a mammogram on a local schoolteacher who works at the same middle school that Sally and Ben attended, and who, I know, finally got married a year earlier and told me with great excitement how she’d gotten pregnant at the age of forty-one. When I saw that nodule embedded in her left breast and could tell immediately it was Stage II (something Dr. Harrild confirmed later), I found myself driving after work down to Pemaquid Point, and heading out to the empty beach, and being oblivious to the autumn cold, and crying uncontrollably for a good ten minutes, wondering all the time why it was only now getting to me.
That night, over dinner with Dan, I mentioned that I had run a mammogram on someone my own age that day (this being a small town, I am always absolutely scrupulous about never revealing the names of the patients I’ve seen). “And when I saw the lump on the screen and realized it was cancerous, I had to take myself off somewhere because I kind of lost it.”
“What stage?” he asked.
I told him.
“Stage Two isn’t Stage Four, right?” Dan said.
“It still might mean a mastectomy, especially the way the tumor is abutting the lymph nodes.”
“You’re quite the diagnostician,” he said, his tone somewhere between complimentary and ironic.
“The thing is, this is not the first time I’ve lost it recently. Last week there was this sad little woman who works as a waitress up at some diner on Route One who had this malignancy on her liver. And again I just fell apart.”
“You’re being very confessional tonight.”
“What do you mean by that?”
“Nothing, nothing,” he said, but again with a tone that, like so much to do with Dan right now, was so hard to read.
Dan is Dan Warren. My husband of twenty-three years. A man who has been out of work for the past eighteen very long months. And someone whose moods now swing wildly.
“Hey, even the best fighter pilots lose their nerve from time to time.”
“I’m hardly a fighter pilot.”
“But you’re the best RT on the staff. Everyone knows that.”
Except me. And certainly not now, positioning myself in front of the bank of computer screens, staring out at Jessica on the table, her eyes tightly shut, a discernible tremor on her lips, her face wet with tears. A big part of me wanted to run in and comfort her. But I also knew it would just prolong the agony, that it was best to get this behind her. So clicking on the microphone that is connected to a speaker in the scan room, I said:
“Jessica, I know this is all very spooky and strange. But I promise you that the rest of the procedure will be painless—and it will all be over in just a few minutes. Okay?”
She nodded, still crying.
“Now shut your eyes and think about Tuffy and . . .”
I hit the button that detonated the automatic injection system. As I did so a timer appeared on one of the screens—and I turned my vision immediately to Jessica, her cheeks suddenly very red as the iodine contrast hit her bloodstream and raised her body temperature by two degrees. The scan program now kicked in, and the bed was mechanically raised upward. Jessica shuddered at this first vertical movement. I grabbed the microphone.
“Nothing to worry about, Jessica. Just please keep very still.”
To my immense relief she did absolutely as instructed. The bed reached a level position with the circular hoop. Twenty-eight seconds had elapsed. The bed began to shift backward into the hoop. Thirty-six seconds when it halted, the hoop encircling her small head.
“Okay, Jessica, you’re doing great. Just don’t move.”
Forty-four seconds. Forty-six. My finger was on the scan button. I noticed it trembling. Forty-nine. And . . .
I depressed it. The scan had started. There was no accompanying noise. It was silent, imperceptible to the patient. Instinctually I shut my eyes, then opened them immediately as the first images appeared on the two screens in front of me, showing the left and right spheres of the brain. Again I snapped my eyes shut, unable to bear the shadow, the discoloration, the knotty tubercle that my far-too-trained eye would spot immediately and which would tear me apart.
But professionalism trumped fear. My eyes sprang open. And in front of me I saw . . .
Or, at least, that’s what my first agitated glance showed me.
I now began to scrutinize the scan with care—my eye following every contour and hidden crevasse in both cerebral hemispheres, like a cop scouring all corners of a crime scene, looking for some hidden piece of evidence that might change the forensic picture entirely.
I went over the scan a third time, just to cover my tracks, make certain I hadn’t overlooked anything, while simultaneously ensuring that the contrast was the correct level and the imaging of the standard that Dr. Harrild required.
I exhaled loudly, burying my face in my hand, noticing for the first time just how rapidly my heart was pounding against my chest. The relief that Jessica’s brain showed no signs of anything sinister was enormous. But the very fact that my internal stress meter had shot into the deep red zone . . . this troubled me. Because it made me wonder: is this what happens when, over the years, you’ve forced yourself to play a role that you privately know runs contrary to your true nature; when the mask you’ve worn for so long no longer fits and begins to hang lopsidedly, and you fear people are going to finally glimpse the scared part of you that you have so assiduously kept out of view?
I took another steadying breath, telling myself I had things to be getting on with. So I downloaded this first set of scans to Dr. Harrild, whose office was just a few steps away from the CT room. I also simultaneously dispatched them to PACS—that’s the Picture Archiving and Communication System, which is the central technological storage area in Portland for our region of the state (known by its code name: Maine 1). All scans and X-rays must, by law, be kept in a PACS for future reference and to ensure they are never mixed up, misplaced, assigned to the wrong patient. It also means that if a radiologist or oncologist needs to call up a specific set of patient scans, or compare them with others on file, they can be accessed with the double click of a mouse.
The images dispatched, I began running a second set of scans to have as backup, to compare contrast levels, and to double check that the imaging hadn’t missed anything. Usually, if the first set of scans is clear, I relax about the second go-around. But today I heard a little voice whispering at me: “Say you got it all wrong the first time . . . say you missed the tumor entirely.”
I grabbed the mike.
“Just a few more minutes, Jessica. And you have been just terrific. So keep lying still and . . .”
The second scan now filled the two screens. I stared ahead, fully expecting to see proof of my corroding professionalism in front of me as a concealed nodule now appeared in some ridge of her cerebellum. But again . . .
That’s the greatest irony of my work. Good news is all predicated on the discovery of nothing. It must be one of the few jobs in the world where “nothing” provides satisfaction, relief, the reassertion of the status quo.
A final scan of the scan.
I hit the Send button. Off went this second set of scans to Dr. Harrild and the PACS Storage Center. I picked up the mike again and told Jessica we were done, but she would have to remain very still as the bed was brought back to ground level again.
Ten minutes later, dressed again and sucking on a lollipop, Jessica was reunited with her father. As I brought her into the waiting room, where he sat slumped, anxious, he was immediately on his feet, trying to read me the way a man on trial tries to read the faces of the jurors filing back into court with a verdict already cast in stone. Jessica ran over to him, throwing her arms around her father.
“Look, I got four lollipops,” she said, holding up the three untouched ones in her hand and pointing to the one in her mouth.
“You deserve them,” I said, “because you were such a brave, good patient. You would have been proud of her, sir.”
“I’m always proud of my daughter,” he said, picking her up and putting her on a bench, asking her to sit there for a moment “while this nice lady and I have a talk.”
Motioning for me to follow him outside into the brisk autumn morning, he asked me the question I always know is coming after a scan:
“Did you see anything?”
“I’m certain the diagnostic radiologist, Dr. Harrild, will be in contact with your primary-care physician this afternoon,” I said, cognizant of the fact that I also sounded like a scripted automaton.
“But you saw the scans, you know.”
“Sir, I am not a trained radiologist, so I cannot offer a professional opinion.”
“And I don’t design the ships I work on, but I can tell when something’s wrong if I see it in front of me. Because I have years of on-the-job experience. Just like you. So you now know, before anyone, if there is a tumor in my daughter’s head.”
“Sir, you need to understand: I can neither legally nor ethically offer my opinion of the scans.”
“Well, there’s a first time for everything. Please, ma’am. I’m begging you. I’ve got to know what you know.”
“Please understand, I am sympathetic—”
“I want an answer.”
“And I won’t give you one. Because if I tell you good news and it turns out not to be good news . . .”
That startled him.
“Are you telling me there’s good news?”
This is a strategy I frequently use when the scan shows nothing, but the diagnostic radiologist has yet to study them and give them the all clear. I cannot say what I think because I don’t have the medical qualifications. Even though my knowledge of such things is quite extensive, those are the hierarchical rules and I accept them. But I can, in my own way, try to calm fears when, I sense, there is clinical evidence that they are ungrounded.
“I’m telling you that I cannot give you the all clear. That is Dr. Harrild’s job.”
“But you think it’s ‘all clear.’”
I looked at him directly.
“I’m not a doctor. So if I did give you the all clear I’d be breaking the rules. Do you understand, sir?”
He lowered his head, smiling, yet also fighting back tears.
“I get it . . . and thank you. Thank you so much.”
“I hope the news is good from Dr. Harrild.”
Five minutes later I was knocking on Dr. Harrild’s door.
“Come in,” he shouted.
Patrick Harrild is forty years old. He’s tall and lanky and has a fuzzy beard. He always dresses in a flannel shirt from L.L.Bean, chinos, and brown work boots. When he first arrived here three years ago, some unkind colleagues referred to him as “the geek” because he isn’t exactly the most imposing or outwardly confident of men. In fact, he veers toward a reserve that many people falsely read as timidity. Before Dr. Harrild, the resident diagnostic radiologist was an old-school guy named Peter Potholm. He always came across as God-the-Father, intimidated all underlings, and would happily become unpleasant if he felt his authority was being challenged. I was always ultra-polite and professional with him and simultaneously let him play the role of Absolute Monarch in our little world. I got along with Dr. Potholm, whereas three of the RTs actually left during his fourteen-year tenure (which ended when age finally forced him to retire). Dr. Harrild couldn’t have been more different from “Pope Potholm” (as the hospital staff used to refer to him). Not only is he unfailingly polite and diffident, he also asks for the opinions of others. He’s a very decent and reasonable man, Dr. Harrild, and an absolutely first-rate diagnostician. The slight social awkwardness masks reinforced steel.
“Hey, Laura,” Dr. Harrild said as I opened his office door. “Good news on the Jessica Ward front. It looks very all clear to me.”
“That is good news.”
“Unless, of course, you spotted something I didn’t.”
Peter Potholm would have walked barefoot across hot coals rather than ask the medical opinion of a lowly RT. Whereas Dr. Harrild . . .
“I saw nothing worrisome,” I said.
“Glad to hear it.”
“Would you mind talking to Jessica’s father now? The poor man . . .”
“Is he in the waiting area?”
“We have Ethel Smythe in next, don’t we?” he asked.
“Judging by the shadow on her lung last week . . .”
He let the sentence hang there. He didn’t need to finish it—we had both looked at the X-ray I’d taken of Ethel Smythe’s lungs two days earlier. And we’d both seen the shadow that covered a significant corner of the upper left ventricle—a shadow that made Dr. Harrild pick up the phone to Ethel Smythe’s physician and tell him that a CT scan was urgently required.
“Anyway, I will go give Mr. Ward the good news about his daughter.”
Fifteen minutes later I was prepping Ethel Smythe. She was a woman about my age. Divorced. No children. A cafeteria lady in the local high school. Significantly overweight. And a significant smoker, as in twenty a day for the past twenty-three years (it was all there on her chart).
She was also relentlessly chatty, trying to mask her nervousness during the X-ray with an ongoing stream of talk, all of which was about the many details of her life. The house she had up in Waldoboro, which was in urgent need of a new roof but which she couldn’t afford. Her seventy-nine-year-old mother who never had a nice word for her. A sister in Michigan who was married to “the meanest man this side of the Mississippi.” The fact that her physician, Dr. Wesley, was “a dreamboat, always so kind and reassuring,” and how he told her he “just wanted to rule a few things out, and he said that to me in such a lovely, kind voice . . . well, there can’t be anything wrong with me, can there?”
The X-ray said otherwise—and here she was, now changed into the largest hospital gown we had, her eyes wild with fear, talking, talking, talking as she positioned herself on the table, wincing as I inserted the IV needle in her arm, telling me repeatedly:
“Surely it can’t be anything. Surely that shadow Dr. Wesley told me about was an error, wasn’t it?”
“As soon as our diagnostic radiologist has seen the scan we’ll be taking today . . .”
“But you saw the X-ray. And you don’t think it’s anything bad, do you?”
“I never said that, ma’am.”
“Please call me Ethel. But you would have told me if it had been bad.”
“That’s not my role in all this.”
“Why can’t you tell me everything is fine? Why?”
Her eyes were wet, her voice belligerent, angry. I put my hand on her shoulder.
“I know how frightening this is. I know how difficult it is not knowing what is going on—and how being called back for a scan like this . . .”
“How can you know? How?”
I squeezed her shoulder.
“Ethel, please, let’s just get this behind you and then—”
“They always told me it was a stupid habit. Marv—my ex-husband. Dr. Wesley. Jackie—that’s my sister. Always said I was dancing with death. And now . . .”
A huge sob rose in her throat.
“I want you to shut your eyes, Ethel, and concentrate on your breathing and . . .”
“I’m going to step away now and get all this under way,” I said. “Just keep breathing slowly. And the scan will be finished before you—”
“I don’t want to die.”
This last statement came out as a whisper. Though I’d heard, over the years, other patients utter this, the sight of this sad, frightened woman had me biting down on my lip and fighting tears, and yet again silently appalled at this newfound vulnerability. Fortunately Ethel had her eyes firmly shut, so she couldn’t see my distress. I hurried into the technical room. I reached for the microphone and asked Ethel to remain very still. I set the scan in motion. In the seconds before the first images appeared on the screen I snapped my eyes shut, opening them again to see . . .
Cancer. Spiculated in shape. And from what I could discern, already metastasized into the other lung and the lymphatic system.
Half an hour later Dr. Harrild confirmed what I’d seen.
“Stage Four,” he said quietly. We both knew what that meant, especially with this sort of tumor in the lungs. Two to three months at best. As cancer deaths go, this one was never less than horrible.
“Where is she right now?” Dr. Harrild asked.
“She insisted on going back to work,” I said, remembering how she told me she had to hurry back after the scan because the school lunch she’d be serving started at midday, and “with all the cutbacks happening now I don’t want to give my boss an excuse to fire me.”
Recalling this I felt myself getting shaky again.
“You okay, Laura?” Dr. Harrild asked me, clearly studying me with care. Immediately I wiped my eyes and let the facade of steely detachment snap into place again.
“Fine,” I said, hearing the enforced crispness in my voice.
“Well,” he said, “at least the little girl’s news was good.”