Herbert S. Heineman, M.D.

TWO

May 1985

Connor Flynn — Con to family and friends — was in the transfusion room for the umpteenth time in the past eighteen months; he preferred not to keep count. His hemoglobin level was back down to 5, a third of what a healthy fifteen-year-old boy needed to sustain the vigorous activity characteristic of his age. He didn’t think he needed to subject himself to repeated blood counts. Loss of energy, shortness of breath on the slightest exertion, and pallor of his fingernails and the insides of his eyelids (that’s where Doctor Ellis always looked) told him — and his mother, though he couldn’t tell whether his father noticed — that he was due for a transfusion.

Until he was fourteen, Con had been his father’s pride, a poster boy of ruddy vigor. There was no sport at which, once he became interested and learned the rules, he did not excel. Then one day he paid the price — a reasonable price, most would say — for his enthusiasm.

With his father as referee, Con and a group of friends played tackle football on a neighborhood dirt lot. Con had learned from experience that with dad watching, anything less than maximum effort could lead to an unpleasant dinner conversation. Unwilling to take that risk, he threw himself headfirst at Paul Bannon’s legs as Paul came thundering down the lot carrying the ball. Paul was a year older and weighed almost half as much again as Con. With minimal effort he sent Con sprawling, inflicting a number of abrasions on his knees, forearms, and face.

“Good try, proud of you!” his father yelled to Con after properly crediting Paul with a touchdown. His mother was less pleased when Con limped home, bragging about his encounter. She considered her son’s play reckless and the entire sport of football violent and conducive to bodily injury. She rushed him to their family practitioner’s office, where Doctor Ellis determined that Con had not broken any bones but had so much dirt in his wounds that even after thorough washing they weren’t really clean.

“Sponge them with lukewarm salt water — just a wee pinch of salt — twice a day,” Doctor Ellis instructed Mrs. Flynn, “and bring him back here in three or four days. You can make an appointment up front. Most of the dirt that’s left will work its way out, though there’ll be some infection for sure. I’ll give him a tetanus booster and a prescription for an antibiotic. Better yet,” rummaging in the refrigerator, “I’ll give you these samples of Chloromycetin. It’s broad-spectrum, so it’ll work against most bacteria. Not much used anymore, but very powerful. Have him take one capsule four times a day with water.” Doctor Ellis treated his patients as whole human beings, not, in contrast to some of the younger medical graduates, as a composite of individual organs. In that spirit he also believed in saving them unnecessary expense and kept, sometimes well beyond their printed expiration dates, the free samples pharmaceutical salespeople left with him. Sooner or later someone was bound to need them. He’d taken care of two generations of Flynns, and they had benefitted from his thrift and generosity more than once. Mrs. Flynn didn’t ask why Chloromycetin was “not much used anymore,” considering how powerful it was. Obviously Doctor Ellis knew what he was doing.

She conscientiously followed the doctor’s instructions, and Con’s inherent tissue integrity, with the help of the Chloromycetin, did the rest. At the follow-up visit Doctor Ellis was very satisfied. Within two weeks Con was back playing football and earning his father’s kudos. Two weeks more and, for all the thought he gave to it, it might as well never have happened. He’d sustained injuries before, and this was just another.

Within three months he would learn the difference.

“What did you bump into this time? Or who did you bump into, I should say?” his father asked with a smile at dinner, more proud than worried. He right away visualized Con in a fight — winning, of course. Nothing builds character like a good fight.

“Just the usual,” Con answered with a shrug. He looked at the bruise on his left forearm. Then a second above his right elbow. He frowned but said nothing. That evening, undressing, he was astonished to see half a dozen bruises on his legs, and a profusion of pinpoint red spots besides. Nothing hurt or itched, so he decided not to create an emergency but go to bed.

He fell asleep comforted by the thought that bruises are part of a football player’s life. He was proud of not feeling the tenderness that ordinarily accompanied bruises. In his dream that night he saw himself as a soldier riddled with bullet holes and still managing to drag a wounded comrade to safety. An officer patted him on the back and congratulated him for his bravery. A medal was just around the corner.

The reality to which he awoke was a different matter. He had not been shot even once, and his wounded buddy was none other than a sleepover friend, with whom he had got into a fight a week earlier and who had emerged with nothing more serious than a bloody nose.

The bloody nose with which Con woke that morning was his own. He had never before gotten into a fight in his sleep, so there was no reason for the nosebleed. He made his way to the bathroom, where the sight of blood dripping from his nose, drop by drop, into the washbowl was enough to scare him into admitting that something was wrong. His parents agreed and his mother once more took him straightaway to see Doctor Ellis. The doctor looked at Con’s limbs, saw the bruises on his torso, which neither Con nor his parents had been aware of, and sent him to the laboratory two floors below with an urgent request for a complete blood count.

The laboratory telephoned the results thirty minutes later, and the printed report was sent up that afternoon. A chill ran down Doctor Ellis’s spine as he studied it. Memories of a warning, which he had dismissed as a statistical rarity, came back to his mind. Surely he could have treated Con with some antibiotic other than Chloromycetin!

Patient Value Units Normal Range
Hemoglobin
7.5 L
grams per deciliter
13-16
Hematocrit
24 L
per cent
40-50
Red cells
2.1 million L
number per microliter
number per microliter
Reticulocytes
none seen
per cent of red cells
0.5-1.5
White cells
1,600 L
number per microliter
4,500-10,000
Platelets
8,000 L
number per microliter
150,000-450,000

L = below normal range

Comment: Strongly suggestive of bone marrow failure, or aplastic anemia

Doctor Ellis was not one to pull punches, and he was scrupulously honest. “This is serious,” he told Mrs. Flynn, who had just hung up her coat when the telephone rang. He admitted the possibility that Chloromycetin was the culprit; there had been published case reports. He did not mention his dismissive attitude toward warnings of just such a catastrophe. “Con will most likely need periodic blood transfusions, depending on how fast his counts drop. If they keep dropping after each transfusion long enough, he might qualify for a marrow transplant eventually, but it’s too early to say. On the other hand, if he’s really lucky, his own marrow may recover and he won’t need any more transfusions. I’ll make an appointment for him at Cresheim Valley to get his blood typed and cross-matched.” That simple procedure was necessary to insure that the patient received only blood that was compatible with his own.

Con was not concerned about his condition. He left the worrying to his parents and thought instead about fitting hospital visits into his schedule and, above all, not letting the whole matter interfere with his life.

On his first visit to the treatment room he found himself in the company of a boy seemingly also in his teens. He was wearing a red baseball cap with the visor pointed sideways. But it was the boy’s pallor that so transfixed Con that he could not help staring. “I’m sorry,” he said once he’d collected himself, “it’s rude of me to stare like that.”

“And sensitive of you to think you need to apologize.” The answer came in a voice whose pitch surprised Con even more than had its owner’s complexion. “I’ll have more color by the time I leave here. Is this your first time? I’m on my seventh.”

Con was still staring. “Yes, I’m a girl!” she said, laughing aloud and slapping her knees. “You should know the difference at your age! How old are you? Anyway, here’s the story. I have leukemia and I’ve been on chemotherapy. It doesn’t change your voice but it does make your hair fall out. Want to see the shape of my skull? No? Need time to digest what I’ve told you? Just say the word,” followed by another peal of laughter.

Con was confused. He realized he hadn’t given his own condition anything resembling serious attention. He didn’t hurt and after each transfusion he even felt more or less normal. And he hadn’t lost a single hair. But then, he could afford to be nonchalant only because he knew next to nothing about aplastic anemia, including the unlikelihood of spontaneous remission, not to mention its occasional prelude to leukemia. He even had trouble remembering the name. To him — so far, at any rate — it was nothing more than a series of brief interruptions in an active life, sort of like paying his grandparents an occasional dutiful visit.

But he had heard of leukemia. Everybody had heard of leukemia. He knew it was serious, that people could die from it. Now he’d met a girl his age who had it.  She seemed cheerful enough, too cheerful maybe, but one look at her was enough to mark her as seriously ill.  She’d lost her hair, even her eyebrows. That really meant something. He could not join in her laughter. He could not see that she had anything to laugh about.

“Yes,” he said, “I’m having trouble dealing with what you’ve been saying. What’s going to happen to you?”

She shrugged. “The chemo didn’t work for long. Now they’re talking about doing a bone marrow transplant. But that’s real complicated. First they’ve got to find a matching donor, which for reasons I don’t understand is harder than finding a matching blood donor. Then the procedure is dangerous, because they first have to burn out my own marrow and for a while I’ll have no defense against infection, or I could have a hemorrhage, maybe into my brain. I don’t like to think about it, but sooner or later I may have to face up to it.”

He was afraid to ask, and even more afraid not to. “What happens if that doesn’t work either?”

She cast her eyes down, then looked him straight in the face, her mirth giving place to sad resignation. “I’ll die, I guess. That happens to kids with leukemia.”

Her eyes were dry, as though weeping wouldn’t get her anywhere. He, on the other hand, felt tears running down his cheeks. How could this young girl be so reconciled to the imminence of death? Suddenly her face, pale as death itself, crowned by a cap that hid nothing but a bare scalp, looked to him as the most beautiful thing he’d ever seen.

“Can I be a bone marrow donor for you?” he asked, desperate to do something to help her.

Her laughter caught him off guard. “If I understood you right, you don’t have any marrow to give! You might end up needing a transplant as well.”

That observation brought laughter to him too. “I guess I’m pretty stupid,” he said.

“I’d say it you’re pretty sweet.”

“You know, we haven’t really met. “I’m Connor Flynn. F-L-Y-N-N.”

“I’m Jill Wonderlin. W-O-N-D-E-R-L-I-N. In the old country it was Wunderlich, with a C-H at the end. My grandparents anglicized it when they got their U.S. citizenship. I think they wanted to hide their Jewish origin, though that doesn’t seem to matter a whole lot in this country.”

“Pretty name either way. Too bad you’ll have to trade it in when you get married.”

If I get married. I may not live that long. But you can help. When you recover and your marrow’s back to normal, I’ll take you up on your offer. Assuming I last that long. And assuming that your history doesn’t disqualify you from being a donor.”

“How would you know that I’d be a match?”

She nodded. “Good point. That would be a real long shot. We could start by comparing blood types. I’m O-negative. That means I can only accept blood from an O-negative donor. But I can give blood to anybody. Not with leukemia, of course; nobody’d want that! I’m what they call a universal donor. I could give blood to you — assuming you wanted to risk getting leukemia. What type are you?”

“A-positive, I think. I heard someone tell my mom. I don’t understand how blood types work, but I think I can accept blood from anybody. Do I have it right?”

“Not quite. You couldn’t accept type B, or AB, but those types are pretty rare. But there’s also the Rh factor, which is what the positive and negative refer to. It’s complicated. Anyway, long story short, I could be a donor for you, but not the other way round, even if there were anything in your marrow to donate. But still, thanks again for your offer.”

Despite being indifferent to his own condition, Con now looked forward to his visits to the transfusion suite, in the hope of again meeting Jill. But what exactly did he expect from indulging his fantasy? Supposing that by lucky chance both of them emerged healthy, would his parents permit him to pursue a relationship with a girl who had Jewish blood in her veins? Could he argue convincingly that her native blood had been replaced by anonymous, probably non-Jewish donors? Maybe even Catholic donors donating Catholic blood? For that matter, can a Jewish girl’s religion be changed by replacing her blood? Was Catholic type O blood any different from Jewish type O blood? The more he thought about it the less sense all that talk about blood made.

He had listened in on his parents’ conversations often enough to be aware of his father’s xenophobia. Luckily his mother seemed to be more tolerant. He congratulated himself on having escaped the worst of his father’s views, but he tried not to argue about them with his father.

For now, there was no need to go into any of that detail with his parents. He’d taken a liking to a girl he’d met in the transfusion unit and he hoped they’d both be well enough to go out together. That was it, totally casual.

As it happened, their schedules didn’t mesh and it was by purest chance that they both had appointments on the Friday after Thanksgiving Day. Already, he was fully determined to meet her someplace other than the hospital, perhaps even ask her out.

Four-day Thanksgiving weekends were just as popular at Cresheim Valley Hospital as at other workplaces, so that on this particular Friday, while officially a workday, the hospital was somewhat understaffed. Still, there didn’t seem to be any reason to curtail routine services such as transfusions to well-known recipients, or regular customers as they were called.

Con arrived to find Jill comfortably seated in her easy chair. To honor the occasion, and to demonstrate the turkey patch on the front, she was wearing her cap visor-forward.

“What a surprise!” she exclaimed. “How was your holiday?”

Con simply stared. He had not seen Jill for six months. She looked just as beautiful to him as he had fantasized all that time. To interfere with her pallor by transfusing blood into her veins bordered on artistic travesty.

“Well, speak up!” she said with a broad grin. “Or can’t you talk until you’ve had your transfusion?”

“I’m sorry,” he answered, “I just had to look. I think you’re beautiful.” The words escaped before he could contain them. They would both have blushed had their anemia allowed.

Almost inaudibly she said: “Nobody’s ever called me that. It’s a lovely thing for you to say.” She turned away hoping he would not see the moistness of her eyes.

“I shouldn’t be so forward. I hardly know you.” But inwardly he was glad that he had made the confession.

“You don’t need to be sorry,” she said. “But if we can meet outside this bloody room — pardon the pun — we can get to know each other better. They say a friendship is good for your health. Might even cure me.”

“You’re way ahead of me. I don’t know whether I have to keep coming, or how often. I have aplastic anemia, and they think it’s because of Chloromycetin. The antibiotic, you know. Poor choice. Maybe I’ll recover.”

“I have leukemia, and I won’t.”

“Yes, you told me, and I haven’t forgotten.”  She was right, they should get to know each other before it was too late. He had an urgent desire to walk with her, hand in hand, along Wissahickon Creek, talking of this or that, or of nothing at all.

Now unashamed to show his emotions, he said: “Let’s make a date for this weekend. Is Sunday afternoon good for you?”

“One day’s as good as any other. For now leukemia rules my life, and I don’t expect to be in remission day after tomorrow. Call for me about two o’clock. Here’s my address and phone number.” She found a sheet of paper and wrote them down. As she gave him the paper she asked:

“Are you doing this out of pity, knowing what I’ve got? I mean, no healthy person would want to date someone like me.” She didn’t want to elaborate, to confess that a former boyfriend’s mother had forbidden him to see her again, thinking that leukemia might be contagious.

❖❖❖❖❖

Con had been on any number of dates. He preferred pretty faces but was willing to compromise with availability. Sometimes he had returned for seconds but most of his dates were one-time affairs. The exception was Valerie Gunsberg, whom he found both physically and intellectually attractive. He “went steady” with her for three months, until she decided his values weren’t compatible with hers. The split was precipitated by a proposed double date. Val had suggested that they go to a movie with her friends Latoya and Antwan. Con’s pace slowed.

“Where the heck are they from?” he asked, with a generous shade of contempt.

“Right here, Philadelphia.”

“Let me guess: West Philly. Right? Or is it North Philly?”

Val didn’t like Con’s tone. “No,” she said through clenched teeth, “Latoya’s from South Philly. “I’ve been to her place. Real nice apartment and, incidentally, very nice parents and sister. I don’t know where Antwan lives.”

“Want me to spell Antwan?”

“I don’t care how you spell it.”

“Sounds like a French name. But I bet there’s no o and no i. Probably no e at the end either.”

“You’d be a whiz in a spelling bee.”

“Do your friends know how to spell?”

Val came to a dead stop and turned to him. “Know something, Con? I’m glad this came up when it did, before we really got too involved with each other. Latoya’s one of my best friends and, for your information, she’s sharp as a tack. She has her eyes on Harvard. I don’t know Antwan that well, but she wouldn’t date someone less brilliant than herself.”

Con felt he was at the wrong end of a comparison, and he couldn’t help being afraid of where Val was going next. But he thought better of defending himself and simply said, as pleasantly as he could, “See you tomorrow then. Looking forward to meeting those folks.”

She said no more. Next day she called off not only their date but their friendship.

“What? Why?” he asked, stupefied.

“If you have to ask, I know I’m doing the right thing. Because I’ve overestimated you. I didn’t like how you talked about my friends. It’s disrespectful not only to them but to me as well. And it certainly doesn’t speak well of your values.”

“You know I’m not really like that,” he said, aware that his tone sounded unconvincing. Saying no more, he admitted to himself that he was trying not to be like “that”; that his father was like that; and that he, Con, was trying to break free. Forced by his misstep to accept that he had lost the closest thing he’d had to a lasting friendship, he determined to do better in the future. Which required having it out with his father.

That conversation was aborted by his injury and all the events that followed. He had sat in the transfusion unit to receive blood, and from the chair opposite him had beckoned this seriously ill girl, cheerful and altogether devoid of self-pity. He did not grasp the source of her magnetism. It was not her looks. Good gracious! What would she even look like if her face had eyebrows and her scalp was bursting with a lush growth of hair? What color would it be? What kind of a girl would Jill be if she weren’t ill? Maybe he wouldn’t even like her after — if! — she recovered. Of one thing, though, he was sure: She had had an effect on him that no other girl, including Val, had ever had. The realization both troubled and excited him. Naturally he would have liked to understand why. But if he had had to choose between wallowing in his intoxicated state and understanding it, he would have taken the former. It would have been a wise decision, because intellectualizing his infatuation would have destroyed it — and to what end?

Val and her brilliant friends had ceased to matter.

❖❖❖❖❖

“You’re not sure, are you?” Jill’s voice broke into Con’s musing.

With an effort he remembered what they’d been talking about. “No, it’s not pity,” he said unsteadily. “For some reason I’m drawn to you. Maybe your illness has something to do with it, but pity’s not the right word.”

The entrance of a unfamiliar nurse cut off their conversation.

“Well, hello palefaces!” the nurse, a mere sprite with a healthy tan, jet-black hair, and piercing black eyes, incanted in a high-pitched voice. “Isn’t this a great way to break up the Thanksgiving weekend?” She spoke with an accent, which Con judged to be Hispanic. It would have matched her complexion.

Whatever reaction she expected did not materialize. Her two subjects’ minds were on other matters.

“Now let’s see,” she continued. “I’m Nurse Nightingale, by the way.” She looked around for recognition, perhaps even a laugh, again in vain. For all she knew, they’d never heard of Florence Nightingale. Oh well. There was a job to do, and there was a limit to her efforts to make an impression on these teenagers.

“OK, so we have one O-negative and one A-positive. No problem.” She fiddled with the transfusion bags and tubes.

“Eeny, meeny, miny, moe. Who goes first? Want to flip for it?”

The teenagers rolled their eyes and shrugged. “OK,” Jill said, “let’s get the show on the road. Heads I go first.”

“I just happen to have a quarter,” the nurse said. “Got it in the coffee shop. Thank goodness they’re open. I’ve worked in places where they closed everything, and I mean everything, for the whole weekend — except my workstation, of course. Hah!” She flipped the coin and watched it land on the floor. “Tails!” she announced and winked at Con conspiratorially. Not that he really cared who went first, and even less whether she had hoped for this outcome.  “The gentleman goes first.”

With that she inserted a needle in his arm and hooked up a saline infusion to make sure it flowed freely, meaning that the needle was properly placed in a vein. Next she did likewise to Jill.

“No problem here. See? I’m good with needles,” she said triumphantly.

Jill found this display annoying and wondered whether the nurse, in her spare time, injected materials unrelated to blood — into herself. “Well, thank goodness you can do the job you’re being paid to do,” she said. Con shot her a cautioning look, but Jill obviously disliked the nurse and had said what she felt she needed to. The nurse pursed her lips. She seemed poised to answer this teenage brat’s impertinence but her job could be in danger if Jill complained to the head nurse or, worse, to the doctor in charge. Kids were so unpredictable, and they had no sense of humor and no respect. That’s why she never wanted any of her own. Already looking forward to the end of her shift, she hooked up one bag of blood to each of her charges in turn.

“See you in a while,” she said and left the room.

“Where on God’s earth did they find her?” Jill mumbled.

“Must be a stand-in,” Con ventured, “because of the holiday weekend.”

“I’m going to say something to Nurse Brent next time I come.”

“I wouldn’t,” Con cautioned. “Who knows? They might be friends. Better let it drop. You’ll probably never see this Nightshade woman again, or whatever her name is.”

Both drips were now running. They waited for “Nightshade” to reappear and announce that the session was over. Their mothers, both of whom had killed time in the coffee shop, came to pick them up just as the nurse was disconnecting the tubes.

“Hi, I’m Ana García. I’m filling in for Joan Brent. Someone has to work this weekend.”

“Yes,” said Mrs. Wonderlin with well-faked sympathy and the faintest trace of sarcasm. “Sorry for the inconvenience.”

Stung by Mrs. Wonderlin’s tone of voice, and recognizing her as the fount of Jill’s acerbity, Nurse García decided she’d be really glad when her shift was over. To that end, she withdrew the needles from the recipients’ arms, applied pressure bandages, and sang: “All done! Sit there a few minutes and you can all go home. I have to stay to the end of my shift.”

With that, she sashayed out. “Looks like she shortchanged you, both of you,” Mrs. Flynn said, pointing to the bags, both of which still contained about an ounce of blood.”

“Oh, that’s normal,” Jill said. “They keep a small amount in case they have to run tests later.”

“Won’t it clot?” asked Mrs. Wonderlin.

“Now really, Mom,” Jill said with mock impatience. “They mix something in to prevent that. Else the clots would get stuck in the tubing and the blood wouldn’t flow.”

Mrs. Wonderlin slapped herself on the forehead. “How stupid of me. Thank you, Jill dear, for reminding me that ‘the children shall lead them.’ ”

“A pleasure, mom, but this knowledge comes with a price tag, as you well know.”