Pileated Woodpecker

Clever, Cookie thought. A clever diagnosis. Hypothyroid with no symptoms other than the growth faltering. No one had praised her cleverness; she had not expected praise. Not even from the little girl's mother. People expect doctors to know everything. Cookie touched her own neck, and her smile faded. She felt a small lump just under the corner of her jaw on the right side. Her fingers patted carefully around its edges. How long had it been there? She pushed up at it. Did it move? She pressed. No pain. Probably my parotid gland, she thought. And on the other side? Another lump, but a small and soft one. She felt again on the right. Definitely bigger, firmer. A lymph node, maybe, reacting to a sore in her mouth? But what sore? She moved her tongue around behind her teeth. Nothing. And a reactive lymph node would be painful. This lump wasn't. Cookie was a healthy person who worried a lot. Being a doctor didn't help. In fact, it made it worse. Until she was well into medical school, she hadn't realized how many more things she could find to worry about. Like when the class learned to do breast exams and she found that her own breasts were full of irregular lumps she had never before noticed. Of course, she had panicked for nothing. And the migraine that made her vision blur so that she had backed her car into a wall. The neurologist clearly felt she was wasting his time. He'd said, "You know, if a patient had told you this story, you would have been able to diagnose a simple migraine. But no, when it's your own problem you go to pieces. Too emotional," he muttered, turning away. Angry as she was, Cookie said nothing. Should I call Bob Gross? she wondered. He was the internist she had asked about her breasts. He'll be fed up, too. Especially since she had decided to stop doing breast self-exams. With so many lumps, how could you remember which were old and which were new? And how could you live with your breast gone. Even her mother had been sickened by the jagged healing wound reflected in the mirror. Cookie, helping with bandages, had faced the immediate reality, unsoftened by distance or reflection. She had tried to remain expressionless, looking at her mother's skin blotched purple with extravasated blood. Her mother had decided to keep living. A brave woman they said. A cure, her mother had boasted. But the payment for that cure had been too high. Cookie paged her boyfriend who was a sixth year resident in thoracic surgery. Jav met her in an empty patient room on the Pediatric floor. Down the hall a child screamed as the IV team tried to find a vein, and Jay hunched his wiry shoulders and grimaced. His thin face looked pinched with strain and fatigue. "I can't stay long," he said, reaching for her neck almost before he had planted his feet. "Dawson is on my back about yesterday's double bypass. We had to go back in for a bleeder. And the guy's family went berserk, even though he did great afterwards." He frowned and pressed upwards. "Put your chin down." Cookie watched his eyes, focused, intense. In bed, his gaze was softer. There was no intimacy now. "OK, turn to the right a little." She waited, holding her breath. "Yeah, I definitely feel something. And it doesn't hurt?" "Maybe it's a lymph node," she said, wanting him to hold her. "I suppose." Jay sounded doubtful. "Look, phone Gross. Page me later and tell me what he thinks. I can't leave the hospital tonight; I've got to deal with the new interns. But we can have dinner in the cafeteria. I'm sure I can get free for half an hour." He looked at his watch, and kissed at her, his lips barely brushing hers. Cookie started to cry. "I've got to run. Don't worry," he said, opening the door to leave. He didn't say the word they were both thinking.

Although Gross agreed it was probably a lymph node, he got Cookie an immediate appointment to see an ENT guy. McAndrews was a tall and hearty, red-faced man in his forties with a thick southern accent. When he bent down over her, Cookie smelled pungent after-shave lotion and juicy fruit gum. "Ex-smoker," he explained about the gum, as he prodded Cookie's neck and jaw with large well-manicured fingers, all the while humming to himself. It sounded like the Anniversary Waltz. McAndrews shook his head and stopped humming. He frowned at his resident who was dozing over a pile of charts. "Rod! Get a feel," he barked. Startled, Rodney jumped up and knocked a chart to the floor. Cookie wondered if he were as sleep- deprived as Jay. Did McAndrews give him a harder time because he was black? Rodney closed his eyes as his fingers probed Cookie's neck under the jaw. His skin looked richly chocolate against the crisp whiteness of his hospital jacket. The closed eyes and gentle pressure reminded Cookie of a former lover who had seemed always to be dreaming of someone else as he caressed her. She tried to think instead about the chart on the floor. Was it hers? Did it feature snide comments by Gross about her lumpy breasts? Her emotional lability? "So?" McAndrews asked, giving Cookie a broad, reassuring smile. "Probably nothing, right, Roddy? Want to try her on Keflex for a week and see if it goes away, or do you want to operate?" He winked at Cookie, as if they were colleagues testing Rodney's medical acumen. Rodney said, "Let's wait." Cookie said, "So there is something'" McAndrews shrugged, still smiling. "Who knows," he said. "Look, a week one way or the other won't make the slightest tiny bit of difference. Maybe save you an operation, maybe not. You can never tell. Write her a prescription," he ordered Rodney. Turning back to Cookie, he said, "See you next week," and waved his hand as he walked out of the examining room. Cookie felt tears rise again. "What do you really think, Rodney?" she whispered, as soon as the door was closed. Rodney directed his analysis to the prescription pad. "Well, it's not matted down to anything, and it's pretty soft-feeling. On the other hand, there's no tenderness or redness, no sign of infection. I don't think it will be any different in a week." He finished writing and ripped the prescription off the pad. "Call me if you have any problems," he said, handing her the prescription.

Cookie got through the weekend by first finishing her review on Rocky Mountain Spotted Fever, then rereading most of Rasselas. Even as she laughed, she thought it was a little late to be choosing the best way to live one's life. Is there any point in calling Dad? What if he says it's a judgment on me? That I'm getting the punishment I deserve. The great cancer cure commuted into a living death. A blood clot in the brain. A stroke. He'll drag up the whole business about not moving to Chicago to keep Mommy out of that awful nursing home. Why was I supposed to be her nurse? She doesn't know where she is anyway, so what's the point? Was I so bad? You abandoned her, she told herself. Maybe her mind still functions, even though she can't talk. Maybe the neurologists are wrong and she understands more than anyone thinks. Does she realize that nobody is there with her? Does she know that everyone has written her off, that we have all deserted her?

Cookie patted her neck several times each day to see if the antibiotic was working. In the pediatric clinic, she acted as if nothing were wrong, maintaining her usual calm attentiveness as she focused on feeding problems, constipation, bedwetting. She was full of cheerful advice about school phobias and temper tantrums. The clinic nurses surprised her with a birthday cake. She blew out the three candles, one for each decade, imagining how their startled eyes would dart away from her with embarrassment, if she said she might never have another birthday. At home when she cried, her collie Zora whined anxiously and nuzzled her hands. "You're the only one I can talk to," she told the dog, enjoying the feel of her wet face against plumes of golden fur. Enjoying the feeling of having been misjudged by her father, thinking how anguished he would be when he found out. How remorseful. Jay was too exhausted to help her, too worried about his patients, his mistakes, the attending doctors. Dawson, still fuming about the guy who bled, had berated Jay during the weekly Morbidity and Mortality Conference. "He humiliated me in front of everyone' All the new interns, the attendings, nurses, everyone! How can they call it a teaching session? So what if we had to go back to tie off a bleeder! It's not as if I'm the only one ever to screw up sewing a graft." At last month's M and M Conference, Jay had condemned one of the interns for giving the wrong antibiotic. Cookie didn't remind him. Jay thought only about work. Surgery and sleep. He hardly had the energy to make love anymore, and when, Cookie asked herself, were they going to find time for a conversation about that? At night he either dozed in front of the TV, or else he ran back to the hospital to help deal with victims of multi-car pile-ups. Cookie spent her evenings filing the journal articles that lay in untidy heaps on the floor. She went back over her checkbook and found the error that had been annoying her for months. She organized the mess of scarves, gloves, and sports shoe's in the hall closet. Tennis, running, racquetball, aerobics, none of which they did any more. Still full of energy at midnight, she took Zora jogging, even though Jay had warned her not to run after dark.

On Thursday after supper, Cookie couldn't find her old Judy Collins LP with the whale song. "Jay, what did you do with it? I've asked you a million times to put my records back in alphabetical order. Don't you ever listen?" "Cookie, just leave it, " Jay said. He stalked out of the room, and turned on the TV in the bedroom. Cookie was incensed. She decided to reorganize her CDs, and began to put them in piles according to category. At ten, she heard Jay get up to brush his teeth and then get back into bed. He won't even come out to say goodnight, she thought. She lay on the living room couch, stubbornly waiting. In the morning she awoke stiff and chilly, despite the comforter that Jay had thrown over her before he left for rounds. She paged him midmorning after she saw McAndrews in the clinic. Rodney had been right. There had been no change in a week. Still cheerful and reassuring, as though she were a fool. McAndrews scheduled surgery for the following Thursday.

Jay decided that they both needed to get away for the weekend. "Things can't get any worse," he said. '''Now the bypass guy's lawyer wants to read the op note. Maybe I should look for a dermatology fellowship. Let's go to the coast and hunt for that bird you're always talking about." "You mean the pileated woodpecker? But you can't just find a bird in the middle of winter, a rare bird like that." "I don't think it's so rare. Anyway, it will be a quest, like Bill is always saying," Jay said. "To take your mind off things." "My brother!" It sounded like a curse. Another one who hadn't forgiven her. If he was so anxious for involvement, why hadn't he moved to Chicago? A hotel manager could surely get a job anywhere. Why did everyone always assume that she was free to pack up and leave whatever she was doing, that she would take charge of their problems? Why did it always come down to her? She pictured her mother, a tiny mound pushing up against a spotless white sheet, mindless, waiting for death, her family bickering over who would do the least. Cookie drove, Jay slept curled up in the back, and Zora, in the passenger's seat, watched for other dogs. Every time she spotted one, she jumped up, ears alert, tail twitching. Cookie gave up telling her, "Sit!" In Edenton, they sneaked Zora into the motel room and left her while they ate a greasy supper of fried oysters and hushpuppies at Captain Ed's. When they fell into bed, Jay was grateful, Cookie supposed, that she claimed exhaustion. Neither of them had any trouble sleeping. In the morning a pale sun shone faintly through clouds as they walked to the pier. When she looked through her binoculars, Cookie was startled to find that she had double vision. She squinted at a shrimp boat far in the distance. With the binoculars, she saw two boats side by side, the image on the right a little sharper than the one on the left. Without the binoculars she could barely see the boats against the gray sky. Everything close appeared normal. She lifted the binoculars again and trained them on a gray house near the water. Two images overlapped, the one on the right still better defined. Without the binoculars, there was no double image. This isn't a migraine, she thought. It's in my brain. The cancer has metastasized from my neck to my brain. She tried to remember the neuroanatomy she had learned. Saul Lipshutz, the chief neurologist at her medical school, did such brilliant neuro exams that he could pinpoint the exact location of any brain lesion. Skills retained from the old days before MRIs and CAT scans. No matter how thorough she thought she had been, he would always find something neglected: "You mean you never did the red glass test!" or "What do you mean. you never tested for apraxia? Second-raters. You'd better get your act together before you kill someone." Cookie had lost her confidence very quickly on that rotation. Lipshutz would know where in her brain the metastasis was. She watched herself point her right, then left index fingers at a nail that protruded from the top of the fence. Her arm was still steady. Then, she tried walking, as if on a tightrope, to see whether her balance was OK. "What on earth are you doing?" Jay asked. She had forgotten he was there. "I think I'm seeing double," she said. "What?" "Double. I see everything double." Jay, his widened eyes showing white above the gray-brown irises, opened his mouth as if to speak, swallowed and began again, "What are you saying?" "With the binoculars. Really," she started to cry. "Leave me alone," she said, twisting out of his attempted embrace. "I don't want to talk about it. Let's go to the lake. We can eat the rest of the bread and cheese in the car." Jay didn't argue. They got in the car, Zora in the back seat now, glad to be off the leash. Cookie thought about the woodpecker. One of the family practice residents had told her that he had seen a pileated woodpecker at Phelps Lake. The sound of its hammering was like a machine gun. Just what you would expect from a two foot high bird with a beak like a spike. She tried to imagine what such a big bird would be like. The drawing in Peterson's showed a male with fire-red feathers, flaming back from the crown. It's my last chance to see one, she thought. The ranger said that he hadn't seen a pileated woodpecker since the fire. "They've moved on. I don't think there are any left here," he said, patting Zora through the window. "Keep the dog in the car, in case there are deer." Jay chose a path that led away from the lake and into the woods. He muttered that the trip had been a mistake, and Cookie snapped, "It was your idea to come here, not mine!" The afternoon had grown chilly and overcast. Rain had washed the last leaves from the trees and the ground was soggy. Cookie walked ahead, her hands shoved into her jeans pockets. She wished she were alone. If I could only see one of those birds, she thought, then.... Then what? Then, it would be a sign. What sign, she mocked. Sign! There are no such things as signs. There was no sign for my mother, alone and deserted. She'd sacrificed a breast, imagining a cure. The lvmph nodes in her armpit were free of tumor. That was a sign. Sure. And then the blood clot wiped out her mind. Just let me see it, she argued with herself. Just this one time. Her eyes filled with tears, and she stumbled over a fallen branch. She looked up to try to get the tears to stay in her eyes and drain away without Jay seeing. She didn't want to have to talk. As her vision cleared, she saw it. Far up in the pine. Not hammering. Not moving. Its outline sharp against the bright leaden sky. Cookie drew in a sudden breath and held it, trying not to make any sound. The bird twisted its head to look down at her. A huge black woodpecker with a burning crown. As, finally, she let out her breath, the bird fanned its wings, exposing a band of white on the underside. "Is that it?" Jay whispered, rubbing his eyes as though trying to wake from a dream. He looked through the binoculars. "You're right about these," he said. "I can't focus them either." Cookie stared, unblinking, at the bird. The woodpecker looked away from her into the distance. Warm tears ran down Cookie's cheeks. Finally the bird drew itself up, spread its huge wings, and sailed off, its fiery crown bright against the sky until it disappeared beyond the trees. Let's go home," Cookie said, reaching for Jay's hand. "I'Il be all right now."

Cookie checked into the hospital on Wednesday afternoon. The admission proceeded with the usual parade of functionaries. The technician who drew the pre-op chemistries, the LPN with the urine collection cup, the dietitian requesting a list of food preferences. An anesthesiologist visited briefly to ask whether she had false teeth and to listen to her chest. In the radiology waiting room, she slumped low in a chair, hoping that she wouldn't see anyone she knew. She had told the Division secretary that she would be out until Mondav, but hadn't said why. After the chest X-rays were taken, she took her films into the radiology reading room and flicked them up on the light- box. Dutifully, as she had been taught, she looked at the bones first, then the heart, then the mottled blackness of the lung airspace. She saw no "huggers," no widening of the middle soft tissues, no "rnets." Nothing that looked like a spreading cancer. The radiology resident looked over her shoulder. "Normal chest," he said.

Later, while she was picking at the hospital's tasteless dinner of Salisbury steak, mashed potatoes, and overcooked cauliflower, McAndrews, still smiling and trailed by a cluster of white-coated residents and medical students, waved at her from the doorway. Cookie knew they must be discussing the mass and the likelihood of malignancy. As she considered sneaking to her door to listen, Rodney walked in She analyzed his examining skills critically. He spent a lot of time feeling her neck, but barely listened to her heart, and didn't examine her breasts. He asked whether she'd had a pelvic exam recently. "Well, I don't have to repeat that," he said, his eyes brightening, when she said yes. She wondered if he felt relieved because she was on the faculty or because he didn't care about anything so far away from the neck.

Jay's visit was brief. "Dawson let me do proxirnals and distals on two anastomoses." He smiled with unsuppressed satisfaction. Suddenly he was confident that everything would turn out equally well for Cookie. "What about the bleeder and the lawyer'" Cookie asked, annoyed by his good humor. "Oh, no problem. The guy made such a good recovery, they decided a lawsuit wouldn't fly. Too hard to prove injury." Another technician interrupted them to draw a 'type and cross', "in case you need a transfusion," she said, when Cookie protested that it should have been done the first time blood had been taken. "Don't be difficult," Jay said when the technician left. "It's not her fault." "And since when are you so considerate of people's feelings?" Cookie asked. "Look, probably Rodney forgot to order it. It's not a big deal."

After Jay went home to feed Zora. Rodney returned with the op permit. He patted his pockets, looking for a pen. "You need to sign for Intensive Care," he said. Cookie gave him a puzzled look. In case we have to do a radical neck dissection." he added. "What?" Cookie sat very still. "A radical what?" she said. "Radical neck dissection." Rodney held the op permit out to her. "Didn't McAndrews tell you?" "Radical neck dissection?" Cookie repeated. Her hand, reaching for the operation permit, stopped in midair, just as Rodney released the paper, which drifted to the floor under the bed. They sat in silence for a moment. "I didn't think he would," Rodney said. He glanced at his watch, gave a sigh that was more like a groan, and slumped into the chair opposite her bed. "But McAndrews was so upbeat." "Just in case," Rodney said, focusing his gaze on the op permit under the bed and avoiding Cookie's eyes. "You know. Just in case it's malignant." Cookie did know what a radical neck dissection looked like. All the flesh cut away from one side of the neck. It looked hideous. Sickening. Maybe you could hide it under a turtleneck sweater, but what would you do in the summer? "Why?" she asked. Rodney looked at her, perhaps for the first time, and sat up straight. "It's to get any cancer that might have spread. We remove the sternocleidomastoid muscle and all the lymph nodes on that side of the neck. You have to be in Intensive Care and have an endotracheal tube because of all the tissue swelling. But it would just be for a couple of days; you know, only until the swelling goes down. I mean," Rodnev said leaning forward, "you wouldn't need to be on a respirator. He slapped his hands twice on his thighs, fingers splayed out, as if trying to inject energy into this picture. "You'd be breathing on your own. You'd just have the tube down temporarily to keep your airway open." Cookie's images shifted from neck coverings to waking up connected to a respirator in Intensive Care, machines beeping, IVs dripping, bits of her semi-naked body exposed, unable to speak with the tube shoved in past her larynx. She remembered the time in medical school when she and Al, her lab partner, were learning to pass nasogastric tubes on each other. Al had pushed the end of the tube, greased with KY jelly, through her nose, and, then, further and further down to reach the stomach. The point was to collect stomach acid. All around them, her classmates were gagging, choking, and retching. She herself had felt as though she were going to die. She remembered the feeling of not being able to breathe. Of not being able to talk. She had waved her arm in a rapid, beckoning motion, trying to tell Al that he should be fast about it. Just push the tube down to get it into her stomach as quickly as possible. One of the instructors had come over, looked at her for an instant and then wrenched out the tube, "Didn't you see she can't talk!" he had yelled at Al. "You were shoving it down her windpipe!" Rodnev squatted down and reached under the bed to get the op permit. "Do you have any questions?" he asked. "No," said Cookie. She took the paper and scrawled her name on the bottom. When Rodney left, she thought about calling Jay, but he had now faded into a remoteness as distant as her father's. She tried to regain the image of the woodpeeker sailing into the sky, unbelievably big, improbably red. But what has it got to do with me? It means nothing. A big stupid bird looking for slimy grubs in the tree bark. Why had it seemed magical? How could I have imagined that anything would be changed by seeing it? Wishing like a child. Imagining is not the same as doing.

Early the next morning, Cookie was brushing her teeth when the day nurse walked into the bathroom, and without warning, lifted up Cookie's nightgown, and gave her the pre-op shot in the hip. Cookie sucked in a startled and incredulous breath. Yesterday she might have hinted sarcastically about the woman's training; today, what did it matter? A cheerful young black man wearing OR greens arrived to help strap her onto a stretcher. Cookie pulled the sheet and blanket up over her nose so that there would be a smaller chance of being recognized as she was pushed through the corridors and into the elevator. Ceilings floated by, a new view of the hospital. A lot of cracked tiles needed repair. She was past the hard edge of anxiety, past hoping. She felt as though she were watching from a great distance. She, who had always played the active role, had to bear things that happened to her. Every part of the pre-op procedure was familiar, Except that the focus of everyone's energy was her own body. Her credentials were lost. Apart from an occasional "Move your hips over this way, honey," Cookie herself was no longer there. Her mother, at least, didn't know what had happened, that her sign had betrayed her, that nobodv had come to Chicago, that her world was populated by strangers, that she had ceased to exist, though she still breathed. Cookie thought, it will be like this when I'm dead. Afterwards, she could recall every detail about the OR, the smell of disinfectant on metal, the anesthesiology assistant who started the IV drip, a distant argument between Rodney and the scrub nurse, the feeling of not being able to take a breath as the paralyzing drug dripped into her vein. Her fogged vision. Against the brightness of the lights overhead, she saw the woodpecker, now colorless, drift over the silent black forest. Hours later, she fought to awaken. "Is this Intensive Care?" she whispered. The blurry face of a nurse appeared above her. "No, honey, it was benign. This is the recovery room." But Cookie was already lapsing back into the anesthesia's unconsciousness, still cold, still alone.