The Endometriosis Factor

Chapter 1

The forest was dark and still. A thin film of mist sat on the branches, making them slimy to the touch -reptilian. Repulsive. He crouched quietly under a dripping bush, barely visible in the gloom, breathing in short, silent gasps. His left hand hurt, and he could barely bend the fingers, but as long as he didn’t move, he was undetectable. The mist that blanketed the trees stifled all movement, muffled all sounds. But nothing stirred anyway, nothing dared.

He fingered the knife and shifted his weight slightly. His knees were beginning to lock up and his hips ached. At his age, he realized, he needed the element of surprise. Take them from behind, or be taken. It was as simple as that.

He strained his ears in anticipation, but all he could detect was the erratic dripping from the chitenous sticks that served to hold what leaves remained. Although it was barely afternoon, the barkless trunks had choked off most of the feeble light the grounded clouds could not absorb. Somewhere nearby, a creek burbled over a field of rocks desperately seeking the river he knew was just ahead. Nothing stayed, let alone lived here by choice.. Why? Why was the forest and anything imprisoned in it dying –or about to? It was a question he’d never thought to ask until now.

He focussed for a moment on the bush that sheltered him. Brown, lifeless, rotting stalks poking up from the soggy ground, as empty of soul as they were of leaves –dead from roots up, waiting for release, decomposition: the after-image of a shrub. And he, as part of the Gestalt, was anticipating –no, participating in- a similar liberation.

Suddenly, the mist fragmented into a billion unbearably bright slivers, and he found himself fighting for breath in a raging sea. All around him, he could feel the reverberations of huge waves crashing rhythmically, malevolently, against...

He opened his eyes to find himself lying on a bed in a tiny room. There was some feeble light coming through a few opaque glass bricks on a wall over a cheap Ikea-type desk, and he could just make out a reclining chair with some clothes draped over it, a white lab coat on the floor, and a TV set skulking in the far corner of an otherwise unremarkable room. Beside the bed was a little table with a light, a glowing clock, and a ringing phone. Christ, he thought, almost out loud, I’m on call again!

Dr. Edwards? a female voice said from somewhere inside the phone.

Mmmh! He purposely willed the red numbers on clock into focus. Three-thirteen A.M. Jesus!

Sorry to wake you up, Dr. Edwards. But the voice didn’t sound sorry. On the contrary, it seemed to be taking great delight in it, to judge by the tone. He could almost see the sarcasm. But when he didn’t reply, it continued. We’ve been asked to see a woman down here by general surgery...

He shook his head and opened his eyes wide to dispel the still-real image of the dying forest and said, Down where?

Down in Emergency, said the voice, pronouncing the last word slowly. This is Jessica, the senior resident on Gynaecology... Implied in the pause was, Remember? But she was too clever to insult him to his face, so it remained unsaid, albeit echoing.

Anyway, they’ve asked us to see the woman, so I thought I’d run it by you before booking her, okay?

God he hated her arrogance, her barely subliminal disrespect. Sure, he said, not certain what else to say.

"She’s a twenty-something white, heavy-set woman who comes to us from the street. She’s a tad confused because of recent cocaine and... oh, some other drug she inhaled a few hours before admission. She has an acute abdomen. A few days ago she began to have cramps and diarrhea, but yesterday the pain got so bad she couldn’t even walk. So she did a little cocaine... Didn’t help, so she did some more. And then the other drug.

Anyway, somebody called an ambulance and here she is.

Christ, he thought, Jessica takes a lousy history. So... It was intended to spur her into continuing with more details of the history –he hoped there were more details- but there was silence at the end of the line.

So I’m going to book her for a laparoscopy.

Ahh, maybe I’ve missed something here, or perhaps I’m just old school, Jessica, but you haven’t told me enough about her to put her in a phone book, let alone the operating room.

Silence. Sorry. I thought the medical student had already called you with the details. You’re lying, he thought, but said nothing. "Anyway, she’s a twenty-four year old nulliparous female with a forty-eight hour history of lower abdominal pain that radiates through to her back and down her legs. It’s associated with diarrhea and sweating, but she’s afebrile. Oh yeah, and she’s had her appendix out. Her last period was about a month ago and her pregnancy test is negative. She’s had no vaginal bleeding, periods are a bit irregular, especially when she’s doing drugs. Which is most of the time, I suspect. She’s not using any contraception, but denies any recent sexual activity or STDs despite an obvious vaginal discharge. Because of the confusion, I’m not sure how reliable her history is, though. On examination, her vitals are stable, abdomen is tender and she has rebound and guarding. Couldn’t do a pelvic because she was so tender, but I did manage to get some cultures. Hemoglobin is normal, white count’s up a bit but no shift...

General surgery originally thought she might be in their ball park, but when they phoned the staff surgeon on call, he figured she was PID, so they dumped her.

Pelvic inflammatory disease? What do you think?

Sure.

But you said she denied any recent sexual activity...

That’s what she said...

And she’s premenstrual?

I guess...

So does she usually get pain before her periods?

Not like this.

It was an open and shut case for the resident, he could tell, but he was not so sure. Okay, Jessica, book her, but I think I’ll come down and have a look at her before she goes to the OR.

Silence. Residents didn’t like the staff person to come to Emerg unless invited. It was their turf, and they guarded it jealously. Oh thank you, Dr. Edwards! Maybe I should wait till you’ve seen her before I book her... Just in case, I mean.

Just book her! he said before he slammed the phone down.

As they were standing at the scrub sink preparing to operate, Jessica half turned to Dr. Edwards and sighed loudly. She was short and on the plump side of normal. Her short, dark hair was covered with a paper OR cap but a few unkempt threads of hair had worked their way under the rim and hung down like ornaments around what little face was not covered by her mask. He wasn’t sorry it was hidden. In fact, he wished the mask could have hidden her eyes as well; her eyes were her most effective weapons and she used them like knives. He’d never had the courage to look into them for long: they dissected flesh better than a scalpel. Jessica had an attitude, a contempt for most men, and wore a sneer that alternated from time to time with an annoying smirk. She might have been pretty if she weren’t continually affecting a mood of bored indifference. It furrowed her brow, and highlighted her complete lack of makeup. Her small brown eyes were always unsheathed, and fastened on the world like rusty fishhooks. She looked as if she were always just getting up from bed in the middle of the night.

You know, she said after staring at him and shaking her head, I wonder if we should have tried I.V. antibiotics first. An attempt to regain control?

With no fever, no white count, and no boyfriend for two years?

Do you believe her?

He thought for a moment then shrugged. Why not?

Two years, a drug habit, and living on the street? No boyfriend just means she’s not in a relationship... Relationships don’t make money.

He smiled behind his mask. Jessica was a tough one, all right. So you think she’s selling herself to men? he asked innocently.

Jessica stopped scrubbing for a moment and stared at him. Don’t you?

He shook his head and kept scrubbing. Nor do I think she has PID. Might as well confront Jessica head on.

Excuse me, Dr. Edwards, she said with a little shake of her head –meant, no doubt, to convey annoyance, An acute abdomen in a drug addict who comes to Emerg in the middle of the night with a negative pregnancy test and a vaginal discharge.. It’s sure as hell not a urinary tract infection..!

It was his turn to sigh, but he did it quietly so she wouldn’t hear. That’s an interesting point, Jessica. How do you know that? Did you do a urinalysis?

She turned away. Well... No, but they do that routinely on admission to Emerg, and they would have told me if...

Routinely? So didn’t you look at the chart? She was beginning to get him angry.

I spoke to the medical student... He...

Jessica, you’re training to be the gynaecologist, not him.

She was silent for a moment, but obviously not repentant. So how do you explain her symptoms, Dr. Edwards? What else could produce an abdomen like that?

I think I should be asking the questions, Jessica. You should be giving me a differential, instead of jumping on the first and easiest diagnosis. Many things produce pain. Try thinking of what she told you, but without the prejudice. Forget that she lives on the street and that she’s doing drugs for a moment. Pretend she’s a friend who was brought into Emerg. So, how would you read those same signs and symptoms? Well, let’s see... Sudden onset of pain premenstrually, negative pregnancy test –she’s got no boyfriend, so you were just being thorough- no history of sexually transmitted diseases, and she’s had her appendix removed... What else? Oh yes, diarrhea, some urinary frequency... He managed to make eye contact with her. You missed that, by the way.

I meant she had no burning with urination, I never said...

So, continuing the unbiased appraisal, you note that she has no fever, has no elevation of her white count, and when you examine her, you detect a mass in the area of her left ovary on pelvic exam.

Jessica stared straight ahead and stopped scrubbing. I didn’t examine her because the Emerg doc had, and she was in so much pain! It sounded like she was making her excuses through clenched teeth, but he couldn’t tell because of her surgical mask. She’d hang herself, yet.

And the Emerg doc missed it, didn’t she? He rinsed his hands off and started for the operating room door. Any diagnoses come to mind, Jessica?

She started to rinse her hands, but looked somewhat bewildered. Well, I suppose she could have bowel disease... Maybe Crohn’s disease, or ulcerative colitis, or something.

How about a ‘something’ in our field?

She shrugged. I still think it’s PID! The mass you felt is an abscess in the fallopian tube. She stopped and stared at him. And what’s your diagnosis, Dr. Edwards?

His face crinkled in a smile. There are several things it could be, all right, and PID’s one of them. But if you want me to pick one, I think it’s endometriosis... Your specialty, I believe.

She continued to stare at him, eyes widening in disbelief. Endometriosis? Sir, she said, with almost a growl, endometriosis is created when the lining cells of the uterus back-flow through the fallopian tubes at the time of menses, and begin to grow elsewhere. It therefore produces menstrual pain, and it...

Jessica! When did you last read about endometriosis? He tried to ask the question kindly, but there was really no way to do it. Your model is dated. And you very well know the symptoms can occur at any time in the menstrual cycle, but most frequently immediately premenstrually. Probably because the lysosomes in the endometrial cells rupture with the falling hormone levels and liberate prostaglandins, which are the chemical mediators of inflammation. He added this almost defensively, to show that he was still up on the literature. So endometriosis is now the Great Masquerader. The historical reference to what syphilis used to be called was lost on her.

In a prostitute?

Why not? And anyway, I don’t think she’s selling her body!

Jessica chuckled sarcastically. So do you think she’s giving it away..?

He stopped midway through the door and pinned her to the sink with a glare, then relented and turned to enter the OR. Not to men, Jessica.

The operative findings were those of endometriosis and the mass on the left had been, as Dr. Edwards had predicted, a blood-filled sac on the ovary called an endometrioma. It was produced by the ectopic endometrial cells bleeding into a cavity they themselves had created. He smiled on leaving the OR with Jessica but she did not acknowledge it.

I’ll dictate the operative report, Dr. Edwards. Do you want me to say that we’ll put her on Endelete and follow her in the office?

You’ve got the ‘follow’ part right Jessica, but it’s her first episode of endometriosis. I think I’d like her on nothing for a while... at least until she comes for her follow-up visit.

But... She looked puzzled and cocked her head to one side like a bird, listening.

Jessica, he paused for a second to calm himself; she could be so annoying. Endelete is to prevent recurrences; she hasn’t had any. If she still has pain when I see her, Danazol will take care of any residual endometrial cells we either haven’t been able to remove or destroy. He tried a smile again. And there were probably a lot of those, don’t you think?

That seemed to satisfy her for a moment, but he could tell she wasn’t finished with him, despite the fact that it was almost five in the morning. Okay, I accept that. But what if it comes back, as it probably will?

Mmmh. Well, there’s a considerable body of literature validating visualization techniques, and also hypnosis...

Huh?! He had said it partially to be provocative; to teach her that there were other strategies than medicating people, but when he saw her reaction, he realized he had pinched a nerve. Why in the world would you resort to that kind of stuff? People used to use those strategies as a last resort in patients for whom there were no acceptable therapies. She was clearly upset.

"Do you think so? Do you not accept the evidence implicating the immune response? That the endometrial cells while in the uterus are somehow protected from that response –presumably so a pregnancy won’t be treated as a foreign substance in the body? That when those same endometrial cells leave the uterus, they stimulate an immune response and are summarily dealt with? Unless, of course, the immune system is suppressed, or doesn’t recognize them as being in the wrong place... Hypnosis has been shown to be capable of mounting a directed immune attack –on warts, for example- and visualization was been used for years in kids with terminal leukemia.

So I use Danazol sparingly, and only if necessary to treat residual endometriosis, and while the patient is on it, I teach her other ways of coping with stresses that might diminish her immune response. In that way, she actively participates in her cure –becomes the therapist, and not the victim.

She wasn’t listening, he could tell, so he softened his polemic. I suppose if the patient requested Endelete I might consider it. Or if the other techniques were not helping.

Jessica’s eyes were hard, her facial muscles frozen in a scowl. I don’t know why you wouldn’t just go to Endelete as soon as the Danazol treatment was finished.

Why not use that four to six months of Danazol to teach her hypnosis? What is there to lose by involving the patient in her treatment?

But Endelete works, the hypnosis or visualization probably won’t!

He sighed. And how do you know they don’t work?

Double blind, randomized controlled experiments are how we validate scientific hypotheses, right? He nodded. Well, how many experiments like that do you know of that have validated hypnosis? Or visualization? For that matter, how could you possibly design a randomized study in which neither the patient nor the doctor knew what treatment the patient was getting so there would be no placebo or expectation biases?

A good point, Jessica. It’s possibly one area in which our scientific paradigm fails us.

Huh? If it fails us, then why not use Endelete?

Lots of things seem work in the short term. But it’s the long term that is a problem when you are dealing with a condition like endometriosis. Could a preventative medication be said to ‘work’ if it prevents a condition for just one year? Or does it have to do it for two? Or five? Or forever? And suppose you randomized the patients to a treatment group and a placebo group and found that neither group got a recurrence for two or three years..? After all, not everybody gets a recurrence. There are simply no long-term data on Endelete’s effectiveness after 18 months. He paused for a moment, considering whether to confide his concerns about Endelete. She stood, arms akimbo, staring at him. Jessica, suppose you tell me how Danazol and then Endelete –or estrogen, for that matter- works.

It flattered Jessica, he could tell. Well, in general terms, any cell –such as an endometrial cell- that responds to a hormone like estrogen has receptors for it on the surface of its nucleus. Estrogen comes along, gloms onto the receptor, and activates something in the cell –growth or cell division, for example. So, when the lining cells of the uterus get to grow elsewhere, they still have receptors and so still respond to estrogen. So Danazol, a type of anabolic steroid...

An anabolic steroid that resembles the one Ben Johnson was on... Jessica’s expression went blank. She had no idea what he was talking about, so he added, the runner who was stripped of his Gold medal at the Olympics when he was found to have used a banned substance.

"Whatever. Anyway, as I was saying, one way Danazol probably acts is by decreasing the number of estrogen receptors on the endometrial cell, so it can no longer be stimulated by estrogen. Danazol may even have a destructive effect on the cell itself, but the former reason is why you probably have to keep people on the medication for a while: the cell is no longer capable of being stimulated to reproduce itself, so eventually it just dies off. Left alone, an endometrial cell likely has a life span of about three months –plus or minus...

Of course, there are different forms of the estrogen receptor: alpha and beta. They occur in different tissues that respond to estrogen throughout the body. Depending upon how the receptor proteins are deformed by the hormone, different effects are produced as well. And there are probably variations in these two types of receptors depending on the cell, its location, etc. Danazol’s a bit of a sledgehammer: it hits receptors indiscriminately. Willy nilly.

Dr. Edwards smiled approvingly. Jessica’s clinical skills might need a little work, but she certainly knew the literature. Very impressive Jessica. And how does Endelete work?

"Well, it turns out that endometrial cells have alpha receptors and either because of local tissue factors, or lack of oxygen at the start, the alpha receptors become modified in a predictable and reliable way when the cell grows outside of the uterus. The new receptor has been called the alpha2 receptor because it shares many similarities with the original one. Estrogen can still attach to it for example. So, a molecule was designed to irreversibly bind with alpha2 that doesn’t fit the regular alpha one –so no estrogen effects. And because it sticks to the receptors, estrogen can’t stimulate the cell.

"As I said, endometrial cells, like all other cells, have life spans and if they can’t reproduce themselves, they die, leaving no replacements. It’s another way that Danazol works. But Danazol also attaches to all alpha receptors –even in the uterus- so there are multiple side effects related to the lack of estrogen in those tissues. And Danazol doesn’t stick to the receptors for very long, either, so it needs to be given frequently and over a time equivalent to the life span of an endometrial cell.

"Anyway, Endelete only needs to be given once a month, post-menstrually so it can neutralize any endometrial cells that have back-flowed into the pelvis, or wherever.

He felt like clapping when she’d finished, but he contented himself with merely congratulating her on her depth of knowledge and heading back to bed for an abbreviated sleep.

She stared at him with her brow furrowed for a moment, and then shouted to him down the hall. At the Vancouver Hospital, the consultants are putting everybody diagnosed with an endometrioma on Danazol plus Endelete...

He stopped and turned around to face her. She was so hostile, so intense, that he sometimes had difficulty responding to her. ‘At the Vancouver Hospital’ was a phrase he had come to hate. Sure it was a bigger hospital, and sure, most of her teaching came from the consultants there –most of the gynaecological research in the city emanated from there as well. But they had no monopoly on treatment –just on the minds of impressionable residents like Jessica. They, too, rushed into things they didn’t understand on the basis of inadequate research. Jessica, I am well aware of what the folks at the Vancouver Hospital are doing. In fact I’ve seen a few of their patients in my office with... complications.

She wandered down the corridor towards him, staring incredulously all the while. Like pain? It was clear she couldn’t -wouldn’t- believe that. Period.

No... He hesitated putting his thoughts into words for her; her mind was made up. She knew how to treat endometriosis. Knew how the receptors and everything worked.

So did they get bleeding? What..?

Angry. Aggressive. Hostile. They get profound mood changes -far more than with just Danazol alone. In fact, one or two of them became psychotic.

Jessica rolled her eyes. I haven’t seen that reported in the literature, Dr. Edwards. Disbelief dripped from her words.

He sighed and then yawned. Five A.M. –he glanced at his watch: no, five-eighteen! It was no time to continue an academic discussion. He had an office in about three and a half hours. Haven’t seen it, Jessica? Maybe you just haven’t looked in the right places.

Jessica stayed up and headed for the Delivery room till her shift ended at eight A.M. Todd, the medical student, was sitting behind the nurses station writing a history on an obstetrical patient when Jessica arrived. He was a large man like Edwards, but better looking, even in operating room greens that fitted him like pajamas borrowed from a child. Although he was in his forties, and had obviously come to medicine after another career, he kept running his hands through his short blond hair, and straightening his red-rimmed glasses on his nose as if he were nervous talking to Jessica.

Todd, I’ve always wanted to ask you something... Todd blinked and straightened his glasses again. Jessica laughed and touched his arm. No, not about Gynaecology, this time. It didn’t make him any more relaxed, however. Jessica noticed this and smiled warmly. No, I’ve always wondered how you always manage to look so well dressed.

Todd looked down at his OR greens that everybody in the department seemed to wear. Then he looked back at her, obviously confused.

I mean when you’re not on call.

You’ve been watching me, Jessica, he said and blushed.

Yeah, I guess I have. I think the glasses are cute, by the way.

Ahh, yes. They’re a remnant of my former life.

Which is..?

My goodness, you’re rather forward, aren’t you?

Modern woman, she said with a wink.

Well, in case you ask, I was once a biochemist.

Wow! So what made you want to join the ranks of the sleepless?

He shrugged. Oh, I don’t know. I suppose it was to actually do something with the knowledge... I’m still completing my thesis, he said, and looked down at his shoes for a moment. I haven’t actually got my PhD yet.

Jeeze, and you’re in, what, third year Medicine now?

He blushed again and nodded.

So how can you afford it? I mean when I was going through I was studying too much to hold down a job.

He shrugged. Apparently my thesis is of some commercial value...

Jessica looked puzzled. I don’t see what...

Grant. He smiled broadly. Keeps me in clothes.

Wow, again. So what’s your thesis all about?

He blushed once more. Sorry, but one of the conditions of the grant is that I don’t discuss it until it’s published.

It was Jessica’s turn to blush. Sorry.

It’s me who should say sorry, but I... He adjusted his glasses again and ran his fingers nervously through his hair. So, what did you find on that woman?

Sylvia Pitt? she said, while she watched his obvious discomfort.

The one I saw in Emerg with the abdominal pain. Was she PID like we figured?

Jessica looked at one of the fetal monitor screens for a moment. The patient was obviously in labor and having a contraction. The fetal heart was decreasing in tandem with the contraction. Room 5’s probably fully, Todd.

Yeah, I know. She’s just started pushing.

What’s the differential on that Emerg patient? You never did go through it with me. She smiled to encourage him a little. Actually he was kind of cute... for an older man.

Abdominal pain in a young woman? Ahh... Well, GI, GU, Infectious... he repeated like a mantra. Let’s see. Gastrointestinal: Appendicitis, bowel inflammation like ulcerative colitis, or Crohn’s disease. Those’d be the biggies, there. Umm, Genitourinary: PID, or ovarian cyst... He thought for a moment, then his eyes brightened. Pregnancy related stuff like a threatened miscarriage. Oh, and ectopic pregnancy. Yes, definitely tubal pregnancy..!

Anything else, Todd? Yes, definitely cute, especially when he gets nervous.

Ahh... I can’t... I mean there probably is, but those would be the most important ones, right?

A smirk appeared on her face. You missed a big one, actually: endometriosis. Have to show him who’s the senior here.

Damn! and his face fell again.

You have to think of these things before you decide to take somebody to the OR. Her pain was pre-menstrual, she denied sexual exposure or previous sexually transmitted diseases that could have damaged her tubes. She had no fever, no elevated white count.

Jeez. I never... He looked genuinely upset.

Sometimes we get caught thinking of a patient as a good candidate for something because they come in off the street and figure they should have an infection, so we read the signs too subjectively. It’s called observer bias.

So she had endometriosis? Did Dr. Edwards get the diagnosis pre-operatively?

She smiled patronizingly. He... He included it in his differential, yes.

He sighed and stretched. He’s a good clinician, isn’t he?

She hesitated a moment and ignored the question. How would you treat her after the surgery?

You mean medications? Jessica nodded. Well, Danazol, then... En... He looked up at the ceiling as if the answer were written there. En-something. You know, the Post Menstrual Pill. His eyes suddenly locked on her face. Endelete! The newspapers and magazines are all calling it the Post Menstrual Pill, so it’s hard to get that out of your head. He chuckled for a moment. The Miracle Pill.

Jessica smiled empathetically: it was hard, for sure. There had been such a media blitz about the medication, that it was hard to find a magazine on any shelf that didn’t have an advertisement for it somewhere inside.

So, did Dr. Edwards say he was going to put her on the miracle pill? She crossed her arms and shook her head. Oh, so what’s he going to do?

After the operation?

He nodded.

Hypnosis.

What? Her turn to nod, but smugly, this time. Isn’t that a little... umm, unorthodox? I mean there is a treatment, and...

I know, Jessica said, conspiratorially.

I mean, isn’t it a little like not giving insulin to a diabetic, or something?

Well, that’s a little harsh, I think. But it’s maybe more like replacing a flu shot with a lecture on hygiene: it may be a good thing, but it doesn’t treat the disease.

Todd shook his head in disbelief. That’s so unethical, you know! No wonder he’s not a very popular gynaecologist. So what did you say to him?

What can you say to a staff doctor? But I did dictate that we planned to treat her with Danazol first and then follow up with Endelete so if something happens, he’ll be caught out.

Todd looked at Jessica. Is... Is that okay? I mean, can you dictate that even when he didn’t tell you to?

It’s a discharge plan, right. They’re not written in stone; plans change.

Still...

Look, the guy’s getting old, she said, watching Todd’s expression and raising her voice. And it’s not just a question of being old fashioned; he’s not keeping up with the literature. In this case, I think it’s not only cruel not to treat, but it can have profound consequences with her fertility.

You sound angry. He made brief eye contact with her and then looked over at the fetal monitor screen.

Her face relaxed a bit. Do I? She took a deep, tired breath and exhaled slowly. Well, maybe it’s a little close to home for me. Damn! I hope I haven’t turned him off.

Maybe it’s because I’ve had endometriosis for years and only since Endelete came along have I felt there was some hope for a career.

He glanced at the monitor for a moment, then seemed to remember something. Didn’t I hear that you’re chairman... -he blushed- Chairperson, of something to do with...

Endometriosis? she finished for him. Yeah, I’m chair of FEM. Ahh, that stands for Females on Endometriosis Medication. Pretty good acronym, eh?

Todd nodded, and turned to look at her again, a sympathetic smile on his face. He reached out and touched her arm. So you obviously know a lot about the treatments, I bet. Did any of your members ever go see Dr. Edwards as a patient?

Jessica looked around the room to see that they were alone, put her hand over Todd’s and sighed. Are you kidding! she whispered conspiratorially, He’s not only dangerous, he’s weird.. She smiled wickedly. Besides, even the other group can’t stand him...

Other group?

She smiled. Yeah, there’s another group.

Chapter 2

Dr. Michael Edwards leaned heavily against the post by the charts, his lowest shirt button was open and the white flesh of his abundant abdomen stared through it. He was a large man, lately unkempt, who always seemed to wear the same, shiny dark suit, the same thin, wrinkled and twisted, too-short red tie, and one of three creased and un-ironed but distinguishably different white shirts with fraying collars whose lower buttons were usually missing or coming undone because of the girth they were forced to straddle. His head was balding, and his chin sagging; what muscles he once possessed had long since given up. So had he. The separation –divorce, he had to remind himself- had extinguished whatever was left of his motivation. Medicine –life, for that matter- was a hollow shell where he was detained indefinitely, on the one hand because of economic necessity, and on the other, cowardice. At least that was what Gloria had called it.

The waiting room was empty, and he seemed upset. Leslie, his typist and secretary, sighed quietly. She didn’t like Edwards, but she could feel his distress. Tall and large -huge, in fact- with shoulder length untidy blond hair, she was new to the office and wasn’t allowed an opinion. Nor was she asked. She just sat at the front desk in the far corner with her word-processor and listened. She had already had words with him over his style of practice.

There was only one other person in the room, and she definitely had opinions. Anna, his long-time nurse, was spinster-writ-loud. Anna; somehow the name fit. She was in her fifties but had never learned to apply her bright red lipstick along the proper borders of her lips. One side always looked fatter than the other, and when she smiled, her white-and –brown teeth often sported red splotches. Fortunately she rarely smiled on purpose –only by mistake, or in derision- so most patients would never have noticed.

I don’t think she’ll come, do you Michael? Anna said with feigned innocence and a hint of that smile. We haven’t had much luck with street kids. She was sitting at the front desk with her silly starched white uniform complete with nurse’s cap plunked atop a dyed, but graying bale of short dark hair, white nylons and white, highly polished shoes. She was an anachronism, a monument to where nursing was no longer going. Perhaps that was why Anna had left the hospital: Dr. Edwards’ office was likely the only place left in Vancouver where she could pretend things had not changed. And she was right; in his office, he was still king, and she was still Head Nurse. They both reveled in it.

Oh, I don’t know Anna, she hasn’t always been a street person, and she seemed interested enough when she was in the hospital.

The hospital’s not the street, Michael.

He shrugged and looked down at the open shirt button, tried to fasten it, then gave up in frustration.

Leslie had only worked in the office for three months –her probationary period was almost up- but she hated it. Edwards was a pig, and Anna a passive aggressive sociopath. They deserved each other, maybe, but not the patients. Actually, Edwards seemed well-meaning enough, but... odd. There was something about him she didn’t trust.

Michael, I don’t understand why you don’t have a computer in your office, she said. You could give patients a lot more information and educate them to make more intelligent, and informed choices if you had a list of web sites they could access.

Michael had just stared at her as if she were somebody who had accosted him on the street asking for money. Excuse me Miss Strumther, you are employed here to type, not to advise.

But Doctor Edwards, patients have the right to participate in their care.

They also have the right to uncluttered advice. They come to me because they need help that they are unable to obtain on the internet.

And if they ask you for a resource to help them to decide whether or not to accept your help?

In other words, something to help them decide whether or not I have given the correct advice?

You said it, not me.

Miss Strumther, if you wish to continue to work here, I suggest you pretend to be a little more respectful.

She’d laughed at that –he’d got it bang on: ‘pretend’. Well, if we’re talking respect, Doctor, I find it offensive to be called Miss.

That works out well then, Miss Strumther, because not only do I dislike having you call me Michael, I also dislike having you in this office. Consider yourself absent from the end of this week.

You can’t fire me, Edwards, I’ve done my job and you have no grounds for...

You forget that you are still on probation, Miss Strumther. I’m sorry, were on probation.

Anna listened cow-eyed to the exchange and smiled. And I wouldn’t expect a reference letter will be forthcoming either, Leslie. She turned and looked at Michael, almost triumphantly. I think I’d just write off this Sylvia girl, Michael. Anyway, it gives you a little more breathing space.

She’ll be in pain; she’ll come. he said absently, and closed his eyes for a moment.

She shook her head and then opened a chart. Your discharge note says you put her on Danazol, so maybe it will have...

What? He righted himself and grabbed for the chart, but Anna was too quick for him and snuggled it tightly into her nonexistent breasts.

Dictated the day after the surgery. Says right here that she was discharged on Danazol and...

Lemme see that, Anna! He grabbed it out of her hands and studied the note. Damn that Jessica! I told her that I wanted to put her on the medication at the follow-up visit, not in hospital. Anna looked at him sternly. That way I figured she’d come.

More money then, too, eh? thought Leslie, trying not to let her contempt for the two of them show. Although she’d never been naïve, her opinion of doctors had undergone a radical shift since working in the office. All Edwards seemed to think about was his expenses –how they were so high, how much he had to work to make ends meet. The fees were never enough and couldn’t even begin to compensate him for the time and worry he was forced to expend on the poor hapless creatures who fell into his grips. God, if she made even half of what he did for half an hour’s work, she’d be consumed with guilt.

Well, maybe she’ll get the usual Danazol side effects and come in to complain about her treatment. She semi-smiled at the thought, but her facial muscles tired quickly and soon dropped into their habitual frown. And anyway, Edwards scowled at her for saying anything out loud after their exchange.

He looked at the discharge note for a moment and shook his head. I don’t think so, Anna, he said, as if it had been Anna’s comment. She’s only on two pills a day.

She gave him a knowing glance and turned her head back to his day-sheet. Well, we have no way of getting in touch with her. No address, no phone number, and... -she unfastened her eyes and let them wander onto him again- No medical coverage either.

This was too much for Leslie. I thought everybody was covered automatically, she said with ill-disguised disdain. The government...

Michael glared at her. Strumther, I’ve heard enough from you.

Suddenly, the door opened and a pear-shaped woman with long black hair, an ankle-length green skirt, and a white chemise slipped through quietly. Hi, she said self-consciously, noticing that everyone seemed to be looking at her. I’m Sylvia Pitt...

Dr. Edwards grinned at Anna and waddled down the corridor, past the little kitchen containing the scale and drug samples, and into his office at the end.

No sense letting the woman think he had time to just stand around, thought Leslie. As if Sylvia wouldn’t be able to tell by the empty waiting room.

Ahh, so it’s Sylvia, Anna said with eyebrows straining to merge with her hairline. We thought you weren’t coming.

Sorry, Sylvia said, blushing. I wasn’t sure how long it would take me to get here.

Anna sighed audibly and opened the chart. We don’t have an address for you, Sylvia.. She looked up from the chart and stared at her.

No, I... I’m between places right now.

Anna shifted her head petulantly. Everybody had to have an address or she couldn’t register them properly. A hotel room, perhaps?

Sylvia shook her head, and looked down at her feet.

Well, is there a phone number we could reach you at? Anna said with a barely disguised smirk that made Leslie clench her teeth.

Sylvia shook her head again, still examining the floor. Then she raised her face to the level of the reception counter. Is it really important to have a phone number?

Anna rolled her eyes. We may need to get in touch with you.

"Well, there’s a bulletin board where they can leave messages at the