T ALL HOPE Dr. Paul Adkins Glanced at the Clock Above the Lightbox. he fatigue began in January. It was then that Dr. Paul Adkins first sensed that something might be wrong. He was 54, professor and chairman of surgery at the George Washington University medical school. A nationally recognized thoracic surgeon, he had been surrounded by illness for more than thirty years but had never been seriously ill himself. In the beginning he tried to ignore the fatigue, to convince himself that it was caused by a combination of work and minor illness and would soon pass. But he couldn't ignore the disturbing fact that a man who had seldom needed more than seven hours of sleep a night, whose years of surgical residency had been marked by thirty- and forty-hour vigils, was now napping occasionally in the afternoon on his office sofa. He was a man trained to logic and deduction, and he now was using that training to persuade himself not to become alarmed. But deep inside, down where the gut knows what the mind may deny, there were dark possibilities. It was not always easy to ignore them. He recognized the irony. For his entire professional life he had diagnosed the sources of pain, the sounds of a chest, John Pekkanen-the health columnist of The Washingtonian--had many long conversations with Dr. Adkins and other principals of this story. He acknowledges the cooperation of all. particularly Dr Adkins and family, who generously gave up many hours when every minute was precious. BY JOHN PEKKANEN the rasp of a cough, the manifold mur- The fatigue persisted. He realized that his history was against him. Although his body was still athletically trim, he had smoked cigarettes since he was fifteen. The habit intensified when he served as a surgeon in Army hospitals in Korea and Japan during the Korean War. He understood the implications of smoking up to a pack and a half a day for close to forty years as well as anyone in the country: He had removed some 2,000 cancerous lungs in surgery. But there was so much happening that month that he was easily distracted from thinking about himself. It was in many respects the culmination of his career, because on January 22, in Atlanta, he was to deliver the presidential address of the Society of Thoracic Surgeons, the largest organization of its kind in the Reprinted from The Washingtonian Magazine, copyright © 1980. here, at St. John's High School. He would In his neighborhood on Kirkwood Drive anniversaries. At the hospital he wore quite another face. There he was first and foremost a surgeon: decisive, hard-headed, willing to take greater risks than most. He was a man certain of himself and at the same time shy to an extreme. The surgical residents he loved to teach called him "The Boss." Virtually all the younger residents were, in the words of a GW colleague. "scared as hell of him." He seldom abided small talk. His sarcasm could be biting and his glare intimidating. But those residents who progressed steadily in the residency program began to realize there was more to him than the stern face. By their third or fourth year they came to understand that at least part of their fear was misplaced. They understood that he jealously guarded his privacy and revealed little of his sensitivity or sense of humor to those he didn't know well. They came to realize that it was because he was lost in thought that he often walked down the corridors of the hospital oblivious to the people who said hello to him. When he stopped to listen to someone, he was politely attentive, his look direct 37-524 0-84--23 ..Adkins took the X-rays out of the folder and put them on his own lightbox. "What do you think of these?" Dr. Adkins asked. Dr. Aaron replied, "It looks like a pretty bad cancer of the lung." "They're mine," Dr. Adkins said. chest surgeon. She avoided saying they were for the chest surgeon himself. Dr. Benjamin Aaron, head of cardiac surgery at GW, was also concerned about Dr. Adkins's health. Dr. Aaron's office was next to Adkins's on the eighth floor of the Burns Memorial Building, at 23rd and Pennsylvania, Northwest, just across 23rd Street from the hospital. A Navy doctor for 22 years, he had come to GW a few months earlier. Lately he had begun to notice that Paul Adkins, the man who had hired him, had changed. He had become irritable and his face seemed to be fuller, as if he had gained weight. It didn't look like healthy weight. Why Paul Adkins refused for so long to get a chest X-ray when he passed the outpatient X-ray laboratory every working day was probably due to a mix of dread and optimism-a suspicion that something might be terribly wrong was delicately balanced with a rationalized hope that it was minor and would quickly pass. But finally, when the fatigue and coughing grew undeniably worse, when he felt so dragged out for so long that he wanted to find answers himself rather than put up with feeling so awful, he asked Cindy Fisk to call X-ray for an appointment. She arranged one the same afternoon. It had been nearly three years He operated that morning, removing The X-rays-front and side-took only seconds. While he was buttoning his shirt he glanced up at the technician clipping his X-rays on the lightbox attached to the wall. He stopped buttoning his shirt, his eyes riveted on the lightbox. He moved in for a closer look. In the upper lobe of his right lung there was a large, grayish spot, a shadow. It was irregular in shape, about the size of an egg. In the lateral view he saw string-like tentacles that reached down into his lung, as if grabbing at it. Looking further, he saw a wide shadow in the mediastinum, on both sides of the trachea, where the lymph nodes that drain the lung are located. On the left side he noticed another shadow, just above the aortic arch. He glanced at the clock above the lightbox. It was 3:10 PM Wednesday, Dr. Paul Adkins (front row, center), chairman of surgery at the George Washington University Medical School, was photographed in 1978 with GW surgery residents. Students voted him the "Golden Apple" award as outstanding teaching professor in 1975. To the left of Dr. Adkins is Dr. Stephen Pett, and at the far right in the second row is Dr. John Walshboth had special relationships with Dr. Adkins. April 2, 1980, a time and date he would never forget. As he took a final look at the X-rays, the thought hit him: "I am looking at my own obituary." With all the control he could muster he slipped the X-rays back into a large manila folder and quietly walked out of the X-ray suite. Back in his office he began to pace. His mind swirled. Perhaps he had read too much into the Xrays. Perhaps his imagination had gotten the better of him. He needed a second opinion. He walked next door to the office of Ben Aaron, who was doing some paperwork. "I've got something I want you to see, Dr. Adkins said. "Can you come into my office?" Ben Aaron followed him there. Dr. Adkins took the X-rays out of the folder and put them on his own lightbox. "What do you think of these?" Dr. Aaron, who had performed general chest surgery for years, replied quickly: "It looks like a pretty bad cancer of the lung." "They're mine," Paul Adkins said. Dr. Aaron instinctively put a hand on Dr. Adkins's shoulder. They sat down and tried to regroup their thoughts. Both had diagnosed countless X-rays like these and realized what they had seen: cancer that was inoperable and terminal. Dr. Aaron watched as Dr. Adkins began talking to himself and slamming his fist on his desk. "Damn," he kept repeating. His voice was anguished. To come this far, to reach this point, and now for this to happen. Dr. Aaron tried to offer comfort. He would help in any way he could, he said. After Dr. Aaron left, Dr. Adkins began to pace again. Whenever he called patients into his office to give them news like what he'd just received, he tried to console them, to reassure them. He used words like "tumor" or "malignancy"gentler words than "cancer"-because he wanted to soften the shock of such news as much as he could. But there was no reassuring doctor at hand to convince him that much could be done, that miracles happened. The news had hit him like a snake strike. He wanted one more opinion--that of Dr. David Rockoff, head of diagnostic chest radiology at GW and an expert in and steady. In normal conversations, his voice had a midwestern flatness to it. His hair was flecked with gray and he favored conservative suits and ties. He liked simplicity. He had three loves: his family, his work, and golf. The Atlanta speech drained him further. He thought fleetingly that if the persistent fatigue was a sign of something serious he didn't want to know it now. He'd rather go to Atlanta and give his speech without finding out. "Accentuating the Positive" is what he titled his address. He had bandied about dozens of ideas with his wife before finally settling on it. The address traced the traditions and future of thoracic surgery and identified the problems it faced and offered ways to deal with them. Like many other significant moments in his professional life, it was one he shared with his family: Faith, his wife of more than thirty years, and three of his four sons, David, Mark, and Bill, went to Atlanta with him. Paul, his third son, a junior on the Bucknell basketball team, had a game to play and couldn't accompany them. Dr. Adkins went to the round of cocktail parties, greeted many old friends, accepted congratulations for the speech. After their sons returned home, he and Faith stole away for five days with two old friends, Dr. and Mrs. George McGovern of Pittsburgh. Paul Adkins and George McGovern had known each other since their surgical residencies more than 25 years earlier. Now the two couples went to Ocean Reef on Key Largo, Florida, for sun and relaxation. It was there that someone else noticed for the first time that Paul Adkins didn't appear to be well, didn't seem to have his usual drive. "Why is Paul sleeping in the afternoon?" Dr. McGovern asked Faith Adkins. She said she wasn't sure but assumed it was because of his exhausting schedule recently: administrative chores at GW, surgical duties, teaching, medical rounds, speech-writing. "It isn't like him," Dr. McGovern said. Two weeks after Paul and Faith Adkins returned from Florida, he apparently came down with the flu. It was severe, but he was not alarmed by it; everyone caught the flu in February. Among the symptoms he experienced were nausea, fever, vomiting, and diarrhea. These passed after a few days. Coughing and fatigue persisted and Faith Adkins began to worry. This fatigue was more bone-wearying than any he'd experienced before. It caused him to fall asleep soon after dinner, even though he had continued to nap in the afternoon. When he awoke in the morning he wanted to stay in bed, to get Dr. Paul Adkins and his wife Faith, with sons Paul and Bill, in the backyard of their Bethesda home on July 20, 1980. By then Dr. Adkins had a metastasis of the lung cancer on his upper lip and wore a small bandage to cover it. more sleep. It became difficult for him to go through routine surgery without feeling spent. His cough was low and rumbling, as if coming from deep inside his chest. He tried syrups and antibiotics, but the cough persisted. Finally he became so concerned that he quit smoking. When he told people he had quit, he felt that special pride one experiences after breaking a bad habit. Friends were supportive, and colleagues who had often remarked on the irony of a chest surgeon who smoked congratulated him. No longer would the length of a GW faculty meeting be calculated by how many ashtrays he filled. The cough eased but hung on for weeks. It was particularly bad at night. His second son, Mark-a senior at the GW medical school, who often rode back and forth to the hospital with him--became sufficiently alarmed to tell one of the doctors at GW about the nighttime coughing. Then he confronted his father about it. Ever since Mark had switched from being a Spanish major at the University of North Carolina to enroll in the premed program there, father and son had played games of medical one-upmanship with each other. The father, ever the teacher, would ask the son questions, usually about his own specialty, and Mark would respond in kind, asking his father questions about another area of medicine, perhaps something he had studied recently in anatomy. It was a form of good-natured kidding, father and son each taking a pride in the other's knowledge, each delighting in stumping the other. Now, toward the middle of March. Mark asked a more pointed question: "Do you know what the primary cause of a cough like that is?" "Yes," Dr. Adkins answered. "Bronchitis." "No." Mark said. "Tumors." "Bronchitis." Dr. Adkins repeated, more adamantly. Mark let it pass. But a few days later at the dinner table he said to his father. "You ought to have an X-ray." There was no response, so Mark tried again. "Yeah," Dr. Adkins finally said. I'd better." For as long as Mark could remember, he and his brothers had teased their parents about smoking in a vain effort to get them to stop, and now that he had asked about the cough and need for an X-ray he sensed for the first time that perhaps his father was actually afraid of discovering the truth about his health. Dr. Adkins began to feel worse. One day when he was playing golf at Burning Tree, his caddy, a cheerful man nicknamed Fishcake, remarked that he looked ill and should see a doctor. Dr. Adkins's usual ten-handicap game was badly off. Faith Adkins was increasingly concerned. Toward the end of March the two of them drove to Charlottesville, where Dr. Adkins spoke at the University of Virginia Medical School. During the drive he promised his wife that he would get a checkup. A new bout of nausea and vomiting now hit him, coupled with the fatigue and coughing, and he was forced to do something that no one could remember him doing before. He called in sick. Cindy Fisk, his secretary for a dozen years, had seen him growing weaker. Concerned, she now asked him how ill he was. "Just cigarette withdrawal," he said. She was grateful he'd quit. She always felt awkward when patients asked why there were ashtrays in the office of a |