Bedside Manners Read online

  PAIN AND HEROES

  Look at him. He doesn’t even wince.

  It’s the ER nurse talking, and she’s talking about me. The occasion is a needle about the size of a soda straw passing deliberately, without anesthesia, into my shoulder, the ER doctor leaning on the other end, apologizing.

  I’ll bet he takes no numbing at the dentist, either, she says.

  I know the impact my response will have. It’s already been set up: Wow, she says. You’re either very brave or very crazy.

  I say it’s the latter and provide, as excuse, that I don’t like going home all numb and floppy. This terse explanation, though incomplete, works better than the lengthy analysis it would take to explain that my scales are just tipped that way.

  I don’t love pain. But I don’t love drugs, either. A colorful allergy history that once closed up my throat has made me a little cautious—well, to be honest, kind of phobic—about the use of medications. I don’t take medications. Any medications. I took the antibiotic Cipro once, but it was only to make it safe to participate as a donor in an in vitro fertilization the next day. And I took it one little microscopic piece at a time. Apparently I can do meds better if it is for someone I love. I suppose it might be considered pain of a different sort to fear reprisals from taking a drug. Anyway, there are other factors.

  This joint, for example, is already beyond the Richter scale for pain. With all due respect for the nurse, a whole cartload of Novocain would have little effect. What is needed is to get the poison out, the little crystals I make like a well-intentioned experiment for a high school science fair on intermediary metabolism gone sour, pseudo-gout they call it, spiky needles that lurk, then strike like a pit bull with white hot teeth. Perhaps that’s dramatic. Let’s just say I’m motivated. I can take this needle. Its pathway and my pathway to relief are the same.

  Pain is a strange fellow. It’s modified by the meaning you attach to it. In my case the dentist’s chair and the ER gurney are symbols of progress. Not so for my patient, Walter, with the I-can’t-remember-how-many back surgeries he’s had. He wants drugs. Lots of them. His pain speaks a different language, and it talks to him daily.

  Every month he and I have conversations. They’re always the same.

  My back is the shits, he will say.

  I say that I’m sorry. I truly am. But we both know there’s not much we can do about it. This is not a casual observation. We’ve tried everything in the universe including the last four back surgeries, which didn’t work. In retrospect we were propelled less by reason than by desperation — always a bad indication for surgery. By now the neurosurgeons turn and run when they see him coming. He’s stuck where he is, and he will insist on drugs. He knows his opening line is flawed, but he says it anyway. It makes me think the pain has grown a new function called self-preservation, it just wants to be there, mocking us, peering out from behind the spine, saying, You’ll never find me.

  Well, I know where it is. I just can’t get there. It’s locked somewhere in the automaton-like voice that says more medications, please. In fairness to Walter, his is a different situation from mine. I would probably think differently if this pain were a daily partner. And it’s not that I don’t prescribe analgesics for my patients with pain. I do. It’s just that in Walter’s case the pain relievers are constantly being outstripped by a faster machine. He doesn’t agree, and in the end we negotiate an uneasy peace, fraught with dissatisfaction for us both.

  As a child I watched my father deliberately pull his car over to the curb as a very large bee was embedding its stinger into the back of his neck. In the brief, hyperbright window of that moment, he knew that to let himself react to the pain was to damage his family. You might say he modeled a behavior for me, one that would not let pain get the upper hand. I had to admire that.

  But I don’t like pain, Walter would say.

  Now I feel the tissue of my deltoid muscle spreading in advance of the needle on its way to the exquisite membrane of the shoulder joint, where it will electrify as it nicks a narrow window to suck out the poison. This moment is the door stuck on its sill, the crescendo before the blessed release, and I . . . I do not move.

  The yellow, viscous fluid with its chemical firebrands fills his syringe. He will shoot in some steroid and, for good measure, a little Novocain, upon which we both agree, and then be out of there. And bless him for that.

  The nurse is backing away. I’m impressed, she says.

  Don’t be, I say. And I know, just like my patient, I’m working hard to avoid what I don’t like. The nurse thinks I’m a hero. Maybe. Or maybe just a coward by a different name.

  PART

  FOUR

  AILERONS

  I don’t know if you can tell, he said. But I used to be quite intelligent.

  Cab Cranston is elderly, white-haired, a pleasant old fellow who might have been a shopkeeper or a pharmacist, the kind of good-natured fellow you’d find giving free advice at the corner store. I liked him for that.

  They put us all through that testing, you know. They told us we were the cream of the crop. We probably were. Then they made us into killers.

  There was a lot wrong with Cab: coronary artery disease, two heart attacks requiring angioplasty and stenting— pushing little plastic tubes through the clogging—just to keep the coronaries open, hypertension, and, to top it off, reflux esophagitis that produced symptoms that were, at times, indistinguishable from those of his heart condition. It made it hard to be sure what was going on.

  They can teach anyone how to kill, he was saying. Anyone. When all the training was done, they even asked us about it. I told them I wanted to kill a bunch of Japs.

  His wife, a slight, mellow woman of about seventy, had been watching him quietly and, it seemed, admiringly. At this last statement she turned her head slightly to the side and looked, not at me, but away, and half-laughed, partly, it seemed, out of embarrassment and partly as if to say to no one in particular, He doesn’t really mean it.

  By this time I had performed several endoscopies on Cab. Always at a time when he had been having a bout with chest pain and the dividing line between his heart and esophageal disease was too blurred to know what was what. Mostly it turned out not to be his heart but esophagitis, which gave me an opportunity to give him a little good news. It was easy for us to be on good terms. Today we were assembling the complex puzzle of his interlocking medications.

  Japs, he said. But you know what? The bastards sent me the other direction, flying P-51s over Germany. They needed fighter pilots to escort the B-17s on their raids. And by that time the sonsabitches were throwing everything at us. It was almost over and they were fighting like hell. And you can be damn sure it was the fighter planes they came after first. It was our job to stop them because if they got through us they’d shoot down our bombers. You learned real quick that the guy over there was going to kill you for sure, so you might as well kill him first.

  I told Cab his talk made me think of my brother, who had been in Vietnam. After whatever it was that went on over there, he was never the same. He was hollowed out, damaged. Wouldn’t talk about it.

  All those moves the Blue Angels make, he said, they’re training moves, the same ones you use when you’re killing somebody. The moves become as automatic as breathing, but to beat that bastard you have to outfox him. So when you see him going left, you have to break the habit and go right. Bearing down on him from behind, you have to get in close enough for the bullets to cross, about three hundred yards — and forget the gas tank, hell, we were shooting for the cockpit . . .

  When you’re in that close, you can see his ailerons start to move. That way you know where he’s going before he goes. That’s why, when you’re that close, they move first left and then go right. To fake you out. If you don’t go right first, he’ll dive away, come up under you, and rip out your belly.

  Cab grimaced, placed the butt of his fist against his chest, and forced a small belch.

  You okay? I
asked.

  He laughed. I don’t get too worried about dying from all this medical stuff. I should have been dead a thousand times already.

  Cab’s chest pain wasn’t that easy to diagnose. Frankly, I had the feeling his two embattled organ systems, cardiac and intestinal, were at times playing off each other, each contributing an unpredictable amount to the other, and together to his overall distress. On top of that was the invisible element of the psyche and the role these tensions, carried like a nose cannon, armed and ready all these years, would play. His danger was a cloaked danger, and it seemed to worry me more than it did him.

  I reminded him that his medications were important. They might break the cycle of pain and keep him out of the rushing cascade that got him in trouble. My words were orphaned in the air between us. He was military. He would follow my orders whether he thought they were important or not.

  You have to go in on him, he said. And when you get close you keep on going, even though you know he’s shitting and you see him turning in his cockpit—and all the time he’s falling apart, you’re pissing and vomiting. That’s what it’s like. That’s what it’s like to kill.

  He paused a minute. I wasn’t sure where we were going next. Or if we could go anywhere else. But I knew the story was on automatic pilot.

  And when you get him you can’t stay there, he said. ’Cause some other son of a bitch will be right on your tail.

  His wife was still looking away. Whatever she was thinking, she stayed right with him.

  I think my brother probably went through something like that, I said. I guess I’ll never know.

  When I got back from my first mission, my pants were wet, he said. I didn’t know it until I stood up to get out of my plane. My goddamned pants were wet. You’re up there sweating and pissing and you don’t even know it.

  Once I went down. I got hit over France, luckily, in a part we’d already taken over. When you go down like that, they send you back from the front. If you’re in the infantry, you’re discharged. But flyboys stay in. And what was a P-51 pilot to do in the States? Sit back on his ass and get fat? Not likely. They sent me out on a C-47, a goddamned troop carrier in the South Pacific.

  By now I had finished my treatment plan and we were way over the allotted time for our visit. But something important was issuing forth here.

  Our mission was to fly from Okinawa, drop paratroopers in real low, so low they wouldn’t be sitting ducks, so low they hit the ground with a hard bump — then fly to China for supplies and ammunition, come back and drop all that stuff on top of the paratroopers, if you could find them . . . then return to pick up more troops . . . and keep going . . . and keep on going . . .

  He made a circular motion with his hand.

  They briefed us about it. It was perfectly clear to me I was going to die. They said: If you’re in the water you put your .45 to the roof of your mouth and pull the trigger. It’s a hell of a lot better than what they’ll do if they catch you — all those peasants who hate Americans—they’ll stretch you out in the sun and skin you fucking alive.

  We lined up every day for a week, paratroopers stuffed in the back of the planes and everything, but we didn’t take off. Just lined up every goddamned day. The fourth day a telex appeared on the bulletin board: ATOM BOMB DROPPED — AWAITING RESULTS.

  What the hell was that?

  We’d never heard of an atom bomb.

  Then, SECOND ATOM BOMB DROPPED—AWAITING RESULTS. I know now that if they hadn’t dropped that bomb, I wouldn’t be here today. Those Japs had been planning for our invasion. They knew it was coming. And they probably knew when. Everything they had was going into defense and it wasn’t going to be pretty. We were in for a lot more than shitting in our cockpits.

  I would have liked to stay in after the war, but my wife couldn’t take it. Years after, I still dreamed about it. During those times, there was a rubber band pulled tight around my chest. I couldn’t breathe. Then one night I woke up screaming. She asked what was the matter. I think I’m home, I said. I think I’m finally home.

  The wife remained silent and looked away. She had gone dutifully where he’d put her, speaking as if she weren’t there.

  I didn’t think about it for a long time, he said. But now, forty-five years later, it pops up now and again. I’ll just be washing dishes and I’ll think about it. I’ve even started to dream about it all over again. I don’t know what it means. Maybe I’m about to die.

  I was silent.

  You see, he said, that’s why your brother won’t talk about it. I wasn’t in Vietnam, but I can imagine what went on. Think about it, he said, leaning into the desk. If he talks about it, then he lives it. And if he lives it, then when he goes to bed at night, there it is — all over again.

  The room was silent.

  I’ve been thinking about it a lot lately, he said. And I only have one regret. I never did get to kill a Jap.

  The weight of his story pushed hard against all three of us. For my part, deliberations about adjusting medications, differentiating between heart disease and esophagus disease, were still in my head alongside a silence as loud as the engine on his P-51 Mustang. Even meaning seemed to be displaced, shrunken. Pain was a just check mark on a sheet of paper. Death was just a page to turn.

  MOTIVATION

  I am sitting on the exam table, waiting for the doctor to come and look at my . . . lesion . . . third time, second recurrence. He will probe it, cut on it, decide whether to ellipse it—lift it like an overripe plum from the surface of the earth and toss it out of the body—or do something else. And I will welcome whatever he does.

  And I feel the turn, the departure from procrastination that certain symptoms produce, like that for the dentist, which now shifts like a keel ballast, whipping the boat around. Yes, indeed. I am almost willing to beg to be seen.

  It’s a wen, and love the name, as Raymond Carver says, but not the thing itself. And yes, it does rise up late at night and hurt like a cigarette burn, and I feel alone and miserable . . . my body aches, my hair stiffens . . .

  I enjoy the practice of medicine, the competent certainty of diagnosis and decision, how it all works together to bring assurance, healing. I know a little bit about that. Still, when it comes to me, I am fueled by the usual suspicions, knowing a little too much about complications, bad outcomes, chemical reactions—the paranoia that knowledge and experience can give a doctor who’s not yet had occasion to face it down.

  But a few nights of sleepless pain, a rising bump on my leg that, I am told, is not cancer but related to it, and here I am, half-naked on the examining table in the precise position I have looked forward to for two nights now and, yes sir, loving to be here.

  Something is about to be dealt with. Just the dealing is almost enough.

  The crater in my leg looks at me like a sick eye. Out from under where I have unbandaged it, peeling back the gauze and the tissue debris that comes with it, the pus—débridement, now there’s a name for it, a beautiful French word for the ugly work of scavengers, which, in this case, means to cut away the dead and dying to make way for the living.

  It is the little thing that began as all apparently insignificant things begin, with no announcement of intent, just an unobtrusive bump above my right knee that I thought was acne, or maybe a small abscess. I waited for the opportunity to pick off its top, drain the cavity of its cheesy matter, and be done with it. But it mounded like the crowning of a baby’s head at her mother’s crotch. Crowned, but not born.

  That’s when the burning pain shattered what reluctance I might have had to go see a doctor.

  You tell me, he had asked his assistant-in-training as they peered over my leg the first time it was laid out on the table like a modesty set to the side. Keratoacanthoma, was the immediate response from behind eyes trained to apprehend the sine qua non, the characteristic sign.

  He told me that some people think it’s really a squamous-cell carcinoma that your body is somehow able to deal with. Not ma
lignant. Won’t metastasize. But pesky, aggressive. Probably a virus.

  He cut it out. Cauterized the base like a lightning storm in the underbrush. Then told me to clean it twice a day.

  That was the first time. And I felt better. It felt better. It looked like it was healing for a while, then the burning came back. He cut it again, deeper. Electrocuted it. In a week the pain was back.

  Visions of aggressive cells began visiting my dreams. I came to understand why my patients ask the questions they ask: Are you sure about the diagnosis? Is this the best way to go about it? Should we get a plastic surgeon or maybe a second opinion?

  Today I will ask questions I already know the answers to. But something about the asking is absolutely necessary.

  I look around me at the bandages, the glass jars filled with tongue blades and cotton balls and alcohol swabs, the scalpels and curettes laid out and gleaming like fine silver on a linen cloth.

  It feels good to be here. Just me and my wound, alone and waiting in the room.

  THE PATIENT NAZI

  You have not begun to see . . . the trouble . . . I will cause you . . .

  She had appeared a month ago, as if arriving from no point of origin—no referral, no telephone call from a doctor—just showed up and spoke of her many, many medical problems, mysterious problems, not clearly diagnosed but precisely articulated: pituitary adenoma, Sjögren’s syndrome, Waldenstrom’s macroglobulinemia . . . I was fascinated by her deliberate speech, her hard, splashy accent.

  She lived alone, had no family, required assistance in order to accomplish her goals. She would need blood tests, X-rays, a scan of some sort, and a colonoscopy. She would need to see the hematologist, Dr. Dalton, whom she described as a troubled man with certain deficiencies but basically a sound doctor. Dr. Dalton did not have an appointment available for three more months and . . . Do you realize, Doctor Watts, that my Waldenstrom’s will be hopelessly out of control by then?