Bedside Manners Page 18

  David, why did you change my medication?

  It’s Rochelle, in the hospital back in San Francisco. She’s pissed off because she only gets her Dilaudid suppositories twice a day. She has my cell-phone number because I gave it to her. Saves time, I reasoned, and patients get to feel more connected to their doctor. Most people call less often if they know they have my number. It’s like the pill in the medicine cabinet you don’t take that keeps you well. In Rochelle’s case it was a bad idea.

  By now I had almost grown accustomed to the black negligees, the low-cut necklines, perfume that blistered your nostrils, and the attitude of excessive familiarity she took with her doctors — seductive, the social worker called it. Exhibitionism, I thought. It didn’t seem to have much to do with sex.

  When she was not wearing her bedroom attire, she wore a jumpsuit and a baseball cap with the words “Spoiled Rotten” across the front. She was accustomed to getting her way, and even her doctors finally just gave up and did pretty much what she wanted, took calls at all hours, gave her drugs. Persuasive, charismatic, forceful— she was one of those electric people who change the ecology of the room she’s in.

  I wanted to be responsible. To say that was going to be difficult was an understatement. I wasn’t so sure she was as sick as she thought she was. But her disease was wacky, the kind that’s unpredictable both in how it presents itself and how much she uses it to upset the applecart of equilibrium. She’d already been whittled on several times, and her belly was, in the words of one of my professors, a home run—a scar in every quadrant. Looking back on it, I wasn’t sure if they’d cut her for disease or for symptoms.

  I think you’re addicted, I said.

  She scoffed and rolled her eyes. Don’t you know anything? Don’t you know how I left the hospital and stopped drugs just like that? She snapped her fingers. Could I do that if I was addicted? No way!

  We wandered off to something we could agree upon: the insanity of the current political administration, the inane clerks who have no business controlling medical decisions over the phone . . . She was talkative, gregarious, entertaining.

  You should be a talk show host, I said.

  Now, David, if you can say that, you don’t know my life. How could I do that and have this disease?

  President Eisenhower had this disease, other people . . .

  He didn’t have my disease, that’s all I can say about it.

  It’s a waste. You’ve got talent.

  I’m doing just fine, thank you. I’m hanging. That’s about all I can do is hang. You’ve got to hang to stay around in this world.

  She paused and glared at me. Okay. So you don’t believe my pain.

  I believe it. I’m just not sure I can take it away.

  Then let me get this straight. You’ve just decided to let the patient su fer.

  I anticipated the last four words, and we said them together with a syrupy, musical ritardando accompanied by a little sarcastic lilting crescendo. That’s cute, I said.

  I’m not being cute.

  Yes, you are, real cute. And I shriveled inside. Damn it! I’d let myself be drawn into an unprofessional argument. She’d made me mad, and mad defeated me.

  I wrote the blankety-blank prescriptions.

  In the middle of the night I woke up and realized that what frustrated me so much was that my efforts to take care of her had earned not a farthing of thanks. Her selfcenteredness was immaculate and could shatter glass. No need for appreciation when service is the going currency. That meant the anger she provoked in me came from expecting . . . what? Maybe it was gratitude that was missing, gratitude that gave me a feeling of satisfaction. Right then, I learned something about myself.

  And I changed the plan. I was going to have to get over the gratitude thing. Just do my job the way I was supposed to, and let that be my satisfaction. At least I had control over that. With this attitude I would do a better job.

  And now Rochelle wanted to be in the hospital again.

  I don’t think I’m going to live much longer and I don’t want to be reminded of it, she said. But I’m not doing well and I think about three weeks of in-the-hospital hyperalimentation would do it, you know, a little food in my arm.

  Do what?

  Put me back on my feet again.

  You know it’s not customary to hospitalize patients just for hyperalimentation. The Utilization Review Committee would be on my back.

  I’m sick. I’m losing weight. I’m in pain. What does a girl have to do to get in the hospital these days?

  I could see it in my mind. It wasn’t difficult to assemble the images out of past experience: Rochelle smoking in her hospital room and trying to cover it up with incense, walking up and down the corridor, dragging her IV pole behind her, wearing black negligees that plunged all the way to her belly button, demanding drugs, drugs, and more drugs.

  By now she had already “failed” our attempts to give her intravenous nourishment at home. She was hard to find. Wouldn’t be there when the nurses came to start the infusion. Kept moving back and forth between her parents’ house in Berkeley and her apartment in San Francisco. When we finally did get it started, the infusion line kept inexplicably falling out or getting dislodged. And the paraphernalia, she said, disturbed her spirit.

  We should be able to do this at home, I said.

  I don’t love going into the hospital, she said. I don’t know if you know this, but I’m claustrophobic. I have to tell myself I’m not there in order to survive those small hospital rooms. Whatever is happening, happens to my body but not to me. That’s why I dress the way I do, put on makeup, and burn incense. I play games. It’s just survival.

  We made a contract. No more pain medications than she is now taking. No smoking in the room. Then I called the admitting resident.

  I told her about Rochelle’s Crohn’s, her surgeries, her short-gut syndrome, the recent weight loss, my attempts to build her up with home IV nourishment, the six-pound weight loss in one week, and the crunch I found myself in, needing to bring her in, believing she may have provoked her own weight loss. I told her I wanted to evaluate the ability of the bowel to absorb, to move toward outpatient care as soon as possible and manage her pain. Now the bomb-drop: She’s difficult, I say. Has a problem with pain meds, demanding. I told her about the provisions of our contract. She doesn’t love interns and students and will try to fire them from her case. One thing more: Because of the compensatory hypertrophy of the small bowel, it can at times appear to be dilated as if from obstruction. She’s not obstructed, and her Crohn’s has not, by my estimation, been active for some time. She believes she will die soon, but she is the only one who thinks so.

  The resident took it all pretty well. It was a frank beginning. Everyone was on the same page.

  At 3:00 p.m. my secretary interrupted me to say that Rochelle had arrived on the hospital ward and was demanding her Dilaudid suppository right now. I said nothing and returned to my work.

  After hours I made rounds. Rochelle was as happy as a child with a new toy. I figured she’d gotten her suppository, but when I checked the chart I saw she hadn’t.

  Next day she refused the hyperalimentation line. That’s the reason for this hospitalization, I said.

  I don’t want that thing hanging out of me, she said.

  Then the chief of Interventional Radiology made it known he didn’t feel she was a candidate anyway, because of her attitude.

  That night I got a call from her mother. She said Rochelle had had a hard day.

  So have I, I said.

  Couldn’t you just give her something to make her happy?

  No.

  Why not?

  We have a contract.

  I know about that, but she’s in pain. At the sound of the word, the hairs on the back of my neck bristled. I thought of the millions of freeloaders riding stowaway on the heft of that word.

  Why are you doing this? I asked.

  What?

  Calling me up. As
king for more pain medications for your daughter.

  Why, she’s my daughter. And I want her to be comfortable. Can’t you just give her something?

  I can’t because — and I thought a moment, then decided to be blunt—because she’s probably addicted to narcotics, and the pain may be her avenue to get them.

  Oh! I didn’t know that . . . But can’t you just give her something?

  It took my breath away. I was in the interior beehive, the breeding ground for rituals that spread like instinct down through the generations. It was all beginning to make sense.

  The resident called and said she thought Rochelle was doing drugs in the hospital. The nurses found her stuporous, and she’d been asking for rubber bands.

  We need to do a drug screen, I said.

  Nutritionally she’s doing fine, the resident said, in positive nitrogen balance and the fat absorption is completely normal.

  She didn’t need hyperalimentation in the first place.

  Exactly. And I don’t think she’ll be properly prepped for her colonoscopy tomorrow. The nurses walked in at midnight, and three-quarters of her bowel prep was still there. Eight minutes later it was gone.

  Dumped it.

  She dumped it.

  I went to the ward, but I couldn’t find her chart. The ward clerk was hiding it under the desk because Rochelle had been altering the doctor’s notes. Portions of my writing had been blackened over with a broad dark swipe. I remembered what it was she’d marked out: suicide attempt last fall, three days in a psychiatric institute.

  A little misunderstanding, Rochelle said.

  Any attempt is a serious attempt, I had said.

  You have altered a legal document, the nurse said.

  That afternoon the drug screen came back positive for cocaine and cocaine metabolites. The picture was complete: no malabsorption, no Crohn’s flare-up, no obstruction, no need for hyperalimentation . . . and, by God, no more narcotic prescriptions from me.

  On the way out of the hospital she dropped by the office for her Dilaudid. I told her I thought she needed help with her narcotic problem.

  Now, David, I make the mistake of telling you I did cocaine once around Christmastime, and now you think I’m hooked. I can’t say anything around you.

  Your drug test was positive for cocaine. It means you’ve had it in the last few hours.

  Positive?

  Yes.

  Are you sure it was me?

  Yes.

  They probably mixed up the specimens.

  Not likely. Besides, it matches with you being so gorkedout all the time.

  So that’s how it is, huh? I see. Well, I can look you in the eye and say I didn’t do it.

  I leaned over the table and looked at her up close. Yes, you can look me in the eye and say that you didn’t do it. And that’s just the problem.

  She turned away, screwed up her mouth, and waved her hand as if throwing something out of her ear. Well, you can choose to believe a computer, or you can choose to believe me.

  You’ve got to get hold of this drug thing, I said. Why don’t you enter a rehab unit?

  You know I can’t do that. Those fools don’t know how to tie their own shoes.

  The choices are getting fewer, I said.

  She left. And I felt relieved. But I argued with myself. Couldn’t it be said that if someone wanted to live out her life on drugs, it was really up to her? Maybe the way my predecessor did it, providing her with her prescriptions, was a way of being present in case he needed to dig her out of the hard spots later on. Maybe that was another way of interpreting the phrase giving care.

  No, said the ward nurse. She’s got that attitude that says “the whole world owes me.” And you know what? I’m sorry if she has to do drugs so as not to face her miserable life, but she doesn’t have to drag you into it.

  Rochelle fired me. We’ve been together a long time, David, she said. It’s time we moved on. And, by the way, you probably needed to get my permission to test me for drugs.

  There’s the legal and the medical, I said. I had to know what was going on. If I hadn’t found out, you could have died from some little dose of sedative I might prescribe. Secretly, though, I thought she was probably right about the legal stuff. Even so, I realized that no matter how I’d come by it, I was pleased with the clarity we’d achieved.

  Rochelle wandered on to those “animal hospitals,” as she called them, which sent me reports from time to time: abscess near her spine arising from God knows where, no one seemed to know; six months’ hospitalization for IV antibiotics and pain control; blood infections; spinal fusion . . .

  One day she called. I may have to come back to you, she said.

  Why?

  These fools don’t know what they’re doing.

  My first impulse was to say, as I had before, Sure. Come on back. But my stomach flopped, thinking about the constant arguments over drugs and the load of all that on me and my family.

  Only if you’re under the care of a pain management center, I said, someone qualified to monitor your narcotics.

  David, we’re family. We’ve been together too long not to help each other.

  Okay, I said, I’ll do your medical care, but you’ll have to get your narcotics from someone else. With our history, I just can’t do that.

  Months later a call came from her doctor. I was giving Mrs. Levinsky her B12 shot. I finished my work, said good-bye to Mrs. Levinsky, and turned my attention to the voice on the phone. Rochelle had gotten another infection, waited too long before coming to the hospital. She’d come in nearly comatose. I’m sorry, he said. I couldn’t revive her.

  First came the shock of her death, then the shock that I was so surprised. I guess I’d really never expected it to happen. She’d always said she was about to die, but it seemed more like a joke we laughed about together than something about to take place in the real world. Now she’d gone and done it.

  It made me wonder which was better, the spiky aggravation of having her as a patient or the permanent lament that she might have survived if I’d been there to take care of her. Maybe that had been the source of my predecessor’s endurance, staying with her through the smog and stench of drugs so he could be around to pick her up when she fell. Maybe that was the third satisfaction. To endure, so as to save. I couldn’t tell. It was what it was. Still swirling in my head was her last visit to my office.

  I’ve told you before, she said, I was not born on this planet. I’m serious. I look around at all these people . . . they have nothing in common with me.

  I found myself driving to the ER the other night, David, alone. Here I am sick, in pain, and I asked myself, where is someone to help me? Do you know what I mean? What is wrong with all these people?

  TWO DYINGS

  When the retired professor of anthropology came to talk about death, I was not surprised. I knew we’d talk about it sooner or later. He was ninety-three years old. Over the years we had spent more time talking about philosophy and music than about ulcers and prostate cancer. More fun that way. Yet time passes and some things are inevitable. I expected the talk, but what he had to say had an unexpected spin.

  It’s my wife, he said. The gangrene has set in her leg and she refuses amputation. Absolutely refuses. You see, she has a brother who lost a leg. Just knowing he’s there without one leg bothers her so much she can’t stand to talk to him. If it came to an operation, she wouldn’t do it . . . so . . .

  . . . and his words trailed into a shrug. A little seizure formed at the corner of his mouth.

  Silence soaked into the minutes ticking.

  I remained quiet. The conversation wanted to go where it wanted.

  She would have to go first, he said at last. She couldn’t do it herself. I’m sure of that. I would have to give it to her . . . then, I guess . . . me.

  The last words stuck in his throat like they didn’t want to be out in the room.

  Ninety-three years is an awfully long time to live, he said. And h
e raised his eyebrow as I imagined he might in order to drive home an important concept of tribal unity to his anthropology class.

  Right then I realized I would do almost anything for this man.

  Yet I had no impulse to speak. I wanted to let the idea carry him as far as it wanted.

  He asked what would be painless, how much it took to be certain. If he was going to do it, he didn’t want to mess up.

  We talked about pharmacology and the names of drugs he could have looked up in any neighborhood library. As we talked, I began to see this was not a plan of action but a rehearsal of ideas. The details merely provided something to occupy his voice so his thinking could do its work.

  He came to a stopping point. Something had arrived where it needed to arrive, and the silence returned. This time it ebbed from my reluctance to say anything trite or patronizing.

  But I was still wondering what I might offer, something that might give balance to his thinking, give him a little anchor wedged in the rock of this world. It would have to be something automatic, an obligation perhaps, so small as to be unnoticed, so trivial and so easy that not to fulfill it would be difficult, something just strong enough to hold him here a little longer. A mark on his calendar, perhaps . . .

  . . . and if I walked out to the front desk and bent over the appointment book with pen in hand and personally wrote down his name . . .

  PIANO LESSON

  They came flying around us like pigeons I’ve seen on Parnassus Avenue, domesticated beyond safety among clomping feet and the swift, deadly glide of cars — boys on bicycles, yelling to each other and laughing in that accelerated playful romp that ramps up race-car drivers and athletes, pushing them to take chances.

  Duston, my five-year-old son, was in the backseat. We’d just parked our car. We were going to his first piano lesson. He’d wanted to finish listening to Car Talk before we went in.

  I heard a thump sound—no, more like felt it—behind us. The kind of I-hope-it-wasn’t-something-bad type of sound we hear occasionally and then go on doing what we were doing before, but with one ear cocked.