Bedside Manners Page 4
If I am calling about myself or a family member, press 1.
If I am a doctor’s office, hospital, or pharmacy, press 2.
If I am calling from an area outside my home telephone area code, press 3.
If I want all this in Spanish, press 4.
Here we go, I say, and press 2.
More options.
To access the automated member eligibility information line, press 1. [Is that an automated eligibility or an automated member?]
If you are seeking medication or prescription authorization, or have benefit inquiries, press 2. [Didn’t we do this already?]
For questions about claims, press 3.
For credentialing, capitation, or to speak with a provider-relations representative, press 4.
For all other inquiries, press 5.
Just for fun I thought I’d press 7, but I hated like hell to have to start all over again.
I press 2. More options.
If you are calling about benefits or eligibility, press 1.
If you are calling about prescription information, press 2. [Is there an echo in here?]
For all other inquiries, press 3.
I consider the possibility that there is a plot afoot to make doctors all over the country press 2 a certain number of times in order to induce mass hypnosis. I break the rhythm. I use a different finger, the middle one, and press 2 . . . again.
If you are calling about a refill too soon or a vacation override, press 1. [What the hell is a vacation override? I imagined a vacation gone mad, snarfing up all the remaining dates on the calendar, then the next year’s calendar, then the millennium . . . ]
For all other pharmacy questions, press 2.
Just call me a sheep on Soma. 2 it is.
There’s a break and a voice comes on the line. At last! I exclaim, a REAL PERSON!
Silence at the other end. It’s dead over there. No sense of humor. Maybe I was a bit hasty about that real-person business.
Is this about a prescription refill? she asks.
I imagine an automaton on the other end of the line. I could point out that I’ve pressed that option four times already and that if she just looked at her computer she would know the answer to that question, but I’m staying cautious. Yes, I say. It’s Mary Casey’s Zyrtec.
Do you have her member number?
Damn! Got me already, I say. Check and mate.
Silence again.
What was her name?
C-a-s-e-y.
First name?
M-a-r-y.
Do you have her date of birth?
I thumb through the chart thinking about palm trees on a desert island, windsurfing sails, the beach filled with 10s from the agencies of Beverly Hills . . . Twelve/twenty-nine/fifty-five, I say.
Who are you?
Marley’s Ghost! I’m Doctor Watts. W-a-t-t-s, David.
Telephone number?
I give it.
License number?
I give it.
Narcotics Prescription Number?
I give it.
What prescription did you want?
Zyrtec, ZYRTEC, ZYRTEC — I can hear my voice rising in front of the scream shackled at the back of my throat. That’s Z-y-r-
She cuts me off. Have you tried Claritin?
Christ! Who’s the doctor here! I am just about to lose it. But I know what she’s doing. This is one of those questions designed to piss you off so much that you throw the phone against the wall and break the connection. Then the National/ International Center for Discontent, or whatever it is, doesn’t have to pay for the prescription.
I can’t remember, I say. Maybe we have, maybe not. Anyway, Zyrtec works best for her. That’s why I’m refilling it.
She was, she says.
Was what?
Was tried on Claritin. I see it here.
There is not a civilized phrase in the universe I have left to say. Now I understand why the phone conversation is being recorded.
When did this patient first come to see you? she asks.
A soft humming noise is becoming audible at the periphery of my brain. I discover it in the back of my throat, a sound like the sound on the leading edge of the roar of a samurai warrior just before charging headlong into his opponent. But . . . I am determined . . . to get Mary . . . her prescription. I shuffle through the chart. Four—mmm— twelve—yeah—ninety-eight, I say with undisguised satisfaction. YES!
What’s her diagnosis?
Jeez, next you’ll want my mother’s library card!
Not a glimmer at the other end of the line. Not a beat. I am dealing with a hardened professional.
Her throat swells up and she can’t breathe, I say. Ruins her day. Angioneurotic edema, if you want a term for it.
Silence again.
I figure if silence works for her, it can work for me. Seconds pass. If I had been talking to Jerry Davalos down at Ace Pharmacy, this whole transaction would have taken fifteen seconds. Is it possible to become so conditioned to this kind of harassment you accept it as standard procedure? God forbid. Silence still. I can feel the quiet pressure of my patients waiting in the outer office. They must be wondering what’s going on. But I will not relent. I let the silence run . . . and run . . . and run . . .
Five minutes, and she’s back.
I’ll approve it for six months, she says. Then quickly adds, as if not to admit defeat, But not a minute longer.
I have many choices what to say here. The day has been long. My patients are waiting.
Thanks, I say . . . and hang up the phone.
STRICTURE
I press my finger in the channel until resistance grows too great. His brow is raised, his eyes closed, his chin lifted as in prayer. The stricture is first muscular, thick and slow, like clay hardening in the wall of a quarry. I lean in with my whole body and press for the membrane I know is up there. I can tell when I get to it. It will be sharp on the tip of my finger, like the scrape of an iron ring.
He is sedated—his request and mine. We’ve been here before and we both know what we’re up against. Even after large amounts of Demerol, Versed, and droperidol, he quakes against this invasion as if to shake a bad dream.
I speak in tones low and calm, as if to compose a startled horse, spooked and taut at the edge of flight: Easy now, just a little more pressure. Okay, I’ve stopped. Let’s take a little rest and then we’ll go on. My job is to reach the membrane. And break it open.
Much will be forgotten and much muted by the cloak of chemistry I throw over him. Even so, pain rises from his body like vapor, and reluctance swells within me like that cinch that froze my hand once in its arc of anger over my child. I remember that hand, having begun its descent to spank, halted, not by intent but by some unknown force, as if the body in its wisdom had the will to interfere with itself, refusing to carry out the errant command. Where are the nerve fibers for that antipathy to violence, I wondered. I don’t know. But it was clear that even a deluge of rage could not wash them away.
Now, I shudder against that same resistance, but I hold my place. I have learned that he will not be helped if I shy from my task. I disregard his pleas. I have learned how to do this.
Now the time for the push. I call forth the savage beast that, like the cat, unresponsive to the squeals of the dying mouse in its paws, feels nothing. It sweeps through my body with a shudder. My face contorts, my breath gathers for the scream that will not scream, and together we put aside aversion to pain, antipathy to violence, the protective mechanisms that keep us humane, a paresis just long enough to let me finish: to let me feel the membrane scrape and tear.
I withdraw.
We rest and return to ourselves.
We have been flogging the aftermath of Crohn’s disease, which, by its festering, has turned his rectum into a tar pit of infection and seepage. By all accounts he should have had surgery long ago, a bypass to divert the fecal stream and allow this soppy bog a chance to heal. He has refused.
; He shows no signs of disease. He is handsome. He is young. He smiles a lot. He wants to keep it that way. No ostomies, he says. No surgery.
The future has so many arms. How can I tell where we will be even a few minutes from now? I do not know, for example, that months later I will refer him to a major inflammatory bowel center and he will not return, not schedule another of these sessions. All this moment knows is that the stricture is open, report typed, documentation attached, and copies sent to doctors who need to hear about it. He is sleeping, drifting in that rare caesura of peace that blesses gently before he rises again, stretches, goes back to work, and signs up to play softball with his colleagues this weekend, they who think they know him but have no idea what he’s going through, no notion that the two of us are cruising toward the next time, when we meet like reluctant warriors and do it all again.
ATTRACTION
The intern was shocked by her beauty. She moved effortlessly among her patients, like a breeze in the olive trees at sunset.
He was there to make rounds on the Guillain-Barré patient, a young man with that mysterious neurological disease that paralyzes slowly, ascending the spine like snake toxin: first legs, then arms, and then . . . you can’t take a breath.
The respirator did that for him, attached by a flexible tube to his tracheostomy, a hole in his neck that let the air move more easily in and out. Stable. No problems. It would only be a matter of time until the paralysis released its hold and he would be well again, able to return to a normal life.
She was his nurse, bending over him now to remove the little bits of mucus that collected like raindrops in his tube, detaching him from his respirator for a few seconds as she gently suctioned him. He was awake, not able to talk, not able to move. He could only blink his eyelids to show appreciation or fear.
Her long black hair brushed against his shoulders and arms as she moved over him. The intern watched, imagining her hair touching his arms, his face. She took no notice of him, but he thought he could feel a surge of energy from her, as in that moment when the air in the room ripples toward you, as if she says, in that way, I am opening toward you.
He would introduce himself later. He made a little vow as he left the makeshift ICU— those thrown-together collections of the more seriously ill in the days before automatic monitoring equipment with alarms to warn people of decreasing oxygen, fading blood pressure, a unit entirely dependent upon the close scrutiny of the staff—left to write his note in the chart, wondering if he had a chance with her.
When he finished, he returned to the bedside. He was accustomed to seeing the patient lying still, but there was something different about him now, something strange, as if he were stiller than still. Then it hit him. There was no sign of life. The pulse was gone. Pupils were dilated and fixed. No motion anywhere, just the bobbing of respirator tubing, detached and wavering three inches above his tracheostomy, pushing its noise over the wide expanse of his eyes.
The nursing supervisor came, reconnected the tubing, whisked away the nurse, and began the necessary conversations with the relatives outside the ICU door. It was a terrible disease, they might say, to take the very young. So unpredictable that way.
But the intern could replay the details: the little ritual of suction, the patient watching, blinking his eyes, a little sign of distraction on the face of the nurse, the urge to say, Warning, warning, oh no, be careful, rising like a fist of wind inside him, then the quick blinking, the flutter of eyelids to interrupt what it knew it could not interrupt, waiting for the detached respirator to be noticed, to be attached, as the lights in the room began to fade around the walls where they met with the edge of his vision, the tight cinch against movement or speech unyielding even for this as the tubing hovered, within reach . . . out of reach, no one responding . . . to his quiet petition. Consciousness . . . fading, still conscious of his fate . . . conscious . . . of . . . until the blinking ... stopped.
MONOLOGUE MILLIE AND THE SYSTEM OF CARE
Millicent calls to say she has fired her caseworker. She’s always firing her caseworker. Then hiring her back. Reconciliations like these that repeat themselves are littered with scars and driftwood, and assume, increasingly, an air of impermanence. A mood that, incidentally, matches her world if she were to think about it; more impermanent than her persistence on my telephone would suggest, having survived colitis, a hip fracture, a psychotic son, and multiple nursing homes where the care was, in her words, reprehensible, survived all that to dial me up seven times so far this day.
I remind her that in order to take adequate care of the cellulitis on her leg, she either needs to be in the hospital or to accept the visiting nurses I send her. She prefers instead to call, to instill in my secretary a sense of dire urgency that could overwhelm even the best protectorate, secure a wedge of time in a daily schedule already apprehended by the need and demand of patients more willing to play by the rules than she is, and then show up five hours late, just before the office closes, to undo her legs in my waiting room.
The scene is dramatic. Ceremonious. And very effective. My other patients waiting there are drawn to deep empathetic explosions of support, and I feel—though at the same time I realize I could be making this up—that this performance swings the pointer of anonymous inquisition directly at me. For example, how could I let one of my patients be so humiliated?
She’s not humiliated. But I do not explain this to the audience, nor do I justify. I bend over her with the gesture of a country doctor attending gangrene at the roadside and release what tensions I may have into the beatitudes of care. It is a play with a plot and a protagonist (in my version, myself ) who, helpless in the face of providence, gives in to the power of appearances. Classic stuff. None will know she is unregulatable. She will come see me when she wants to. Exactly.
I return from a few days away to find she is in the hospital. No one seems to know how she got there, only that she has called three times this morning complaining that the house staff wants to discharge her. Prematurely, of course. I take the elevator to the twelfth floor. She is on the phone when I go into her room. He eyes are closed and she is speaking through a fixed smile.
Good morning, Pier 39. I have news for you. Yesterday was Saturday and Sunday. Today is Halloween.
You see, I persuaded them to remove the twenty-ninth and there wasn’t any thirtieth. You may think this is Monday the thirtieth, but it’s really the thirty-first. I made them give me the twenty-ninth to keep as a souvenir. Oh, Doctor Watts, you’re here. Good.
Well, the last time I was here I begged to leave. But it was the day before the weekend and I couldn’t go. They suffered a little calendar confusion then as well.
But I hope they come to get this bedpan. I have signaled them.
My home is not ready for me. They have insinuated that I have not been taking care of myself. There were a couple of glitches with medications, I confess. And I thought it best when Monique got so heavy-handed, bursting in, pushing me around—I asked her to leave my house. I’ve never been so angry in my life.
But this big production led to my arrival in an ambulance. There was my caregiver standing in the door with this expression on her face. There I was with my legs that needed taking care of. So I apologized to her. I do what I can. And I myself got a new refrigerator. Got a new toilet, but there are some problems. It is small, shaped like an egg. Does not fit my buttocks.
At this point, not seeing any clearing in the weather report, and realizing I couldn’t wait long for such an opening, I began the routines I usually do in such circumstances, only not accompanied by the usual commentary, as, in this case, it would be uphill and, anyway, probably without much in the way of recognition.
So, by this time I have examined her legs, not interrupting, but signaling with my hands what I was intending to do. She, responding with a nod or a gesture of the hand, arranges herself while she keeps on talking.
But it was so horrible where I lived after the fire in Pacific Heights. I c
ouldn’t afford it. I had a hard time, so I sat on the brick wall between the two backyards. It was a heritage building. It was built by a father who had two daughters in the same wedding.
I can perhaps survive, but I can’t walk. They say I can. The first day they said, Oh no, don’t get up, so I stayed in the bed three days. Now I can’t walk at all.
I’m now working on getting the old toilet seat back. It’s an old Kohler toilet. And smaller than an egg. I’m trying to get grab bars. But I’m not going to install them. This is an old building and you never know what you are going to get into.
And I thought, Can I really live in this building? But I said to myself, I have to get out of that horrible building next to Macy’s with the fire upstairs. Came back from volunteering at the General Hospital. Fire upstairs. Took me half an hour to determine I had no fire. I had a flood — that’s what I came out of.
The cellulitis is improved, I have determined by my little examination conducted in parallel — the kind of progress that comes from simple interventions applied simply: heat, elevation, and your basic intravenous antibiotics. I am pleased. She continues her story.
Well, I managed to find I had this toilet problem. I wanted to invite Monique back home. I wanted to do everything I could to make it safe.
Let me tell you the Nurses Plus story. I was discharged early. In this situation I had a very excellent man. He knew we needed a special dressing. He came back. But he didn’t pay much attention to my request to have him call your office. (But before 11:30.) He disappeared on the other side of the room—I cannot see across the bed in the arrangement that’s been made. I cannot recall the name of the orthopedist who suggested that we use a love seat with a pillow at the head and to elevate the feet. Hospitals don’t want you to do that. But it’s very effective.
I had even arranged to sleep on a futon like the Japanese do, but I feel that would bother everyone.
But I’m telling you I really have picked my way through a minefield. And I have to say that I was more amused than annoyed by this calendar episode. I do know the date. And I have been established as competent.