Bedside Manners Read online

  He arrived at the endoscopy suite asking to be put all the way out. I don’t want to know anything about it, he said. I reassured him I would make him comfortable and gave the usual doses of Demerol and Versed. He appeared to be adequately sedated, but as I touched him to begin the procedure, he pushed me away. I gave more medications. Same problem. He rose from deep sleep to perform this act of rejection again and again. I increased the sedation. But the more I sedated him, the worse it got.

  I was in a range of dosing that is unusual except for patients with a history of alcohol abuse or long exposure to tranquilizers or sedatives. Billy had neither, yet his resistance to sedation was phenomenal.

  We were bordering on deep sedation, where the respiratory center in the brain becomes suppressed and proper oxygen levels are hard to maintain without external assistance. We could sedate no further. Yet still he rose up against the endoscope. I spoke to him through the haze, reminding him it would take only a few minutes, would not hurt, and if we couldn’t get it done this time, we would have to cancel the test.

  It was difficult. He moaned, almost cried, as we guided the scope along its path. Several times he reached up to pull it out, and we had to start over. Against all that sedation he was still able to fight and resist. I hurried and finished the exam in two minutes. The findings were interesting and worth the effort, for in addition to reflux esophagitis he had a gastric ulcer. The biopsy returned three days later showing Helicobacter pylori, the ulcer-causing bacteria.

  In the office I gave him the report, switched his medications, and added antibiotics. I told him he was likely to do much better now.

  Then I asked about his experience with endoscopy.

  He remembered nothing.

  You put up quite a struggle, I said.

  That’s what the nurses said. Sorry.

  Oh no. No need to apologize. I’m just concerned about whatever it was that made you fight so hard against a procedure that is basically simple and safe. Do you have any thoughts?

  No idea, he said.

  I had reflected back on my interactions with Billy, looking for any clues we might explore. I knew we would need endoscopy again to tell us if the ulcer had healed, and I wanted to protect him from another dreadful experience, even if he didn’t remember it afterward.

  I was struck by the fact that the experience never made it into his consciousness. Amnesia is common after endoscopy, but one would expect that after such a violent, willful opposition there would be some shadow of awareness. The psychic strength needed to erase that force from memory would have to be huge.

  Is there anything in your past experience that might have a bearing on this?

  Not that I know of.

  He shifted uncomfortably in his chair. Something moved uneasily behind the screen of his face.

  I decided to use another patient as an example. I thought it might take some of the pressure off.

  You know, I had another patient who had a difficult time. I thought it might be emotional, since if you think about it in the cool of the day as we are now, there’s no reason for that magnitude of fear.

  I watched his eyes, conscious that I might be teasing a demon. I saw only interest. A little curiosity, perhaps. I pressed on.

  The endoscope is a rather phallic object, I said, still watching his eyes.

  He nodded.

  In my other patient’s case I guessed she might have had a past experience, perhaps abuse as a child, her subconscious still smarting—no, terrorized is a better word—by the memory. Sedation numbs the rational mind, and with it the effort it makes to comfort and reassure, to identify and define and to separate us from our fears. It would be easy, in this altered state, for the rage of self-protection, unopposed, to rise up and fight for all it’s worth.

  He sat still now, eyes averted, thinking. Only occasionally there were small erratic and impulsive movements, little lurches of the body, as if some underwater current were whipping him about.

  How did you know? he asked.

  Know what?

  How did you know I was abused?

  I didn’t.

  His eyes were wide now, soft with exposure. I didn’t know, I said. I just wondered.

  Well that’s probably it, he said.

  The moment swayed a little, outside itself, then returned.

  We were in the presence of an opening, a clearing with an opportunity and a danger. Where to go? It would be wrong to pry open a path to a deep and painful experience and then leave it bleeding. Yet I worried he might have had enough. I decided that how we moved from here would depend on him.

  Would you like to talk about it? I asked.

  No.

  Are you in therapy somewhere?

  Yeah. For years. But we’ve never talked about this. I might not even have remembered it except that you asked.

  Maybe it would be good to talk about it with your therapist.

  For sure.

  A feeling of equanimity came. Neither of us felt a need to speak. Enough for now, I thought. But I wanted to leave on a positive note.

  I have an idea of what might make it easier if we have to do this again.

  What?

  To leave your conscious mind switched on.

  How could we do that?

  Without sedation.

  He raised his eyebrows.

  I know, you’d think the more the better. But this way you can stay in control. We could always add medications if we had to. But we’ve been that way, and frankly, the more we gave, the worse it got. Maybe this way you can talk to your subconscious mind and reassure it that no matter how horrible the experience feels and how much it resembles the ones that harmed you, it is not the same.

  I went on: When I had my own endoscopy, I did it without sedation. It wasn’t bad. Doctors are the worst patients imaginable. So you know that if I can do it, you can. Besides, it was convenient. I got right up and went back to work.

  When the time came, and it did, that’s how we did it. We hooked up an IV just in case he wanted to bail, used a little local benzocaine to numb down the throat, and selected the smallest possible pediatric scope so as to create the least disturbance. Meanwhile, I kept conversation going in which I talked him through every step of the way: Remember this is a scope with a light on it. This will only take a few minutes. You can tell me to stop any time you want to. Are you okay? We’re getting a good look . . .

  Not a ripple. There was no sign of the struggle we’d encountered before. And the news was good. The ulcer had healed and all signs of the offending bacteria had disappeared.

  How did it go? I asked him in recovery.

  No problem, was all he would say.

  The effort must have fatigued him, for he dropped off almost before finishing the sentence. As I sat watching him sleep, it came to me. That’s it, I said to no one in particular: Forbidden Planet— the movie, the character Dr. Morbius, who, jealous of the young spaceship captain who would take his daughter away from him, imagined a monster to fight him off. The key was that the monster was known only to his subconscious mind and came to life when Dr. Morbius was sleeping, released into the moment when his conscious mind, the rational force, was not engaged to keep it in check. He was not aware of this monster. Denied by the conscious mind, it was orphaned and anonymous. But when the conscious mind was not in control, it lived ferociously. Billy had a Morbius Monster.

  Billy got well and went away. I never saw him again. Maybe the experience was too much. Maybe he wanted to leave it behind. Maybe by recovering he no longer needed my services. Maybe his insurance changed. But Billy taught me something, and now I keep an eye out for the Morbius Monster and the sedation that makes it come to life.

  LIVING IT UP AT THE TOP OF THE MARK

  When he got the news, Tony went straight to the Mark Hopkins Hotel and rented the penthouse. He ordered Bay shrimp and Alaskan king crab. He drank martinis when he wasn’t drinking Dom Pérignon. He rented ten pornographic videos and watched them all, back to back.
He ate filet mignon. He stood at the window and grew nostalgic watching “the little cable cars, climb halfway to the stars.” He allowed himself a chill watching the orange glow of sunset wash over the Golden Gate. In the evening he went to the Rockin’ Rabbit Bar and Grill and picked up two floozies and fornicated his eyeballs out. By the end of the first day he’d racked up a $3,000 tab.

  At noon the next day, when his Presidential Champagne Brunch had finished, the hotel manager knocked on his door. We’re concerned, he said, through a fog of Cuban cigars, that you are maxing out your credit card.

  No problem, said Tony, and handed him another. The manager smiled and backed out the door.

  Tony’s fellow students had no idea where he’d gone. He just didn’t show for Friday’s histology or pharmacology classes. By the time anatomy lab came around, everyone started asking questions.

  A group of students formed a delegation and went to his roommate. What do you know? they asked.

  Nothing, he said. He just wasn’t in his bed this morning.

  New girlfriend?

  Not that I know of.

  A singing telegram arrived at Tony’s room, the kind that appears as a giant birthday cake rolled in on wheels. Tony had sent it to himself. The delivery service left the cake standing in the center of the room, and a gorgeous, topless, Marilyn Monroe look-alike named Brandy jumped out of the top and jiggled out a slightly off-tune melody that resembled something you might have heard before.

  After three tunes and three unsuccessful attempts by Tony to get her in bed, she called for her horsemen, crawled into her carriage, and was wheeled to safety.

  Tony decided to go down to the bar.

  By Saturday morning the dean got involved. He found out that Tony had last been seen on campus Thursday afternoon in the dermatology clinic, but the attending dermatologist was in transit to Cairo for the annual international meetings and couldn’t be reached.

  The dean went to the computer and stole Tony’s lab data and path report.

  Sunday afternoon, in a stuporous cloud of alcohol and exhaustion, Tony got a call.

  Hello, Tony?

  Silence.

  Tony, is that you? This is Dean Hammersmith.

  Silence.

  Tony, the police found your name on the hotel register. Are you ready to come home?

  No, I don’t think so.

  Well, what are your plans?

  I think I’ll stay right here awhile.

  Everybody’s worried about you, Tony. The hotel isn’t sure a starving medical student can pay off a seven-thousand-dollar bill.

  Well, that’s the point.

  What’s the point?

  I won’t have to pay it off.

  The dean remained silent for a moment, pondering what he knew and what he didn’t know. He decided to make Tony explain.

  How do you figure that?

  Tony paused. The dean thought he could hear the quick staccato of sucked-in breaths.

  Dead people don’t pay, he said.

  The dean was silent. Pieces were falling in place, but the biggest piece was still missing.

  Why do you think you’re going to die?

  Tony laughed the laugh that is part disgust at the ignorance of the question and part relief to be breaking into the subject with someone.

  I’ve got melanoma, he said.

  I know that, said the dean. I checked. But why do you think you’re going to die?

  It’s metastasized.

  Who told you?

  I did. I mean, I know. I can tell.

  How do you know?

  Well . . .

  The dean couldn’t tell whether Tony was being dramatic or insecure.

  I felt my liver.

  And?

  It’s enlarged.

  How large is it?

  It’s just at the margin. The right costal margin.

  How far does it come down with inspiration?

  Maybe a centimeter or two.

  How high up is the upper border?

  Silence.

  Did you percuss out the upper border?

  I forgot.

  The dean put on his teaching hat. The liver is not enlarged unless the span of the liver is greater than eight to ten centimeters. It’s common to feel a liver edge in young, thin people. It means nothing. If you’re concerned about metastasis, we’ll do a scan or something to find out, get a few blood tests . . .

  Tony hung up the phone. He unplugged it from the wall. He had a lot to think about, but just now Jessica was arriving at his door, and that was a train of thought that couldn’t be interrupted.

  The dean waited until evening, had the maid service go in and plug in his phone.

  Tony, he said.

  Yeah.

  Have you been thinking?

  I have.

  Do you still think you’re about to die?

  Yeah, probably. I mean, I don’t know. Maybe not. Maybe not right away.

  Don’t you think it’s time to come home?

  No.

  It’s reached a critical point. Maybe a bit beyond critical.

  I’ve been thinking about that . . .

  But what?

  I’m afraid.

  What of?

  I don’t know. Suddenly it’s all wrong. It’s gone sour.

  How about if I come downtown and take you home?

  Tony went home. Had a good sleep. And got up for class the next day.

  The dean kept secret what he knew and worked out a nice deal with the hotel. Tony went to work in the physiology lab to pay off some of the debt. The medical school paid some, and the hotel wrote off the rest.

  Tony lived an untroubled life. The melanoma, but for its splash of melodrama, was gone from his body the day it was diagnosed and removed in the dermatology clinic.

  One more ordeal faced him: Monday morning histology class. He wasn’t sure how to play it: remorseful? repentant? foolish? So he didn’t play it at all. He just showed up.

  Maybe it was because he said nothing that things turned out the way they did—the nothing giving no apology and the no apology implying nothing to apologize for— for after the first twenty minutes or so, people started walking up to him, patting him on the back, or just nodding as if understanding was a form of grace that needed no explanation, something beyond explaining, not earned but given, like the little smile that began to form itself in the corner of his mouth.

  NOT WAVING BUT DROWNING

  I’ve got a patient who can’t tell me what her symptoms are, I said.

  That’s hard to imagine, she said.

  The frustrating thing is it’s hard to figure out what to do.

  What does she say?

  Well, she says, I had a terrible night.

  That’s all?

  Just about. I ask her why it was terrible and she says, I’m not sure I can say.

  My wife and I seldom have time to talk about my medical practice, but occasionally, after dinner, after the boys have gone off into the living room, there is a little clearing.

  Is she confused?

  She says she’s confused. She says she’s so anxious she can’t stand it, yet she carries on conversations in other areas quite well.

  What does she say about the nighttimes?

  She doesn’t. But in some vague way she seems to locate the problem in her stomach. So I ask her, Do you have any pain? And she says no. Any distention? No. Nausea? Indigestion? No. No. Any change in bowel habits? Yeah, but not much. The stools are “feathery” instead of formed, and she awakes with this urgency to have a BM but nothing comes.

  What does that mean?

  I don’t know. Doesn’t make sense. We checked her colon a few months ago when she said she was having some rectal bleeding. Nothing abnormal at all. And no bleeding. Besides, I’ve worked her up to the max for parasites, bacterial infection, toxins . . . all normal.

  My wife looked that kind of look that tells me she’s about to disagree with something I’ve said.

  I think i
t’s hard to describe what’s going on in your own body. I had a hard time describing the pain of my ectopic pregnancy, and that was a big deal.

  How come?

  I just couldn’t put it into words.

  Why not?

  I don’t know, maybe because I’m not trained to think that way, maybe . . . a dream . . .

  What do you mean, a dream?

  There was a long silence. See, pain is hard to describe. I can’t even describe how it feels to describe my pain.

  She played with her napkin. All I could say was that I wanted to get in a certain position and stay there. That was the best I could do.

  She paused, moved her fork along the tablecloth but didn’t pick it up. Is she for real?

  Hard to tell. She has a long history of psychiatric problems, largely depression, and she’s acting very confused. Last time she was in the office, I thought about asking her to check in with her psychiatrist, but I don’t feel too good about that.

  Why not?

  Well, she’s lost ten pounds. She’s at an age when she might drop a few pounds without anything being wrong, but you have to take seriously anyone who’s lost weight.

  Does she have a primary doctor?

  Yeah, they’ve tinkered with her thyroid, but she didn’t put back the pounds. I went over to see him yesterday and told him his patient was driving me crazy. I was worried something was wrong, but I couldn’t get a handle on it.

  My wife looked quizzical. Isn’t she the one who calls you all the time?

  Yeah. Same thing over and over. She can’t keep her medications straight. So I went over to Doctor Malhoney’s office and got a list of everything he’d ordered, wrote it down myself, clearly, added my list to his list, and presented it to her. Then she called me the minute she got home to ask about her medications.

  Didn’t she call here at seven o’clock last Saturday morning?

  She did. She can’t seem to remember what I say. We’ve had the same conversation four times already this week.

  Maybe it’s Alzheimer’s.

  The day after my conversation with my wife, my patient called and made an emergency appointment. Well, I’m very unhappy, she said.