Bedside Manners Page 8

  The bleeding stopped after surgery, but she developed gastric outlet obstruction, a post-op complication in which no food passes out of the stomach. This required a second surgery to open up a channel into the small bowel. I counted the minutes until the next disaster.

  She leveled off awhile. By now I knew about her schizophrenic mother, who was the CEO of a major chemical company. I knew about her receding, alcoholic father who was too wimpy or too sloshed to give the children much support. I knew about the emotional famine of her early years, how her mother’s criticism entered her like a violation, how the only way she could get the slightest sign of affection was to get As on her report card or get sick. I concluded she had become proficient at both.

  She made dolls for my children, had crystal sent from Germany, teas from China. She was in my house, among my family, settling in. I came home to find her lying on my living room sofa, waited upon by my wife . . . a little warm broth, a box of Kleenex, perhaps some soda from the corner store . . .

  We had a conversation. I told her she was to limit the extent of her illness. I was certain she could do it, and if I was to continue as her physician, I expected it.

  Two months went by without a ripple. Then I got a call from the ER. The nurse told me that Danielle had pleaded with them not to bother me, but she had become so weak that as a last resort she just had to come to the ER. They discovered a dangerously low blood potassium, the lowest they’d ever seen. For some reason the image of Mrs. Robinson in The Graduate popped into mind—that scene in which she discovers her lover is having an affair with her daughter—the wide camera angle, black dress, white walls looming larger as the camera pulls back. The look in her eyes that has become the look in Danielle’s eyes. That posture. That isolation.

  Potassium is basic. It’s in cells, in blood—moves in through the gastrointestinal tract and out through the kidneys. There are not many places it can hide, not many aberrations that will cause such a dramatic depletion. The nurse said they were admitting her to my service. After a week of blood tests and consultations, we still didn’t know what was happening. And the potassium stayed low.

  The weekend came. Her mother was in town on a visit. Danielle demanded a pass. Passes are not given. If you can be out on pass, you don’t need to be in a hospital.

  But she was insistent in a desperate way I had never seen before, as if the conclusion were foregone—as if all that remained was to force beyond whatever stood in the way, no matter what. She was out in a flash.

  A few hours later she returned. Any trace of desperation was gone. Her potassium, which had been creeping back to normal, was down again. I made a few calls. I reached her mother at home. Yes, Danielle was in a very strange mood that day. They ran errands. Went to a pharmacy.

  A pharmacy?

  Yes, she had to fill a prescription.

  It was Saturday evening, but I had the pharmacist on the phone in ten minutes. Yes, he had filled a prescription for her. It was Lasix. Lasix, a strong diuretic that sweeps potassium out of the kidneys like crazy. Who signed the prescription?

  Everything came clear, bursting open, spreading out and sinking in like water over sand. Part of me couldn’t imagine such a thing and had struggled to keep me from discovering the truth. Another part had known it all along. That part was now feeling triumphant. It made me feel strangely excited, powerful. I went back to the hospital. She was surprised to see me.

  I know where you went today.

  No response.

  I know you filled a prescription for Lasix. You forged my name.

  No response.

  That’s what made you lose so much potassium. You’ve been taking that to fool us. You must have run out and panicked.

  Silence was a gel in the air of the room.

  Out loud I wondered if even the bleeding was self-induced. I asked her point-blank.

  Silence.

  I was remembering some reference to a crumpled-up transfusion bag in the wastebasket of her apartment. Was it my imagination? Was it her roommate who’d told me? Was that information just too improbable to be believed?

  As a physician she would have known how much blood to take out and when to stop. But the part that required a giant leap was that she would then have had to swallow her own blood. It was hard to imagine.

  I called the psychiatrist. We’ve got a problem here, I told him. You’d better take another look.

  Things went orbital. She developed meningitis, pneumonia, urinary-tract infections, several kinds of bacteria growing in her blood at the same time—I imagined her injecting herself with fecal material, but could never catch her at it. I began to have a strange admiration for her talent, how she walked the tightrope between life and death with immaculate skill. It was desperation elevated to an art form.

  Each time she was admitted to the hospital, the house staff would get agitated after a few days. We’ll never get her out of here, they’d say. Just watch, I told them. I’d walk into the room, sit on the edge of the bed, and say, Danielle, I’m going to discharge you in thirty-six hours. You’d better be well by then. And I’d leave the room. And she would be well. Fevers defervesced, septicemias cleared, rashes resolved, meningitis went away, and she walked out as if nothing had happened, whole, intact, steady.

  It was the nurses who were trapped, caught between their desire to relieve suffering and the clear perspective from the bedside that questioned Danielle’s illness. They suffered a schizophrenia of thought and deed. Picture a volcano crater, I told them. Imagine standing on the rim, tossing small pebbles into the center. You’ll never fill her need. Fine, they said, but what’s wrong with her? I said, She has Mrs. Robinson eyes.

  I learned which moments to let ceremony continue and which openings I could take that would steer it to conclusion. I became the visiting expert, the magician from a foreign country called in to cast out the spell.

  In time she drifted away. I supposed that the balance between what I knew of the secrets about her and what I could do to help eventually tipped into the red zone and she had to go. She needed freedom to drift in and out of care without the weight of history dragging her down. For when that part of her rose with its Mrs. Robinson eyes, she had to have a place that would give it what it demanded, a small emergency room perhaps, a protected place somewhere deep in the night, where the patient like a map could spread herself on the table, open and hungry for the close attention of physicians, who, like cartographers with their needles, scopes, and scalpels, would touch her in a way that almost felt like love.

  ECTOPIC

  How is it going to die? That was her question.

  The obstetrician looked like he’d never thought about that before, and took a moment to recover.

  Her husband remembered their first night, how they fell so easily together, how for a moment the next morning they thought she might be pregnant. He encountered there her first flash of opinion: no pill, no abortion, absolutely not.

  By first light they had a history.

  By now there had been multiple attempts to get pregnant, followed by the news they’d missed their chance. FSH too high. Eggs old before their time. The irony was inescapable. Microsurgery, hormones, the long waitings suffused with waves of apprehension, hope, and despair—and now, after several attempts at in vitro fertilization, a sudden pain in the ninth week and there are two pregnancies, one in its perfect path, one crimped in a barren tube.

  I guess by cautery, the doctor said. That’s how we open the tube.

  No one said a word. It will be instantaneous, he added, in a tone meant to reassure.

  If it was a gesture of reassurance, it was passed over. The full weight of her thinking was on the next decision: spinal or general. Spinal would be painful when they tipped her up to free the pelvic organs. All that air in the belly. All that pressure against the diaphragm. But general might endanger the other pregnancy. She had no hesitation. It would have to be spinal.

  There was hardly a ripple of the first night in this one
. He nuzzled back into the small space on the periphery of the imagination from which he had just stepped forward to encourage and support, back to where he only observed, conscious now, how the playing surface changes the game — peritonitis would set in, both the mother and the other child might loose their lives — how we are not given rules like these until the championship game, our only certainty the will to keep playing.

  His glances to the past for wisdom had found none there. He was in the present and in this disconnected present he had a wife on the operating table and a good embryo in the womb’s heart. Certain confusions fall away in the presence of that.

  It was late, past midnight, in the hours long after the work of the day had passed and there was a soft hum of space into which all the irregular and unappropriated could be placed. Laparoscopy. Suction. The strained, thin blood of the overexhausted drawn into waste and discarded. And with it, that which was alive until now.

  It remained only to wait in that quiet arrangement of suspension so familiar to them by now, made for events one could not expect nor control to play out, not made but mandated, in which there is no accounting for the separation they feel from time: the OR emptying itself of its scheduled cases, the anesthesiologist making ready, the pendulum, deliberate in its swing.

  He could do no more than to love these lives, flourishing in the afterglow of a night that had launched them with no backward glances, and to love the life that was fading away, her name not yet spoken into the resilience of the world.

  ME AND THE HEC

  The person at the Human Experimentation Committee said my study sounded simple enough—just give a few poems to people about to have surgery and see if it calmed them down some. He said it should pass through on the expedited path—not have to go through the whole committee—and would I please go online and take this little test to see if I knew enough about the current regulations.

  I just wanted to give my patients a few poems, so I wrote up this little description about what I planned to do and bundled it up and sent it away, and I went online and took that little test . . .

  Three weeks, and a letter comes that says the full committee has to review this study of mine and my consent form needs to be two consent forms in order to accommodate all the new regulations — and by the way, did I take that little test yet?

  I said I had, and my name was posted right up there on his Web site with all the others who had taken his test— and they wanted to know why did I think poetry might calm anybody down . . .

  So I told him the story about my patient who freaked out on the table and who, after we sat around twiddling our thumbs awhile, wanted to know if I’d recite her a poem.

  I did that.

  And she lay right down and had her surgery. Just like that.

  Three weeks, and I get it all back—they said they didn’t understand how I meant to compare those blood pressures I meant to compare, and I thought it sounded a little like the Department of Defense asking Lockheed for a business plan — but I figured they were just trying to teach me something about clear thinking when it comes to comparing blood pressures . . . So I went to the biostatistics guy and he asked me why did I think poetry might have an effect in the first place.

  And I said, Let’s skip to the numbers . . .

  So the guy wrote up some fancy formulae that signified we’d thought about the problem and might even have ascended to the level of clear thinking (in thirty-two pages in a ten-point font), and I hadn’t given a single poem to a single person yet.

  It was a good experience, the way they made me think about things I’d never thought about before that may have saved some hardship for somebody about to be abused by a poem somewhere.

  And the news is we finally did get that approval. Conditional, it was . . .

  If I’d just go online and take that little test.

  PALOOKA

  She came to my office with a husband and a son. I need an internist, she said.

  That would be me, I said.

  Extra people are sometimes useful. The patient can be so nervous her circuits get overloaded and she may not hear things right. But it can also mean there is an abiding distrust of doctors or maybe a personal character flaw she hopes to override by plurality. Something about the theatrical way she paused before speaking, something about the way she looked to make sure her entourage was at full attention, made me lean in the direction of the flaw.

  I’ve got a lot of problems, she said, raising one eyebrow to warn me.

  Here we go. So far we’re on track with my instincts. In the early going, my job was shaping up to this: be of service and don’t be easy to scare off.

  I’ve had some pretty complicated patients, I said. And if something comes up I can’t handle, I’ll find someone who can. And I’m thinking to myself that I really do want to be of service to this woman. I just have a tendency to analyze as I go along.

  I feel better already, she said.

  I was pleased, but thought her comfort was a little too easy. More important, I thought, would be how she felt at the end of the visit.

  I’m having surgery tomorrow, she said. And I’m nervous.

  Tomorrow. Jesus! One day from surgery and I’ll be called upon to ascend to a state of instant familiarity and wisdom about someone I’ve just met.

  Then we’d better get busy, I said.

  You see the bandage on my nose.

  It was a Joe Palooka bandage. I couldn’t have missed it. It was the kind cartoonists draw to depict big-time failure in the ring the night before. Anything that obvious had to be of pivotal importance.

  At the mention of the word bandage, the son reached over and patted her forearm.

  Her husband spoke. I’d like you to know, Doctor, she’s been through a lot. She’s nervous. She’s not herself. She’s really a very different person from what you see today. More patting. I realized, all this time, I hadn’t learned a thing about her illness.

  Maybe someone could give me a little history, I said.

  You see, Doctor, she began, I’ve got . . .

  And at this point she sort of slumped in the chair and looked helplessly off to the side. Air escaped from her mouth, luffing the upper lip like a deflating rubber balloon. As I watched the two men turn in toward her like petals over a wilting stamen, a strange sense of frustration, almost impatience, came over me. I wasn’t sure why I felt this way. After all, this is my work environment. People come to me all the time with emotions on their sleeves, and I understand, I accept, and I don’t let it bother me.

  Her husband finished the sentence: She has cancer of her nose. She can’t bring herself to say the word.

  Oh. Sorry to hear that.

  But it worried me that she couldn’t bring herself to say the C-word. It has always seemed to me that patients who take an assertive, self-protective, shall we say almost combative posture, do better than those for whom depression or dependency slows down the clockwork. We didn’t have time to go into the psychiatry of it. I needed rudiments.

  She gained strength to speak again: I’ve got this awful hole. You will be my doctor, won’t you?

  I think you’re stuck with me, I said. And I threw in a little smile. It felt a little like we were becoming friends. And I scolded myself. Who was I to judge this person’s emotions? This lady was coming to me with a stinking-awful cancer on the end of her nose, a repulsive and dangerous aberration apt to disfigure her greatly before it was done. Wasn’t she entitled to be a little overwhelmed? I was overreacting. But I was also aware that no evidence of my argument with myself would escape to the surface. It wasn’t that I was hiding something; I was just responding at two separate levels, one of which was invisible, both genuine. Furthermore, these observations would not drag on my desire to help this lady. I would be her doctor, follow her through surgery, be available for her questions . . . and do this feeling no restraint on passion or respect.

  I already like you, she said.

  I didn’t feel very worthy, but desp
ite my best efforts a rather undeserved rush of pleasure swept through me.

  The husband made a gesture that indicated the hole was substantial and the repair would be extreme. Three years ago she had had a small lesion on her nose shaved off. That’s okay for well-behaved cancers. Not this one, it appeared, which had leapfrogged over neighboring cells. Now she had to have a wide excision.

  I said I understood her fear, but there were at least two points in her favor. As surgeries go, this one wasn’t life-threatening. And because I guessed she needed proof, I made a short list of horrendous surgeries to locate her at a more reasonable point on the curve of perspective. I guessed she wouldn’t stay reassured very long, but I forged ahead anyway. And if you have to have it done, I said, you’ve got the best surgeon to do it. I know him personally, and he’s first-rate.

  It was true, what I said, but it was also very good for confidence. And it was working. I could see it flicker in the quick gesture of her hand, her back straightening up from a slouch. To nail this I would have to go one step further. I leaned over and looked her in the eye. You’ll come through this okay, I said. And I knew as I said it that no one could know that. But you can’t just spew out numbers and odds like a computer. Especially for this person, who was more likely to be moved by the wisdom of my gut than the computations of my brain.

  Statistics can be harmful. If you tell a patient she has a 0.5 percent chance of dying, all she hears is “dying.” Mix in a little neurosis or too much stress, and the word enters her so fully she believes she’s just received a death sentence.

  And she would be painfully afraid of death. If she couldn’t say the word cancer, she sure wasn’t going to say death.

  I think I can say the surgery won’t kill you, I said, offering the little smile that says, We all know that’s obvious but it feels good to say it anyway.

  You’re a nice man, she said.

  Not so nice, I said. But I would not challenge her further. I knew that soon enough too much praise can turn into too much rage. I was in her world now, and somehow it served her to think well of me.