Based on my experience with David, I feared that I would ultimately internalize all of my patients’ symptoms—that an AIDS rash would become my rash, that the intractable abdominal discomfort would become my pain, and that the misanthropy, which was pervasive on the HIV floor, would become mine, too. Many felt uncared for, unloved, as though life had passed them by because of the stigma of their illness. It terrified me to think I might join this group. Insomuch as I had a plan, it was to do whatever I could to improve my patients’ health so that their condition might karmically rub off on my own.
First up on the scut list was the patient with the possible breast paraphernalia. I noticed that there was no information yet available on her. She had been admitted overnight and would be presented on rounds later in the morning. I trudged up the stairs and braced myself as I approached her room. It’s possible I was too close to this disease to treat it effectively.
“Hello?” I said, slowly opening the door.
“Hello,” replied a soft, deep voice. I found myself looking at a middle-aged black woman weighing no more than eighty pounds. She was wearing baggy scrub pants and a white T-shirt and had dozens of smooth bumps on her forehead and cheeks that recalled a textbook image of smallpox, a disease that had been eradicated in 1979, the year before I was born. They were different from the abscesses I’d seen on David—the sores didn’t appear to be filled with pus. They seemed like they’d been on her face for a long time and weren’t going anywhere anytime soon. What could it be? Measles? Chicken pox? Acne? She turned her head away from the door. “Who is it?”
“Dr. McCarthy,” I said. “I heard there was some excitement in here.”
“No excitement,” she said, still looking away.
“One of the nurses paged me,” I said, pausing to consider the proper phrasing, “because there was an item found in your blouse.”
“I’m not wearing a blouse.”
She wasn’t. “In your bra.”
“I’m not wearing a bra.”
I was miffed and let out a quick sigh. “I was paged because a nurse found something and wanted me to have a look.”
“Have a look,” she said, turning to me. I started quietly as we made eye contact. Her eyeballs were almost completely whited out, as if snow had accumulated on the sidewalk and no one had bothered to shovel it away. What could cause that? A few tumbleweeds drifted across the serene vista that was my uncluttered mind; my differential diagnosis consisted solely of glaucoma. Moranis could probably name thirty things that would cause her eyes to look like that.
“What am I looking at?” I asked.
“There,” she said, pointing to a stack of clothes, “probably over there.” She motioned to the corner of the room, which meant she might have some vision. I again looked into her eyes, hoping to find some clue that would tie everything together, that would explain the bumps and the eyes and the HIV, but I was stumped. I picked up a red and black plaid shirt and a pair of shorts. In the breast pocket of the shirt was a small plastic bag containing something resembling marijuana.
“It’s medicinal,” she said flatly.
“Is it?” I asked with optimism.
“Yes.”
“For what?”
She scoffed. “I’m blind. I’m homeless. I have AIDS. Want me to keep going?”
“What’s it for…specifically?”
I was fairly certain that medicinal marijuana wasn’t legal in the state of New York. Were there exceptions for AIDS patients? I should know this. “I want to believe you.”
“Then believe me.”
“Do you have a prescription for it?”
She leaned back. “And if I don’t?”
I wrinkled my brow. “I’m not sure. I guess I’ll have to…I’ll…”
She shook her head. “Why are you doing this to me?”
I looked at the green leaves in the plastic bag and sighed again. “You know I have to report this.”
The words sounded funny coming out of my mouth. Did I need to report this? I wasn’t sure. In medical school I had tended to a lot of admitted drug users, but none of them had brought the material into the hospital. This seemed more like a job for security than for an intern.
“You don’t have to.” She flashed a handful of yellow-brown teeth. “Please. Please don’t.” There was a note of desperation in her voice, and I genuinely wasn’t sure what I should do. Was I just another guy trying to make her life more difficult? Or was I a responsible intern, appropriately seizing and reporting banned items? And anyway, what was the point of taking away a blind, homeless AIDS patient’s marijuana? It seemed borderline cruel. Where did this fall on the spectrum of Do no harm?
I made a snap decision to hide behind the lab coat. “I hate to use this phrase, but I’m just doing my job.”
“Come here,” she said, waving me toward her. “Come here. Close.”
“We have rounds,” I said, planning an escape route and then aborting it as Benny’s advice flashed through my mind. If there was one thing that Benny had impressed upon me, it was the importance of giving patients my time and my full attention. It was the same thing Jim O’Connell had preached. Since my talk with Benny and then catching myself in the act of backing away from Peter Lundquist, I had willed myself to be more present with my patients. Even so, it was exceedingly difficult to do. Interns were needed in six places at once, and the pager never stopped buzzing. The day was highly scheduled, with meetings and rounds and note-writing, but it was also incredibly unpredictable. Chatting with a patient often seemed like a discretionary activity, even when it wasn’t.
I took off my white coat and sat at the edge of the bed.
“What’s your name?” she said.
“Dr. McCarthy. Matt McCarthy.”
“Matt McCarthy…M and M.”
“M and M, just like the candy.”
“And the rapper. Eminem.”
“Indeed,” I said. And just like the Morbidity and Mortality conference, I thought. “What should I call you? Your first name or—”
“Call me Dre,” she said, giggling to herself. “You’re Em and I’m Dre.”
“Excellent.”
She shook her head. “So why do you want to snitch on me?”
I almost snorted. She had found her way right to the heart of my dilemma. “I don’t want to. What am I supposed to do?”
Before I knew what was happening, she’d reached out her hands and put them on my face. One covered my left eye and the other pressed into my right cheek. The move left me frozen. No one had ever done something like this to me before. Her moist, callused hands moved across my face, briefly pausing on my eyebrows and lips. She smelled of lotion, something lavender. I hoped that whatever had caused the bumps on her face wasn’t contagious. The needle stick popped into my mind and I pushed it out. “I can tell you’re conflicted,” she said, sounding like a late-night television fortune-teller. “I can tell.”
“I’m not actually conflicted,” I said, leaning back slightly.
“Didn’t they teach you that the patient is always right?”
I laughed and she grabbed my hands, putting them on her face. She had innumerable keloid scars on her ears from piercings gone awry. What looked like little mushrooms on her earlobes were actually the results of skin healing improperly. I had seen it often in medical school and knew they weren’t contagious. But by the sheer number of mushrooms, I doubted that she had been informed of her condition and had tried to pierce the ears over and over again, which only made the condition worse. I wondered what she knew of her other medical conditions. Were we connecting here? In the hospital movie in my mind, touching her face would help me to know her in some unique, previously unavailable way. But in reality, it didn’t. It only made me feel bad for her. It made me want to know more about her condition and how I could help her get better.
“I think the saying is that the customer is always—”
At that moment, as our hands were on each other’s faces, Ashley had the good fortune to
enter the room. “I was looking for my intern,” she said, looking up from her pager. “I think he— What the fuuuuck?”
Stunned by the scene before her, she did a pirouette and exited the room in one motion as I dropped my hands. I got up, squeezed the small bag of marijuana in my palm, and straightened my coat. “You’ll see me again.”
“No snitchin’!” Dre said as I closed the door. “Don’t do it, Em!”
As I walked toward the nurses’ station, a number of thoughts buzzed through my head. I’d just been pawed by a legally blind AIDS patient and was suddenly carrying about a hundred dollars’ worth of weed in my white coat. This wasn’t how Jim O’Connell would do things. I couldn’t imagine him seizing drugs from one of his patients. But I also thought that Jim might have appreciated some aspects of the exchange. Dre wasn’t the typical patient. Not least because of the mutual face massage, but also because of the undercurrent of humor in our conversation. This was the kind of patient I could see him reaching, the type he’d spend extra time with to make a connection. Why? What was it about her? I wasn’t entirely sure. I often had trouble predicting which patients would receive extra attention from Jim, but I felt confident that Dre would’ve been one of them.
I dropped the bag on the large wooden table and took a seat next to Ashley. “I had to confiscate this.”
“That’s some freaky shit, man,” she said, laughing. “I said you were the eyes and I was the brain. Clearly you’re also the hands.”
23
Rounds started a few minutes later. Donuts were passed around, and my ears pricked up when the overnight intern, Lalitha, presented Dre’s case.
“A congenital infection left her without vision before she reached adolescence,” Lalitha said, as she tied her dark hair into a ponytail. “She was infected with HIV a decade ago and since then has lived a life of almost implausible hardship, bouncing from one abusive relationship to the next, rarely living at the same address for three consecutive months.” Dre had not taken any of her pills for months and, based on some preliminary laboratory information and physical exam findings, appeared to have neurosyphilis, a severe neurologic complication of untreated syphilis. The disease can cause the brain to see and hear all kinds of unusual things—from mysterious voices to symphonies—and the diagnosis is made via spinal tap, which Dre was refusing.
Dre had provided Lalitha with some of her medical history but not all. Large gaps existed regarding the way she’d contracted HIV, what infections she’d encountered, and what medications she was currently taking. Dre had informed the overnight team that the information would be provided on a need-to-know basis because she wasn’t convinced that all of the intrusive medical questions were necessary. And she was refusing HIV medications, which made me want to know more about her. Why would someone turn down potentially lifesaving treatment?
I thought about how neurotic I’d become after acquiring my own set of pill bottles. I didn’t want people at work to know how or when I was taking my medications, or what the pills were doing to my insides. Every time I swallowed a pill, it felt like I was ingesting a tiny hand grenade, one that would explode when I least expected it, leaving me doubled over in abdominal pain or rushing to the bathroom to shit my brains out. I didn’t want other doctors to know that I occasionally excused myself from rounds because I thought I was going to vomit, or that my bowel movements fluoresced, because I didn’t want to be judged. Perhaps Dre thought she would be judged, too. Perhaps she just wanted to be left alone.
There was something about her, however, that made me think she could be reasoned with. Maybe it was that moment when she’d touched my face, maybe that was her very literal way of reaching out to me. Perhaps I was someone she wanted to connect with. My mind started to race with possibilities. If I could engage with her in a way that was comforting, or that she respected, I might be able to get through to her and unlock the details of her medical history the way O’Connell would. Someone needed to; whether she knew it or not, Dre was a very sick woman. Without taking HIV meds she might be dead in months, and if she had neurosyphilis, things could get even more complicated. The more we could find out about her, the better. But that would come from sitting with her, talking with her, getting to know what made her tick. It would not come from reading a textbook or from snitchin’.
“Excellent presentation,” Dr. Chanel said when Lalitha had finished. “Anyone have anything to add?”
Ashley glanced at me and put her hands to her face, fighting back laughter.
It was time to snitch. Now that I’d told Ashley, I had no choice. “Yes,” I said. “I was called to see the patient this morning because she had something that looked like marijuana in her shirt pocket.” Collective nods. “I gave it to the nurse manager.”
“Very good,” Dr. Chanel said. “Shall we go see the patient?”
Apparently this nugget of information was inconsequential. But how was I to know? I wouldn’t tell Dre that I had mentioned the drugs to others. Walking down the ninth-floor hallway, Chanel again put her hand on my lower back. “You doing okay?”
“Hanging in there.” This was situationally true but a lie in spirit. I was a throbbing ball of anxiety, having returned to full teeth-grinding mode in the last eighteen hours. Thinking about Dre’s dilemma was a useful distraction but hardly a cure. A thousand thoughts threatened to spill out of me in response to Chanel’s simple question, but this wasn’t the time or the place to be a patient. I was on rounds and we had work to do.
“Let me know if you need Zofran,” she said, referring to the powerful antinausea medication. “Expensive, but it works.” She gave me a hint of a smile, and I returned it.
“Thank you for getting me through everything,” I said softly, recalling the slew of curse words I’d spat at her the day before. I’d spent the first month of my internship standing in awe of Baio, the man who could handle any clinical conundrum, but in Chanel I saw something unique, something I admired just as much. She had functioned as a sounding board, and let me feel comfortable saying or doing anything in her presence. If I wanted to have a meltdown, I could, and I knew she wasn’t going to think any less of me.
“I’ll let you inform the patient of our plan,” she said softly, running her fingers through her side ponytail. A moment later, our team formed a horseshoe around Dre. Heads gradually turned in my direction, and I cleared my throat, wondering how familiar I should be with her in front of the other residents. I had heard such intimate details of her troubled life, but we’d really only exchanged a handful of words and they were all about marijuana.
“Is that you, Em?” she asked.
I blushed at the nickname. “I’m here. With the entire team, actually. Before we get started, would you prefer to be addressed by your first name or last?”
“Just call me Dre,” she said.
After summarizing our interpretation of her case, we examined her one by one. Her neck was exceedingly stiff, so rigid and tender she couldn’t touch her chin to her chest, and she was mostly numb below her shins. I had hoped to examine her pupils to look for one of the hallmarks of neurosyphilis, but she told me she’d had enough of being prodded and wanted to take a nap.
“The long and the short of it,” I said as I put my penlight back into my white coat, “is that we’re worried about you. You need a spinal tap.” Lalitha had explained this to her overnight, but I wasn’t sure how much of it had registered.
“No, thank you,” she said, closing her eyes.
“And you need to get back on your HIV meds.”
“No. Thank you.”
I turned to Dr. Chanel for guidance; she raised her eyebrows as if to say, “Go on.”
“You need the test,” I said firmly, “and you need the meds.” Perhaps it was just a matter of persistence.
“No.” She folded her arms and again turned away from me. “Not happenin’.”
How could I reach her? Did Dre realize what she was up against? Maybe not. Maybe that was the problem. “You
could die. Honestly.”
“Fine,” she said, “let me.”
I opened my mouth, but nothing came out. She had short-circuited my one ironclad logical point. Let her die? What was I supposed to say? I could treat her HIV and what appeared to be neurosyphilis, but how was I supposed to treat whatever made her favor dying over taking the pills?
Standing before her, I felt the glare of my colleagues. Chanel must have sensed my cognitive dissonance. She sat down on the edge of the bed. “Can we talk about this later, one-on-one?”
“You can talk,” Dre said, “talk all you want.”
“Very well,” Chanel said. “I’ll come back later.”
We stepped out of the room and discussed the approach to this difficult patient. Everyone agreed that a multidisciplinary approach would be necessary, incorporating psychiatry, social work, nursing, and potentially a host of other specialists.
As we discussed options, I went over the interaction again and again in my head. Why had my approach foundered? Could what I had said even be described as an approach? All I did was explain the scenario and try to scare her into compliance. I had assumed the specter of death would be enough. It was more than enough for me. In less than a day the pills I was taking had already begun to liquefy my insides, but I’d take pills that rotated my head 180 degrees before I’d give myself over to fate when it came to HIV. If I was going to get through to Dre, I’d have to figure out how she saw things.
The challenges I encountered on the HIV floor were so different from what I’d dealt with in other areas of medicine. There was a right way to do chest compressions, a proper way to adjust a ventilator. Do this and don’t do that. The skills I needed on the HIV floor—tact, patience, empathy—were more abstract. But the stakes were just as high; if I failed to acquire these traits, patients could die.
What if something else was going on with Dre, something I’d missed entirely? Maybe there really were voices in her head telling her not to take the pills. Then what? Could we force her to accept treatment? The ethics of medicine were bewildering.
The Real Doctor Will See You Shortly Page 14