Elderhood

by Louise Aronson

  In the trauma room, an EKG revealed a largely completed heart attack. It had probably happened overnight, but it might have still been partially treatable if I’d waited to give a report to a doctor or nurse, or if the paramedics had left their documentation. Millie also would have received the prompt care her symptoms warranted if someone in the emergency department had noticed the disconnect between her appearance and story of an unbothersome minor illness. Since more than a third of people over age eighty-five have dementia, those discrepancies should have provoked a brief cognitive assessment and then a call to me or the paramedics to find out why she was there. While most older people do not have dementia, it’s common enough that checking should be the norm, especially in a patient like Millie, who was neither homeless nor mentally ill but had the dirty fingernails, skin, clothes, and feet of a person unable to care for herself well enough to meet usual social standards.

  * * *

  Like coins, the common challenges of old age have flip sides. If Millie’s experience in the emergency department was tails, then Ray’s stay upstairs on the medical wards was heads.

  At age one hundred, Ray was admitted to the hospital with a blood clot in his leg. On the third day of his hospitalization, the hospitalist—a doctor specialized in the care of hospitalized patients—called me to discuss how they should decide among outpatient treatment options, since Ray’s partner had died years earlier and he didn’t have other family.

  “What does he want to do?” I asked.

  The hospitalist laughed awkwardly. After a pause, he said, “We thought his mental status put him beyond decision-making capacity for something like this.”

  In medicine, when it comes to a patient’s ability to make decisions about their own care, we consider two distinct but related states: competence12, a legal status decided by a judge and rarely revoked without evidence of dangerously impaired judgment; and capacity, which is situation specific and can be assessed by any clinician, though many call psychiatry consults, a situation that makes many psychiatrists roll their eyes. Capacity comes down to the person’s ability to accurately assess the implications of each possible course of action. If they can do that, they’re entitled to decide however they want, even if their decision differs from what their doctors recommend and seems to go against their well-being13 or best interests.

  Ray was fully competent and perfectly capable. “Is he delirious?” I asked. When I’d spoken to the intern earlier, he hadn’t mentioned that.

  “No,” said the hospitalist. “We think he’s pretty much at his baseline.”

  At this point, I was feeling confused. “Sorry if I’m not following. What would he like to do?”

  There was a pause, then the hospitalist asked, “He doesn’t have dementia?”

  Suddenly, I had an idea of what might be going on. “He’s profoundly deaf. Is he wearing his hearing aids?”

  Although more than 80 percent of people over age eighty-five have at least mildly disabling hearing loss,14 the team hadn’t considered the patient’s hearing and the hospitalist couldn’t answer that question. It’s the rare centenarian whose ears are still working normally.

  The inpatient team thought Ray had dementia because whenever they asked him a question, he gave nonsensical answers. Ray’s brain was just fine. That was why he’d left his costly hearing aids at home, so they wouldn’t get lost in the hospital, as had happened to him once before. Later he told me he’d tried to get by reading lips. “I guess that isn’t my forte,” he said, and we laughed.

  I suggested the hospitalist borrow the pocket talker from the nurses’ station.

  “The what?” he asked.

  Although an associate professor well into his career, this doctor didn’t know about the little devices that enable communication with hard-of-hearing patients. Pocket talkers consist of small, over-the-ear earphones for the patient and a sound amplification microphone for the speaker. They are primitive, only making speech louder without mitigating the sound distortions of impaired hearing or muting background noise the way good hearing aids do, but they help.

  With the pocket talker, Ray easily made and communicated his own decisions. The nursing home bed the team had ordered for their “demented patient” was canceled, and he went home, where he completed his six months of blood thinner medication without any trouble.

  SHAME

  Here is another scene from my training years that I cannot forget. It’s early evening in San Francisco on the sort of cool, clear fall day when you can turn a corner and see a long, horizontal line where the flat expanse of Pacific Ocean meets the glow of creeping dusk and understand why humans thought the world was flat. But instead of walking out the hospital’s sliding double doors into a satisfying night of exercise and dinner, friends and sleep, I am a second-year resident in the days before duty-hour restrictions, on my way to see the sole patient on my service whom I don’t particularly like.

  His room is midway down the hall, not far from the nurses’ station. It is dimly lit, less because of the time of day than because he prefers it that way. He is full of demands. I rarely dislike patients, yet I’m struggling to find something in this endlessly dissatisfied man from which to create even a thin laminate of affection or respect. I sincerely hope that I will be able to make it through the procedure he needs without saying as much to my team.

  Of course, the patient is only part of the problem for me this evening. Our team is on call. For the next twenty-four hours, we are responsible for all admissions to the medical service, our significantly sick current patients, and those of the several other teams who get to go home. Also at play are one solid but not stellar intern, another enduring her year of medical training before she can sink with relief into the words and milder rhythms of a psychiatry residency, and three medical students, including a third-year I am working hard to help but who, barring a miraculous transformation, will fail his core medicine rotation.

  We will not leave the hospital until we have done everything that needs doing for both our new admissions and all the other sick patients on our service, work that generally takes an additional nine to eleven hours after we hand off on-call responsibilities to the next day’s team. At this point in my training, I have been on call every third or fourth night for the better part of four years. I do not expect to have much of a life and have put aside not only thoughts of the world outside the hospital but also images of the garden burger I like to order for dinner at this hospital, the lumpy mattress in the medical resident call room, and the one not completely revolting water fountain a few floors down. Strangely, I don’t feel tired; working despite chronic exhaustion has become as natural as breathing, even if it is not without its impact on my physical, intellectual, and emotional well-being. Efforts on behalf of patients and my endurance during this arduous young adulthood of medical training often fill me with the smug warmth of righteous self-satisfaction. Nevertheless, this particular call day is testing me. To use proper residency lingo: we are getting slammed. This is better than “getting killed” or “getting slaughtered,” but our growing tallies of admissions, or “hits,” and the large burden of other patient tasks, or “hurts,” mean we might yet achieve an even less desirable status.

  I am thirty years old. The patient in question is older than me by ten or fifteen years, also white, but male. He has AIDS, as so many of our patients do in this San Francisco hospital in 1994. He is not a new admission. Those acutely ill patients are gathering elsewhere in the hospital: in a handful of other rooms along this same hallway, in the intensive care unit two floors below us, and in the emergency department on street level awaiting the availability—via discharge, transfer to another service, or death—of a free bed upstairs.

  He has a fever. We have already sampled the usual sources: sent his urine and blood to the lab, X-rayed his lungs, surveyed his skin and looked in his ears and mouth, pressed on his belly, and tested his nervous system. Since we cannot adequately explain or treat his fever, protocols requir
e that we pull from his spinal cord a few tubes of the hopefully clear—but, because he was ill, perhaps cloudy, straw-, orange-, or red-colored—fluid bathing his brain and test it for bacteria, fungi, and mycobacteria.

  The subpar medical student and I collect the lumbar puncture supplies, have the patient sit up so we can identify the correct level of his spine for needle entry, position him on his left side in the fetal position facing the pulled shades, and clean and disinfect his skin. Before we entered the room, I had run through all these and the subsequent steps with the student, and now I stood back and let him take charge. Except for the patient’s demeanor, this is a perfect student case because the patient is relatively young and has terrific bony landmarks.

  The student is slow but appears to be doing everything just right. I hover while pretending not to and he frequently looks up at me for confirmation. We silently confer about entry place and direction, and he inserts a local anesthetic and then the thick lumbar puncture needle, pushing first through the skin and next toward the slim space between vertebrae. The needle goes in smoothly. All three of us release breaths we didn’t realize we were holding. Then the needle stops. From the way it stops, I know it’s hit bone. We had discussed this. My student looks at me, I nod, he makes an adjustment and tries again. And again, and again.

  I step in without tipping off the patient that the student had failed, assessing the patient’s position and adjusting the needle until it’s just right: angled slightly toward the patient’s head and aimed at his belly button. I am good at lumbar punctures. In over two years of residency, I’ve never missed one … until now. I pull back slightly, shift the needle upward a fraction of a centimeter, and push it forward. When you find the right spot, the resistance feels rubbery. If you push a little harder, the needle successfully pops through and then you pull the stylet out of the needle and the syringe fills with fluid. I hit only bone, solid and impenetrable.

  I smile apologetically at my poor student. His situation was like mine the day before I took my driver’s license test, when my mother took me out for what we were sure would be my last practice session. I couldn’t even start the car. I tried and tried. Nothing. Exasperated, she insisted we change places. But the car wouldn’t start for her either. We called a tow truck.

  I again try the lumbar puncture. Each time I move the needle, our patient tenses. He asks if I know what I’m doing and doesn’t believe my answer. I march along the seemingly endless hard surface of his spine with the needle, feeling for the slightest change in resistance indicating I have reached the soft space between bones. His already curled body is coiled with tension. Goose bumps cover his skin. Now and then, he gasps. At the needle’s tip, I encounter bone, and bone, and bone. Each time the metal hits the highly sensitive periosteum, he protests.

  I look at my medical student. He can’t take a coherent history or do a competent physical exam, but he has well-developed muscles and can hold in place our patient—thinner than he is, sick, and twice his age. Sweat forms dark stains on the armpits of his blue scrubs, but if he is disturbed by what we are doing, I can’t tell by looking at him. More obviously present in his eyes is the unwavering desire to please me. On academic thin ice, he will do whatever I ask.

  “Try to relax,” I say to the patient in as gentle a voice as I can manage. But what I’m thinking is: I’ve never had a problem doing this procedure, even in patients whose landmarks were obscured by obesity or whose ancient spines were distorted by arthritis, but of course with this patient, who is unpleasant and often dramatic under the best of circumstances, I can’t get in.

  I am usually vigilant about premedication, pain control, bringing bedpans, and whatever else patients require to feel as comfortable as they can in a hospital. This evening, I don’t care. I suppress a desire, an almost physical urge, to stab the patient more and harder. I need this procedure over and done with. My pager keeps alarming. My interns need supervision. I have no idea where the other student is and hope she isn’t still with the new patient I asked her to admit three hours ago. All over the hospital there are other patients with my name on their charts. I would rather be doing anything else other than dealing with this particular person. I am hungry and have to pee and my desire to flee this room is like an itch I can’t reach.

  Time to heed my own advice. I take a deep breath. I reassess the situation. I pull the needle all the way out and start from the beginning. I speak little and move quickly, intent on success. The patient’s breath becomes audible as the needle slides in. He groans as I feel the pop. The medical student hands me tubes and we collect the fluid we need.

  The patient remains in a fetal position, his back to me, trembling. We lower his thin gown to his waist for the procedure and the air in the room is cool, but I know his shaking isn’t just a matter of temperature.

  “Okay,” I say. “Okay. It’s over.” I cover him. The room is quiet, though beyond its closed door we hear voices and a beeping machine. He looks frail beneath the sheet. Looking at him, I realize that for a doctor, for me, there may be a fate far worse than failing at medicine’s necessary violence. I have just hurt someone I am meant to help.

  When I put my hand on his shoulder in a lame, late gesture of comfort, he flinches. The answer to what’s making him sick may be in his spinal fluid, and the sooner the fluid gets to the lab, the sooner we’ll be able to give him the medication he needs to get better. He knows that as well as I do, but both of us also know that’s not the reason for his submission. In becoming a doctor, I have become a monster. Instead of taking time to ensure his comfort, physically and psychologically, I have used my power, position, and physical strength to get the procedure over and done with. I have defeated him, and I have never felt so ashamed.

  BIAS

  In The White Album15, Joan Didion quotes a transcript from the Alameda County grand jury in which a nurse describes the day the Black Panther founder Huey P. Newton showed up at the Kaiser emergency room with a bullet in his stomach from an encounter that left one police officer dead and another wounded. Newton became a political martyr as a result of this incident and received a (subsequently reversed) prison sentence of two to fifteen years for voluntary manslaughter. During the quoted exchange, Newton asks for a doctor, and the nurse, who describes Newton as “this Negro fellow,” repeatedly asks whether he’s a Kaiser member. She insists that he sign the admission sheet while he yells that he’s bleeding and needs medical attention. The year was 1967.

  Didion, who is white, offers the excerpt to illustrate a “collision of cultures.” By cultures she seems to mean not so much the cultures of black and white Americans as those of the sort of person Didion thinks would be a Kaiser member and the sort of person she believes would not. When she discovers Newton was indeed a Kaiser member, she feels that her theory of him as a historical outsider confronting the established order has been shattered.

  Since this story is at least partly medical, it might be useful to borrow a medical concept to better understand it. In medicine, the “differential diagnosis” is the list of possible explanations for a patient’s condition. Items that might appear on the differential diagnosis for Newton’s encounter with the Kaiser nurse as Didion presents it include:

  The supremacy of bureaucracy over human decency and good medical care.

  Racism, conscious or unconscious, on the part of (a) the nurse, (b) the system, or (c) both.

  Differences in points of view, namely, how the same amount of blood can appear quite different from different perspectives: Huey says, “Can’t you see all this blood?” and the nurse says, “It wasn’t that much.”

  A collision of cultures, version 1: “He didn’t appear in any distress,” said the nurse. It’s now well known that people from different backgrounds and demographic groups express distress in different ways,16 whether they’re contending with a gunshot wound, a heart attack, childbirth, a broken bone, or the death of a loved one. It’s also well established that doctors and nurses respond differently t
o people in pain depending on their gender and skin color.

  A collision of cultures, version 2: “He called me a few nasty names,” continued the nurse. Though rude behavior is rarely if ever called for, it’s also true that there are individuals who curse when frustrated or otherwise upset—Newton and me, to name just two examples. Newton, in pain, bleeding, and being given the bureaucratic runaround, had reason for frustration, if not for rudeness.

  A collision of cultures, version 3: A white nurse saw a black man with a bullet wound in a city and country where poverty and violence are ubiquitous in most black lives and bullets regularly penetrate black skin. A black patient saw a white nurse in a white institution saying Hold on a minute, saying Calm down, saying I need to know that you belong here, saying I know better, saying We have rules and procedures that need to be followed and have nothing to do with the color of your skin.

  Evidence that medicine is not outside or above the fray of social issues.

  Evidence that James Baldwin was right: the story of “the Negro in America”17 is the story of America, and it is not a pretty story.

  In medicine, a doctor generates a differential diagnosis in hopes of identifying all possibilities and arriving at the right one. That approach works best if one looks only at disease, not illness. If we look instead at the individual patient as a human being in a larger social context, single explanations rarely tell the whole story. In Newton’s case, it seems likely that each of the explanations on the “differential” of his Kaiser encounter fit. Certainly, it’s hard not to suspect that an entirely different conversation might have ensued on both sides of the equation if a white man had presented with the same bleeding gunshot wound and, equally, that it might have been a different conversation regardless of whether or not he was a Kaiser member.