The Mid-Town Inn had cheap rooms, hourly rates and the bonus of a closed-circuit blue movie channel. The motel attracted out-of-town salesmen looking for a little action, or locals in need of a place for a few hours. Sporadic arrests of female prostitutes near the Mid-Town Inn suggested that the action there was both gay and heterosexual. A lounge attached to the motel, despite numerous changes in name and ownership and brief periods of near respectability, was a place where the women had a reputation for being older, divorced or widowed and hot to trot. Men in search of these qualities in a woman flocked there.
The cruising round the block in cars, however, involved only gay men. Cars would drive up Roan Street, past the old Johnson City Medical Center (now a nursing home), turn on Millard where the Mid-Town Inn sat, turn on Boone, then turn on Fairview and be back on Roan.
Of course, to circle the block so obviously was to give it away. Typically, then, the players would construct a complex loop, coming up through back streets like Montgomery or Davis to pop up behind the Mid-Town Inn where a few doctors’ offices—those that had not made the move to the Professional Building by the new hospital—and a few lawyers’ offices, and a block of residential houses could mean one had come from any of those buildings. Then one could cut straight across Roan and head out to the Country Club, drive south for a detour of two or three miles before coming up Roan again.
Eventually one car would tuck in behind the other as it looped in and out of the back streets, the Mid-Town Inn still the heart of this fandango on wheels. Soon, there was no mistaking the intention of either party. Both cars would pull into the parking lot of White’s supermarket, three blocks down the hill from the Mid-Town Inn and opposite the public library and the telephone company. The cars would come together, so that driver’s-side window of one car pulled up alongside driver’s-side window of the other.
Now the first words were spoken—“Are you a cop?” “No. Are you?” “No.” This prerequisite exchange supposedly had the magic quality of excluding a cop who it was said could not lie and still make an arrest. From there it was off in one or two cars to someone’s house—the ideal scenario—or to a parking lot, or to the park.
And it was in the Rotary Park, after just such an encounter, that a chicken hawk had lost his life in a robbery-murder by the young man he had picked up. The inquiry and the trial made the news, and then this too died.
The town returned to issues such as the price of tobacco, the Vols’ winning streak, a flash flood in Unicoi and other items of news that were, be they good or bad, in their own way reassuring. The town was aware of homosexuals and AIDS, but by God, the less one thought about or discussed these things, the better.
5
ON A TUESDAY EVENING in the fall of 1986, a year after my return to Johnson City, I received a call on my answering service. “Tell him that Essie Vines from Virginia, what works in the laboratory, needs to talk to him. He’ll know who I mean.”
Essie picked up on the first ring. I thought I had been dialing a hospital number, but she was at home.
Yes, Essie, said. She was fine and she still worked in the little hospital in Virginia where I used to moonlight as a resident.
I told her it was a coincidence that she should call me, because she had been on my mind. I was scheduled to give a talk—an AIDS talk—in a couple of days in Norton, Virginia, only a few miles from the hospital where she worked and I had been thinking of looking her and the old gang up.
I asked about some of the people I had known: J.D. from security, Clara, the nursing supervisor. They were fine, Essie said, just fine. “I’ll tell them you asked after them.”
Essie was pronouncing every syllable clearly, as if only a conscious effort could keep her words from running into each other.
“What’s up, Essie?”
She said she had heard that I was back in Johnson City. That I had specialized in infectious diseases. “That’s how come I’m calling you. I’m all to pieces about my brother, Gordon. He just come home after living in Florida for many years. I’ll be honest with you. I won’t beat around the bush. Gordon has the HIV factor.”
She paused here. When I said nothing, she went on:
“He’s been sick a long time—I mean a long time—but he’s very sick tonight.” Here I heard her take a deep breath. “Would you be willing to see him?”
I told her to come right away. “Is Gordon a veteran?”
“No.” Again the measured, clipped speech as if preparing for a blow: “No, he is not a veteran. Is that a problem?”
“Not at all. I was trying to decide which hospital to meet you at. Bring him to the Johnson City Medical Center—you know how to get there? The hospital next to the Mountain Home VA? Come to the emergency room and I’ll meet you there.”
My strongest memory of Essie was of her laughter: If you made her laugh it was as if you released the catch of a wound-up music box and a peal of notes would trill out in a crescendo fashion. She sang in the choir and had done so for years. Her broad bosom suggested that God had blessed her with not just beautiful vocal cords but lungs to match. Essie was one of those who had broadened my palate with her home-cooked meals when I had moonlighted up in Virginia.
Her work as a lab technician meant much more than a paycheck every month; it defined her and she took it very seriously. The hospital was an extension of her home. When she came to draw blood from a child in the emergency room with severe asthma, it was as if it was her child. I had seen her do her part in a Code Blue and then later brush away tears and stay upset for a long time if the Code was unsuccessful.
If there was a husband in her life, I had never heard him mentioned. Outside the hospital, Essie’s life had revolved around her children and her church. She lived a few miles outside the town of Blackwood, Virginia.
I remembered her telling me once about a baby brother who after high school had left their little town for Atlanta. And then he had vanished from the face of the earth. I remembered how the tears rushed to her eyes as she told me this. Had this same brother reappeared?
RAJANI, NOW PREGNANT with our second son, was in the kitchen. I went to tell her I would be going to the hospital.
“Guess what?” I said. “My first AIDS case in Tennessee is on its way!”
She shuddered as if remembering something. Then as she returned silently to feeding Steven in his high chair, her expression changed from concern and anxiety to what I chose, at that time, to think of as inscrutability. I realize now that Rajani was scarcely inscrutable at this moment in our marriage—she was merely frightened, as any wife or mother would be, as so many were in the days when we understood so little about AIDS. For my sake, she swallowed her fear, said nothing when she realized that the sound in my voice was excitement, exhilaration. As if I had been looking forward to this. I wonder now if she was more fearful of the disease or her husband’s excited reaction to its latest appearance in our lives.
In Boston, when I saw Tony Cappellucci, my first patient with probable AIDS, Rajani and I had talked about my risk—our risk. Nobody at that time knew for sure what caused the disease or exactly how it was spread. It was threatening to both of us, but I felt I had no choice in the matter and Rajani went along. I was a doctor, not without my own sense of self-importance. I was even proud that my chosen specialty, infectious diseases, found itself in the front ranks of the AIDS battle.
Later, when I had my first needlestick—a true battle wound—Rajani and I had gone the abstinence and condom route until it was clear that two successive HIV tests some months apart were negative. I was stoic and Rajani seemed to realize that I expected the same from. her. It took a long time for me to realize how much fear she lived with; how it, indeed, filled her days while I was off playing hero. In those days, in this country, the fear of AIDS was palpable. I gave great thought to protecting AIDS and HIV patients from the anger of so-called healthy citizens; I empathized with victims of this disease. But I did not yet see how the disease would enter and change my life
and my family’s. And so that night I chose to think of Rajani as inscrutable and allowed her to face her fear in silence.
I had always believed that doctoring was a hazardous profession, even if in the immediate pre-AIDS era the risks had diminished. Septicemia, tuberculosis and yellow fever had, in the preantibiotic era and prevaccine era, taken the life of many a physician and nurse. My physician-uncle in India told me how, as a young doctor, he had gone more than once into a hushed house where an entire household had bolted, abandoning their loved one because of smallpox. The unfortunate patient, covered with pustules, lay comatose on a mat on the floor, the rice and barley water that had been left beside him now crawling with ants. My uncle had hired a ricksha, loaded the patient on it and taken him to the communicable disease hospital. In the days to come, my uncle waited for the pustules to appear on his own skin, for the rigors and chills to commence. He had been lucky.
American medicine of the 1970s and 1980s was different. The new icons included the Porsche Targa, not designed for house calls. Personal risk had all but disappeared. Professional liability had taken its place. Evening clinics were anathema. In its place were doc-in-the-box centers, emergency rooms, answering services, beepers, cross-coverage and cellular phones. Money was the obvious and very visible reward for being a physician. Lifestyle was a key factor in the decision to become a doctor and the choice of specialties. Surgery, ENT, ophthalmology, OB-GYN—all specialties with procedures that you could bill for—were preferable to the cognitive specialties. Doctors were reimbursed generously for doing, but not for thinking.
A few days before Essie’s call, I had been asked to see a patient in the intensive care unit at the Johnson City Medical Center. He had been there for weeks and had high, spiking fevers. It took me an hour to wade through the chart and retrieve those portions of it that had been thinned and tucked away in the back of the nurses’ station.
I established the sequence of events, the cascade of catastrophes, that had led to the present state: chest surgery for a malignancy, then an infected surgical wound, then renal failure, then respiratory failure, then a blood clot to the lung. And meanwhile an infected urinary tract from a bladder catheter, and an infected bloodstream due to an intravenous needle site from which pus was emerging. I examined the patient carefully and found evidence of disseminated yeast infection: a telltale white splotch in the retina. I removed the intravenous line, cut its tip off and sent it to the lab for culturing. I sought out the family in the waiting room and inquired about prior allergies to antibiotics, skin tests for tuberculosis, and other antecedent disease.
I went to the radiology department and lined up all the chest x-rays and tried to figure out if the streak in the right lung was pneumonia or was it a blood clot? Was it recent or had it been there right after surgery? I went down to the microbiology lab and reviewed all the culture reports of every specimen that had been sent down there on this patient. I made fresh smears of the sputum and urine on glass slides and stained it with Gram’s stain and examined it under the microscope. I found more yeast: deep blue, balloon-shaped structures with buds coming off them.
Finally I went back to the chart and made my recommendations, which included a change of antibiotics and the addition of Amphotericin B. Amphotericin B—“Amphoterrible”—was a toxic and difficult to use agent needed to treat disseminated yeast infection. It had to be administered carefully after premedicating the patient with antihistamines and Tylenol so as to offset the chills and fever it could produce. I left detailed, step-by-step orders for its use, including a test dose following which the nurse was to measure blood pressure and observe for the onset of shock.
I suggested stopping some medications that confounded the situation and that encouraged the growth of yeast. I made recommendations for special blood cultures to try to recover the yeast from the bloodstream. Finally, I recommended a tracheostomy because it appeared the patient would be on the ventilator for a long while. I wrote all the orders on the chart with instructions on the bottom to “O.K. these orders with Dr. ______.”
By the time I was done I had spent two hours on the case. My office would bill the patient for an ICU consultation: the charge was somewhere in the $150 range. If the patient was indigent or on Medicaid we would see none or little of the fee. Our University Practice Group had a large overhead, and as a result, if the patient paid, I might ultimately see between $30 to $50 for my work.
The surgeon meanwhile had telephoned in, approved my recommendations and told his chief resident to do the tracheostomy—a twenty-minute procedure—for which the surgeon would bill $500 or more. This without leaving his house. The original chest surgery had already generated thousands of dollars.
None of these discrepancies in income were lost on the medical students, many of whom were already in debt and looking to pay back huge loans and begin to reap the rewards of their years in school. Specialties with operative procedures were the way to go.
Even if ID made no money, even if it was the pariah of specialties by virtue of its lack of procedures, an unexpected fringe benefit had become evident with the appearance of AIDS: In those early days, dealing with AIDS made us an elite group, an unexpectedly glamorous group. Even the cardiac surgeons could not approach our kind of heroism. Yes, they dealt with death every day. But it was somebody else’s death they had to worry about. Never their own.
I remember playing the role of brave soldier to the hilt when my parents came to visit me in Boston. They were concerned about AIDS, fearful that it might spill onto their son from its victims. To them AIDS was certain death, a merciless killer. AIDS was the haunting image of Rock Hudson emerging on a stretcher from a chartered Boeing 707, unsuccessful in his attempt to find an extension on life in Paris. I was, in the face of my mother’s concern for me, valiant and stoic.
This quality in me—the pride of the front-rank soldier—had gradually disappeared in Boston, but I could see it was now reawakening. I was talking about AIDS on television; I was lecturing to other doctors about AIDS. I stood in front of them in the flesh as someone who had taken care of persons with AIDS and felt positively about the experience, at least in the telling.
And now, finally, as if to justify my expertise, to justify my existence, my first AIDS case was on its way down. A car was speeding to Johnson City from a little coal mining town in Virginia. The excitement in my voice had been difficult to keep out. And Rajani had recognized it for what it was.
LATER, WHEN ESSIE began to tell me Gordon’s story, I learned that the day she called me, Gordon had come over to her house. It had taken a monumental effort for him to cover the fifty yards that separated his duplex from her front porch. When he stepped into Essie’s house, everyone could see that something was terribly wrong. He was extremely pale and swaying precariously. Essie and her daughters, Sabatha and Joy, had rushed to him and supported him and led him into Essie’s bedroom. As soon as Gordon sat down, Essie could see he was in pain.
Gordon asked the children if they would excuse Essie and him for just a minute; there was something he needed to tell their mother. Essie said time stood still for her. “I knew I was about to hear something terrible. I sat down and took a deep breath. I said to myself, ‘Lord, here it comes.’ ”
After Essie spoke to me on the telephone, she and the children helped Gordon to Essie’s car and laid an afghan over him. Essie tilted the seat back as far as it would go. Gordon asked for a cushion: he had a big sore spot at the base of his spine. He had lost so much weight, the knobby ends of the vertebra wanted to grind through the skin. Essie had Sabatha fetch a big empty Crisco can to keep between his feet if he needed to pee.
Gordon insisted they stop by the supermarket. Their mother was working a part-time job taking inventory. Gordon wanted to say goodbye to her. Essie had her mother come outside to the car, telling her only that Gordon was sick and they were going down to Johnson City to see a doctor she knew.
Her mother reached into the car and kissed Gordon and stroked hi
s hair.
“It was the most amazing thing,” Essie said to me later. “There he was, laid back in the seat, a pillow under his bottom, a pee-can between his legs, looking like he was going to die any minute, his skin as cold as a witch’s tit—and Mama couldn’t see that something was wrong with him. She wouldn’t see that her baby was sick. Had been sick for a long time but was a whole lot sicker now. She kept asking why we wanted to go all the way down to Johnson City. Couldn’t we just go in the morning?
“And Gordo just smiles at her, like he don’t even rightly know why we’re going—as if I put him up to it!”
I HAD LEFT WORD with the Miracle Center emergency room to call me when Essie arrived. When I reached the ER, Essie had already told the nurse about Gordon’s “HIV factor.”
As I walked into the ER I felt as if every eye was on me. I was sure of myself, knowledgeable about AIDS, but totally unsure of how this hospital was going to react to its second case.
One of the nurses—a veteran of the ER—entered the cubicle with me. I took this as a show of support.
I hugged Essie, who rose to her feet when she saw me. Now in her early forties, Essie had bobbed her brown hair in a pert look that highlighted her huge eyes. The eyes were full of anxiety.
Gordon was lying on the examining table, and Essie introduced us: “Gordon, this here is Dr. Verghese. Dr. Verghese, this is Gordo.” I shook his hand. It felt hot and dry. The nurse stood to Gordon’s left to assist me in the examination. She had brought a pair of gloves with her. Now she put them aside.
My first impression was that Gordon did not look at all like his sister. Lacking her rotund face and full lips, Gordon appeared frail and wispy—not so much a matter of his illness as a matter of genetics. As if he had come from different stock.
My Own Country Page 9