My Own Country

by Abraham Verghese

  “I was angry with Jewell,” Vickie said, as if reading my mind. “I was furious. And you know me,” she said, making a little flexing movement of her fingers, cupping one fist into the palm of the other, “I could have strangled him if I put my mind to it. But what was the point? It wasn’t like Clyde was innocent. And I don’t think Jewell meant for this to happen. Lord knows he helped us so much over the years—money, food, clothes for the kids. I have to say that he loves Clyde and he loves me and he loves Danielle and Junior.”

  I was incredulous: we were talking about a probable pedophile, a man I would not want anywhere near my kids.

  “Does Jewell have a family?” I asked.

  “Oh yes! He was married for years.”

  This was a picture of Jewell I found difficult to form in my mind.

  “He and Clyde were in the same lodge. Last week Jewell made the lodge come up with a pledge to help me out. Jewell even gave me three hundred dollars of his own money after that for my expenses. And, believe it or not, I know I can count on Jewell in a way that I can’t count on my family.”

  CLYDE WAS STILL sleeping when I left to go back to the VA. Vickie took me for a quick drive through the hollow.

  Before I left, I told Vickie about TAP and about the support group meetings organized by Fred Goodson, “the bear.” I suggested that she and Clyde go to a meeting. I wasn’t sure how much Clyde would get out of it, but I wondered if Vickie would not be helped by seeing that there were others with the disease. “You want me to sit and talk with a bunch of queers?”

  “Try it. This disease is too much to carry alone.”

  “Why, hell, everyone in this hollow knows. I wish they didn’t, but they do. I ain’t carrying it alone.”

  I pictured her life in this isolated hollow where people avoided her gaze, where she and Clyde and even the children were probably social pariahs, the untouchables of the hollow.

  The support group was perhaps the one place in Johnson City where she could be sure that she would not be condemned.

  “Promise me you’ll think about it.”

  “I will.”

  I left her standing in her doorway, a cigarette in one hand, waving at me with the other. I drove up out of the hollow, back into Johnson City.

  13

  BOBBY KELLER called me in the office as I was about to leave for home. He sounded shrill and alarmed.

  “Doc? Ed is very sick! He is very, very short of breath and running a fever. A hundred and three. Dr. Verghese, he’s turning blue on me.”

  “Bobby, call the emergency ambulance service—tell them to bring you to the Johnson City Medical Center.”

  Ed Maupin, the diesel mechanic, had had a CD4 count of 30 the previous week when I had seen him in clinic; Bobby Keller’s was 500. At that visit, Ed’s oral thrush had cleared up but he was still feeling tired and had been missing work. When I had examined Ed, the lymph nodes in his neck, which had been as big as goose eggs, had suddenly shrunk: I had thought to myself that this was either a good sign or a very bad sign; his immune system had either given up the fight or successfully neutralized the virus. The latter was unlikely.

  Bobby, at that visit, had looked well and continued to work in the fashion store. I hoped now that Bobby’s description of the gravity of the situation was just histrionics.

  I was at the Miracle Center well ahead of the ambulance. Soon it came roaring in, all its lights flashing. When the back door opened, I peeked in: Ed’s eyes were rolled back in his head, and he was covered with a fine sheen of sweat. Despite the oxygen mask that the ambulance crew had on, his skin was the color of lead. His chest was making vigorous but ineffective excursions.

  Bobby, who had ridden in the front, was scarcely able to stand up. His face was tremulous; he was on the verge of fainting.

  “Don’t put him on no machines, whatever you do,” Bobby begged me. “Please, no machines.”

  “Why?”

  “Because that’s what he told me. He doesn’t want it.”

  “When did he tell you? Just now?”

  “No. A long time ago.”

  “Did he put it in writing? Does he have a living will?”

  “No . . .”

  In the emergency room, I stabilized Ed as best I could without intubating him. I took his oxygen mask off momentarily and looked at his mouth. His mucous membranes were loaded with yeast again—it had blossomed in just a week. But I was examining his mouth to try to decide how difficult it would be to intubate him. His short, receding lower jaw, which the beard concealed well, could make this a tricky intubation. I asked him to say “aaah.” He tried to comply: his uvula and tonsils just barely came into view, another sign that he would be a tough intubation.

  Ideally, an anesthetist would have been the best person to perform intubation. But I didn’t want to call an anesthetist who, given the patient, might or might not be willing to do this procedure. Time was running out.

  Ed was moaning and muttering incomprehensibly; his brain was clearly not getting enough oxygen. His blood pressure was 70 millimeters of mercury systolic over 50 diastolic. This was extremely low for him, because he had baseline hypertension. His cold, clammy extremities told me that the circulation to his arms and legs had shut down in an effort to shunt blood to the brain; even so, what blood got to the brain was not carrying enough oxygen. Ed’s chest sounded dull in the bases when I percussed it; on listening with my stethoscope, he was wet and gurgly. The reason he was not oxygenating his blood was clear: his lungs were filled with inflammatory fluid. I ordered a stat chest x-ray and arterial blood gases. I had only a few minutes before I had to either breathe for him, or let him go. I needed more guidance from Bobby as to Ed’s wishes.

  I had an excellent nurse assisting me; she had already started an IV and brought the “crash cart.” The respiratory therapist was administering oxygen and had an Ambu bag ready. I asked them to get goggles and masks in addition to their gloves, and to get a gown, mask and gloves ready for me. They were to put theirs on and wait for me. The curtains were pulled and Ed’s presence was largely unnoticed in the bustle of the ER. An orthopedist was putting a cast on an individual in the next room, and patients were waiting in the other cubicles.

  I came out to the waiting room, but Bobby was not there!

  I hurried outside.

  Bobby and three other men and one woman were near the ambulance entrance, smoking. The men bore a striking resemblance to Ed Maupin—the same sharp features, the slightly receding chin. One of them, the oldest, wore a green work uniform. I recognized his face as a familiar one, someone who worked in an auto parts store where I had ordered a replacement bumper for the rusted one that had fallen off my Z. Bobby Keller, still trembling, introduced me to Ed’s brothers, all younger than Ed. The woman was the wife of one of the brothers.

  “Bobby,” I asked, “can I tell them what’s going on?”

  “Tell them everything,” Bobby said, the tears pouring down uncontrollably, his body shaking with sobs.

  I addressed the brothers: “Ed is very sick. A few months ago we found out he has AIDS.” (There was no point in trying to make the distinction between HIV infection and AIDS. If Ed had not had AIDS when I saw him in the clinic, he most certainly did now.) “Now he has a bad pneumonia from the AIDS. I need to put him on a breathing machine in the next few minutes or he will die. I have a feeling that the pneumonia he has can be treated. If we put him on the breathing machine, it won’t be forever. We have a good chance of getting him off. But Bobby tells me that Ed has expressed a desire not to be put on the machine.”

  The assembled family turned to Bobby who nodded vigorously: “He did! Said he never wanted to be on no machines.”

  The family was clear-eyed, trying to stay calm. They pulled hard at their cigarettes. The smoke rose quietly around their weathered faces. They looked like a Norman Rockwell portrait—small-town America’s citizens in their work-clothes in a hospital parking lot, facing a family crisis. But this situation was one that Nor
man Rockwell hadn’t attempted, one he had never dreamed of. I felt they were fond of their oldest brother, though perhaps disapproving of his relationship with Bobby. Yet judging by how they had all been standing around Bobby when I walked out, I didn’t think they had any strong dislike for Bobby—it was almost impossible to dislike him. They had had many years to get used to the idea of Bobby and Ed, the couple; and it was only the idea, I sensed, that they had somehow not accepted.

  “We need to discuss this,” the older brother said.

  “We have no time, I need to go right back in,” I said.

  They moved a few feet away from Bobby and me. I asked Bobby, “Do you have power-of-attorney or anything like that to make decisions for Ed?” Bobby shook his head.

  We looked over to where the family was caucusing. The oldest brother was doing all the talking. They came back.

  “We want for you to do everything you can. Put him on the breathing machine, if you have to.”

  At this a little wail came out of Bobby Keller and then degenerated into sobs. I put my hand on Bobby’s shoulder. He shook his head back and forth, back and forth. He wanted to say something but could not find a voice.

  The oldest brother spoke again. His tone was matter-of-fact and determined:

  “We are his family. We are legally responsible for him. We want you to do everything for him.”

  We are his family. I watched Bobby’s face crumble as he suddenly became a mere observer with no legal right to determine the fate of the man he had loved since he was seven years old. He was finally, despite the years that had passed and whatever acceptance he and Ed found together, an outsider.

  I took him aside and said, “Bobby, I have to go on. There is no way for me not to at this point. There’s a really good chance that I can rescue Ed from the pneumonia. If I thought it would only make Ed suffer, I wouldn’t do it. If this is Pneumocystis, it should respond to treatment.”

  Bobby kept sobbing, shaking his head as I talked, fat tears rolling off his eyes onto the ground, onto his chest. He felt he was betraying Ed. He could not deliver on his promise.

  I had no time to pacify Bobby or try to convince him. I rushed back in. Ed looked worse. As I went through the ritual of gowning and masking (it was reassuring to have rituals to fall back on, a ritual for every crisis), it struck me that the entire situation had been in my power to dictate. All I had to do was to come out and say that the pneumonia did not look good, that it looked like the end. I mentioned the respirator, I offered it as an option. I could have just kept quiet. I had, when it came down to the final moment, given Ed’s brothers the power of family. Not Bobby.

  But there was no time to look back now.

  I LEANED DOWN TO Ed’s ear and explained what I was about to do. He showed no sign of understanding. He was expending tremendous amounts of energy to breathe.

  I stood behind Ed with the endotracheal tube in my right hand and the laryngoscope in the other. I put Xylocaine jelly on the tip of the endotracheal tube. We lowered the head of the stretcher, extended Ed’s head over the edge.

  I had the nurse now give Ed an intravenous bolus of 20 milligrams of Valium. An anesthetist might have used a curarelike paralyzing agent. In a few seconds, Ed’s breathing ceased altogether.

  The respiratory therapist gave him a few brisk breaths of oxygen from the squeeze bag and stepped away. I inserted the laryngoscope blade into his mouth and heaved up on the tongue. I could not see the vocal cords and could only barely see the epiglottis. I pushed the tube past the epiglottis, giving the tube some torque, hoping to steer it into the voice box and down the trachea. It went in too easily and I knew I had missed.

  I pulled out and we bagged him with the squeeze bag again. I was talking to myself: Come on, Abe; hamsters are ten times as difficult as this, and you have intubated 260 hamsters at last count. Another voice in my head replied: This ain’t no hamster.

  Ed was a deeper shade of blue now. If I didn’t do it in the next try, we were going to have to call an anesthetist. Or call a Code Blue. The second time and I still did not see the vocal cords. But this time I felt the tube grate against the tracheal rings, just as with my hamsters. I listened over first one side of the chest and then the other while the respiratory therapist pumped air into the tube. I could hear good breath sounds on both sides; we had secured an airway and the tube was sitting in perfect position, just above the carina, where the trachea divides into the left and right bronchi.

  It had been a while since I had intubated anyone myself; usually there were layers of interns and residents and students who fought for and did all the procedures. I was pleased with our success. The nurse patted me on the back.

  “Did you know,” I asked her, in the glow of my postprocedural success, “that intubation was invented by a physician named O’Dwyer as a lifesaving measure in diphtheria? It’s therefore an infectious diseases procedure!”

  “Yeah, right,” she said, unimpressed. “I’ll keep that in mind. Next time we have a trauma case that needs intubation we’ll call in an infectious diseases consult.”

  I WENT UPSTAIRS WITH Ed to the intensive care unit. Now I wrote orders for the settings on the ventilator that would optimally oxygenate Ed’s lungs. I put him on a 100 percent inspired oxygen concentration (in contrast to the 21 percent oxygen concentration we normally breathe) and dialed in the rate and the volume of each breath the ventilator would deliver. I wrote an order to have an arterial blood oxygen measurement made in half an hour to allow me to cut back on the oxygen if at all possible; pure oxygen in high concentrations is damaging in and of itself. I wrote orders for intravenous fluids and for laboratory tests. I felt better about Ed in the ICU than I had with Scotty Daws. I had inherited Scotty Daws and in retrospect it had been a no-win situation. Ed was the best sort of patient to bring to the ICU. Someone who I thought would perhaps walk out of there.

  Pneumocystis pneumonia is easy to diagnose if you get a good specimen of sputum. Secretions obtained by washing out a segment of lung during bronchoscopy—so-called bronchoalveolar lavage or BAL—are ideal, but even an ordinary sputum, as long as it is not grossly contaminated with saliva, can serve almost as well.

  Since Ed had a tube going down into his trachea, breathing for him, it was simple enough to squirt some saline down it and then suck it back out with a catheter.

  I carried the specimen down to the lab, made some smears of it on glass slides, then looked at them under the microscope after staining them for bacteria and TB. I saw only an outpouring of inflammatory cells and little else. To see Pneumocystis carinii requires a special stain called a silver stain. It would take a day for the pathology department to complete the stain and give me the definitive word on what it showed. The fact that I saw nothing but pus cells on my simple stains—no TB, no bacteria—suggested that this was Pneumocystis. I began Ed on trimethoprim-sulfamethoxazole, or Bactrim, the drug of choice for this organism.

  The only cases of Pneumocystis pneumonia I had ever seen were in persons with AIDS. This was unique to my generation of infectious diseases physicians: We had all come of age in the era of AIDS.

  But Pneumocystis had a long history before AIDS made it a household word. Epidemics of Pneumocystis swept through Europe in the 1940s. They occurred primarily in premature infants in orphanages, in the setting of overcrowding and malnutrition.

  After the war years, the organism began to manifest only in select patients with immune-compromising conditions such as leukemia or after long-term cortisone administration. St. Jude Children’s Hospital in Memphis, at the other end of the state from us, had accrued tremendous experience with this disease by virtue of their patient population—children with leukemias.

  How are we to view this organism? As an invader from outside? Or an opportunist from within? To give a rat Pneumocystis pneumonia, all you have to do is give the rat cortisone—a potent suppressor of the immune system—and the rat then spontaneously develops Pneumocystis infection. By contrast, Betty and I had to pour s
taphylococci in massive doses down the hamster trachea to produce infection with staphylococci. The rat experiment suggests that Pneumocystis is present in low numbers in the lung at all times. The Pneumocystis that at this moment was filling up Ed’s lungs lives in my lungs and in yours. The constant vigilance of the immune system keeps it in check. Immune suppression by steroids or, as in Ed’s case, AIDS results in unchecked multiplication of this organism.

  I SOUGHT OUT Bobby Keller in the ICU waiting room. His eyes were red and puffy from crying. I tried to explain what I had done so far. Bobby listened perfunctorily to what I had to say about Pneumocystis and the amount of oxygen Ed required. It was clear he felt Ed’s time had come and that we had gone beyond a threshold of intervention that Ed had not wanted to cross.

  WHEN I GOT HOME it was after midnight. Steven was in our bed. Rather than disturb them, I went to Steven’s room and crawled into his bed.

  It felt as if my head had just touched the pillow when my beeper went off. It was from the ICU at the Miracle Center. An intern was calling to say that Ed’s heart had gone into a malignant and chaotic rhythm. A Code Blue was in progress.

  “What time is it?” I asked.

  “Four thirty in the morning,” he said.

  “How long has the code been going on?”

  “Five minutes. And there has been no sign of his heartbeat coming back.”

  “Keep going, I’ll be right there. Ask the nurses to call in his lover and the family and have them wait in the quiet room.”

  In the ICU, a furious Code Blue was in progress. All the bustle and activity around Ed was in contrast to the activity in Ed’s body: there was no heartbeat, and only the forceful chest compression by the intern was sending blood around. I reviewed the code chart—everything I would have done had been tried: calcium, epinephrine, bicarbonate. I waved everyone off, thanked them, and we pulled out the tube from Ed’s trachea. Ed now looked peaceful, asleep.