“What kind of work did you do for the CIA?”
“I don’t rightly remember. See they took me and brain-wash-ed me is what they did. Brain-wash-ed me.” Here he will make a scrubbing motion with his hand.
“Why? How?”
“I don’t know why, Doc. They put this metal thing on my head and I believe they shocked me?”
“How do you remember that?”
“It’s about the only thing I still remember.” Then he will smile, come close and whisper conspiratorially: “But they don’t know I still remember that!”
Last summer he told me that they were sending him to the Murfreesboro VA.
“Who?”
“The CIA boys!”
“Why?”
“They say I’m mad.”
“You are?”
“No, Doc. I don’t think so.” Here he will look around, lean close and whisper, “Between you and me, they know I’m remembering too much.”
Two weeks before, I had seen Red in this room after a long absence. I had approached him with delight, pleased to see him in one piece, though looking a little older, the shoulders drooping a little more. He had looked at me blankly when I walked up. He stuck out his hand and said his name was Red. He had no memory of me. We had started all over again. He told me why he was called Red, told me about the CIA. The part he could still remember.
IN THE MIRACLE CENTER intensive care unit, the chief resident discusses the readings taken from a Swan-Ganz catheter that sits inside the heart of a Mr. Tobias. The students and interns are wrapped up in the medical issues of his heart attack, in the urgency of a situation that has lost all its urgency for me. The debate goes from a pacemaker to digitalis. While they debate, I picture Sir William Withering, the discoverer of digitalis, holding foxglove in his hand and wondering if it really cured dropsy, as his patients claimed, or merely created that illusion. Secretly, I believe it was the word, foxglove. Listen to it: fox and glove. What incongruous images: how impossible not to smile. I would like to think that it was the sight of those long tubular flowers spilling from his fingers, purplish and vibrant, that made him pursue his investigations.
We are nearing Luther Hines’s room. I know. I can smell it. There are so many distinct smells in medicine: the mousy, ammoniacal odor of liver failure, an odor always linked to yellow eyes and a swollen belly; the urinelike odor of renal failure; the fetid odor of a lung abscess; the acetonelike odor of diabetic coma; the rotten-apple odor of gas gangrene; the freshly-baked-bread odor of typhoid fever. But this new smell that is not yet in the textbooks tops them all. Now, the redolence is so strong my nose wrinkles. I ask the students and residents if they smell it? They look at me strangely; one student, an obliging fellow, says, “I think I do.”
It is the smell of unremittent fever in AIDS, fever that has gone on not for days or weeks, but for months. It is the scent of skin that has lost its luster and flakes at the touch, creating a dust storm in the ray of sunshine that straddles the bed. It is a scent of hair that has turned translucent, become sparse and no longer hides the scalp, of hair that is matted by sweat, and molded by a pillow.
Luther Hines, who had walked into my office looking like death so many months ago, a blocked Hickman catheter hanging from his collarbone, a face covered with smallpoxlike clusters of molluscum, and big curds of Candida in his mouth, has managed to elude death for so long. He had become my poster boy, a walking testament to how will and belief can make up for lack of muscle, how anger can overcome blindness. He had been blind for weeks now from cytomegalovirus infection but had still continued to sortie out of his apartment, get rides to the mall, take cabs to our office, cuss out the people he bumped into.
When Carol and I first saw him stumble angrily out of my clinic, refusing admission, heading out to the parking lot, we had given him three days.
Instead he had lived on his own for months, making us all dance around him, punishing us all: hospice, social work, TAP, his parents. When he showed up in clinic it was without an appointment. Nothing was good enough for him: If you went to see him in the emergency room at midnight and you wanted to admit him, you were insulting him. If you did not go see him and had the resident see him, you were insulting him.
I had become immune to his performance, almost admiring of it. I could see beyond it and marvel at his unique kind of courage. So now his performance reached for greater heights: squeezing pus from his Hickman catheter onto his finger and wiping it on his shirt, digging in his mouth for a chunk of yeast to display the inadequacy of your treatment, popping a molluscum lesion between his fingernails. Luther did not believe that HIV was killing him. He believed that our inability to treat the symptoms that bothered him, our prescribing the wrong medications, was at the root of his problem. I almost believed him: Maybe if we could put together the right concoctions we could give him ten good years.
On his deathbed now, Luther looks worse even than he did when he was up and about. His mother and father are in the room, pressed into one corner by our entry. Luther’s lips are cracked and his mouth is filled with white patches. He inhales air noisily and erratically into his windpipe, dispensing with the niceties of nostrils, lips or cheeks because of his air hunger. Wisely, many weeks ago, he vetoed a ventilator—it surprised me. I thought out of spite he would say “do everything.” But even he had no stomach for that; he had been on a ventilator for a long spell in California.
A wavy frost line has formed over his forehead. Like the remnants left by waves on a beach, the salt from his sweat has condensed on his brow. His skin is hot to the touch.
I call out loudly, “Luther!”
There is a barely perceptible raising of his eyebrows, a turn of his head, but the eyelids remain half-set. Underneath the lids, the eyeballs are roving, as if scanning the ceiling, searching for someone. This is “coma vigil,” the same as Otis Jackson displayed before he died. In the preantibiotic era, when nothing could be done for most fevers, physicians painstakingly described the features of the “typhoid state,” a terminal event. Luther has not only the “coma vigil” of the typhoid state, but also “muttering delirium” and “floccillation”—picking at the bedclothes. Since there is little I can do for Luther, I too point out to the residents the features of the typhoid state. They are not greatly appreciative: Numbers from a Swan-Ganz cardiac catheter have more allure for them.
The medical students and residents are quiet, hovering around the bed, uncomfortable because death is staring at them. I am uncomfortable too, and I am angry all the time now. This is what I think when I lie awake at night: I want to start all over again. I don’t ever want to leave AIDS work—what else will I do? The battle of white blood cell and antibody and T cell with virus or bacteria continues to fascinate me. I want to start in a new community with a new set of names and faces.
When I began in Johnson City, I was ambitious, fascinated by the virus and by my patients. I maintained no distance, denying to myself that this was a fatal illness. The future, when all my patients were dying, seemed remote and vague. I convinced myself that I could handle that. But I simply did not understand how devastating it would be to watch. All the stories that I have painfully collected have come to haunt me with their tragic endings, as if I am the author and must take full responsibility. In a new place I can begin again from a wiser and more careful vantage.
The students and residents are waiting on me. I have been lost in thought. What am I supposed to do here, at this bedside? I have, for which I will always be thankful, the ritual of the examination. I put my hand on Luther: his pulse is difficult to detect, a faint thread under my finger. His belly is scooped out and hollow. I can feel the liver, and on the left side the spleen; both are much enlarged. As I press down on his flanks, I feel his kidneys slip under my palm with each breath he takes, pushed down by the descent of his diaphragm.
I palpate Luther’s neck, armpits and groin for lymph nodes. I flash my penlight into his pupils, nose, mouth. I pull out my stethoscope an
d listen over his neck, heart, chest, belly, and femoral arteries. I unsheathe my tendon hammer and tap his biceps, then his triceps. I move down to elicit the knee and ankle jerks. Then I flip the hammer over and use its pointed end to scratch softly at the soles of his feet, noting the brisk flexion of his toes and the extension of his big toe.
I have saved percussion for last.
I percuss his chest, and the sound of his right lung is disturbing. Only at the very top, near his collarbone, do I hear the thoom of resonance. Below that, from above his nipple to his belly, it is dull; the sound is indistinguishable from the thunk of the liver. The lung has been transformed from a spongy, light, pliant organ to a solidifying, consolidating mass. The sounds of my percussion on his body fill the room. Thoom, thunk, thunk, thunk, tup, tup, tup. I glance at his parents. They listen to the sound of their son as if mesmerized. Once more: thoom, thunk, thunk, tup, tup—even Luther seems to pause in his delirious muttering, his floccillation, to listen to the music of his body, to relax, to smile.
My tools—the hammer, the flashlight, the stethoscope—are scattered on his bed. As I pick them up one by one, I realize that all I had to offer Luther was the ritual of the examination, this dance of a Western shaman. Now the dance is over, and the beeps and blips of monitors register again, as does the bored voice of an operator on the overhead speaker summoning someone stat.
We exit the room and in the hallway our little group is subdued. We have six more patients in the intensive care unit to see. We move on resolutely, wheeling the silver chart rack in front of us. My heart is heavy. I am already thinking of nightfall, of the comfort of my bed, my body.
31
DECEMBER 31, 1989. New Year’s Eve.
Betty, my technician, watches silently as I pack the books in my office and take down my diplomas from the walls. Everything is almost ready for the movers. The last hamster has been given away. The fluorescent lights hum quietly over my head as I walk down the hall one last time.
At home, room after room is stripped down and the stacks of boxes grow higher and higher. My two boys crawl all over the cartons, excited by the activity around.
During the last few clinics I have said goodbye to all my patients. It was difficult and painful. Felix, who will take care of them for me, has convinced the four University Physicians Group primary-care internists to share the HIV clinic load with him: HIV infection at ETSU has now officially become a primary-care disease.
On the glass pane of the front door of our house I have pasted a bumper sticker that reads: IS THIS HEAVEN? NO, ITS IOWA. Iowa is where I am headed. My clinical commitment will be in the University of Iowa outpatient AIDS clinic. Along with ten other full-time infectious diseases faculty, a social worker, a nurse practitioner, and four fellows, I will be part of an established AIDS team. I will have no responsibility for in-hospital care. I see it as a cooling-off period—a year at the most—before I reenter the fray somewhere else. I have no ambition to do anything but AIDS care. It is my metier. It has found me and will not let me go.
To my tennis buddy, Earl, I leave my Datsun Z; I cannot afford to carry insurance on it. He says whenever I return, it is mine to use. Allen takes my Ford LTD station wagon and works on it for a whole day, replacing belts, flushing out the radiator, changing plugs and points, adjusting the timing, assuring himself that it will carry us safely to Iowa. The car has 110,000 miles on it already.
Both Allen and Earl are certain that I will be back. Allen takes me out into the country and walks me through the six acres that extend behind his barn. It is a perfect plot: trees on one side, a pond, a clearing for a house, a spiraled slope to cut into for a driveway, and an uninterrupted view of the mountains. “You know I’d never sell this in a million years; I won’t even listen to offers people make. But if you ever want to buy it, it’s here for you. Remember that when you get done in Iowa, Doc.”
Rajani is reluctant about this move; she senses, I think, that this is perhaps our last chance. She has agreed to come because she is trying to make herself believe that once I am removed from the maelstrom, I may become someone she can live with again. Rajani believes that safety can be found in the old conventions. But I have come to believe that human life is fast and fleeting, and that our moments of true safety are rare. I fear that this has made me a difficult companion.
By nine in the morning, the movers have loaded the van. We walk around the bare house in shock. Empty rooms. The old house takes back its character. Our presence has been temporary. The place will be whitewashed outside, painted within and the wooden floors polished. Soon it will fill with other voices; the house has seen so many of us come and go.
Our suitcases are on the rooftop carrier of the station wagon. My friend Jay Mehta and his wife, Meena, surprise us by coming by, bringing us a hot breakfast. I am so touched by all of today’s acts of kindness. I feel them deeply. We sit on the window seats by the bay windows and eat puri and potatoes, using the plates and spoons Meena has brought. Meena is Rajani’s closest friend and I catch her glancing at me with curiosity as if to say, “What is going on with you? Why are you putting Rajani through this? Why leave a perfectly secure job?” I can’t explain.
Jay and Meena are longtime residents of Johnson City, the seniormost members of the Indian community. When Rajani and I first came, theirs was one of the first houses we were invited to. Now, the love they show us makes it doubly painful to leave. I push back tears. Before they depart, they bless us formally, wish us God speed. Meena and Rajani hug like sisters. They part reluctantly.
After the Mehtas drive away, I walk around the house with my two boys. They are excited by the prospect of a new geography, new toys, new rituals. They think it is a nice game as we go room to room and say, “Goodbye Steven and Jacob’s bedroom, goodbye Daddy’s study, goodbye porch, goodbye fireflies . . .” We get in the car and the goodbyes continue: goodbye oak tree, duck pond, and one final stop behind the hospital so Steven can say goodbye to the cranes. We wave at the domiciliary residents on the benches. When we leave the portals of the VA, we say, “Goodbye, Mountain Home.”
Rajani’s eyes glisten like rain-streaked windows. All around us the morning is so quiet. Only the sounds of the boys break the silence between us. I have only myself to blame for all these goodbyes.
We drive all day with many a pit stop. There is not much traffic on the road—who would move house on New Year’s Eve? We sing in the car, drink Cokes, tell stories: Rajani and I work hard—too hard—so that the kids don’t feel our sorrow. As the hours pass we leave Tennessee behind us, head north into Kentucky, on into Indiana.
By nightfall we are about to enter Illinois. The back seat is folded down and we have converted the rear cargo area of the station wagon into a cozy nest of sleeping bags and pillows; the two boys are curled around my wife. All three are fast asleep.
Now my familiar Tennessee starscape is behind me. Orion and a Triple-A road map guide my way. It all happened so suddenly. I left my own country, my beloved Tennessee. Perhaps my perennial migrations, almost hereditary, are a way to avoid loss. With deep roots come great comforts. Yet deep attachments are the hardest to lose. Maybe that is why drifters avoid them.
Somewhere in Illinois I feel the weight of five years lift away. It is nearly midnight, the threshold of a new year, a new decade: the ’90s. I feel my belt now and assure myself one more time: there is no beeper there! No electronic summons that might sound its shrill alarm, jar my soul, make my heart race. I feel a lightness in my midriff: I tell myself that the umbilical cords that fastened me to eighty-plus HIV-infected people in Johnson City have detached. I feel so guilty over this sense of liberation. I feel such pain when I think of their faces.
I have lived for five years in a culture of disease, a small island in a sea of fear. I have seen many things there. I have seen how life speeds up and heightens in climates of extreme pain and emotion. It is hard to live in these circumstances, despite the acts of tenderness that can lighten everything. But it
is also hard to pull away from the extreme, from life lived far from mundane conversation. Never before AIDS and Johnson City have I felt so close to love and pain, so connected to other people. How can I pull Rajani across the gulf of our experience?
WE HAVE NOW crossed into Iowa. The sky is rich and huge. My eyes are numbed by mile after mile of dark prairie. A sign says the next exit has a rest stop; after that you hold it for fifty miles. I have shot past the exit before it registers that I need to pee and have just lost my chance.
It is midnight or nearly so. It seems fitting to stop and welcome the 1990s in. I pull over onto the side of the road, the wheels crunching on gravel before the car rolls to a stop. The engine is on, the parking lights on, and in the back the family sleeps; I debate whether to wake Rajani and wish her a happy New Year. I decide against it: she looks too peaceful to disturb.
The wind is biting cold, hinting perhaps at what the Midwest has in store for us. I walk out onto the stone border of a field; I move slowly. The black horizon is so huge, the world so limitless here.
I look up at the stars. I feel connected: legs to earth, shoulders to sky. I squint my eyes and see the lines that link stars to make constellations, feel their umbra extend down to me, connecting me with this parcel of land that I stand on. Everything is united: my children, the clouds, God, the moon, the mother of my children, the Ford station wagon that will overheat soon if I do not get back and keep going. Under this sky I am connected to all I left behind in Tennessee, all the friends and the patients who wished me luck.
I linger outside my car, my gaze directed skyward. My watch tells me it is now the first day of 1990. I suck on the ice-cold air. My guilt, my shame, about leaving is diminishing. At least for the moment.
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