Writer, M.D.

by Leah Kaminsky

  I spotted an acquaintance on the street, someone not in the medical field, and I pointed out the flyer, asking if she had heard about this. “Oh, yes,” she said. “It’s been all over the news this week. His wife was on TV and everything.”

  How could I have been so out of touch with the news while I was in Israel?

  I raced to the medical school library where I knew that a week’s worth of the New York Times would remain stashed on a shelf before being discarded. I flipped furiously through the pages of the back issues until I stumbled upon the headline “Prominent Manhattan Doctor Missing from Upper West Side Apartment.” I scanned the text desperately. “Dr. Joseph Sitkin was last seen Monday morning.” “Always jogged in the early mornings.” “Nothing missing from apartment.” “No sign of foul play.”

  In the issue two days later there was another article, entitled “Missing Doctor Left Note on Computer.” My heart pounded as I read on. “The letter on Dr. Sitkin’s computer spoke of his despondency.” Despondency? The man who always had a joke on hand? The man who marveled at his daughter’s ability to fit all of her toes in her mouth? “Dr. Sitkin’s long, rambling letter chronicled his increasing despair as well as his love for his wife and two daughters.”

  The newspapers crumpled in my hand and I crumpled in my seat. How could this have happened? Were there any signs? Could we have known? Or helped? For the next week, there was a palpable tension at the medical center. Rumors circulated that Dr. Sitkin had had a nervous breakdown and was recuperating somewhere anonymously. Someone said there was a report of a credit card purchase in East Hampton and that he must be out at their summer home.

  On January 29, two weeks from the date of his disappearance, a body washed ashore. “A badly decomposed body was found on the rocks,” the New York Times read the next day, “under the Manhattan side of the George Washington Bridge yesterday, and the police tentatively identified it as that of Dr. Joseph Sitkin, a prominent Manhattan doctor who disappeared two weeks ago and left a note—”

  I closed my eyes from the headlines, unable to read on. How could it have felt, I agonized to myself, to stand on that bridge in the early chill of the morning and stare down at the Hudson River swirling below? How much must his heart have ached as his palm rested upon the frigid metal handrail? With how much despair must his legs have trembled as he eased his athletic limbs over the edge? How much anguish must he have possessed to combat the vertiginous assault of facing down the furious river?

  I could only put my hand over my mouth and clamp my already closed eyes even further shut to block out the vision of his final moments. But I couldn’t erase the internal vision of his pain and that of his wife, Julie. I shuddered at the thought of that icy moment of transition from her annoyance at his being late to her panic at his absence. The distraught days of unknowing, like a slowly cranked torture rack. The discovery of his letter, of the worst fears confirmed. And the baffling illogic of the world to render this comprehensible to two little girls.

  The next day I found myself crammed in the downtown No. 1 train with the press of morning commuters. I slithered open my New York Times just a crack to peek at the news. I found myself at the obituaries, and there it was: “Sitkin, Joseph, beloved husband of Julie, devoted father of Andrea and Ellen, dead at the age of 39. According to his wishes, the family has donated his body to the Microbiology Department at NYU Medical Center.” It was suddenly so real, so final. I began to sniffle and swallow. And then the tears began to creep out. Someone offered me a seat and suddenly I began to cry unabashedly. The commuters looked on in helpless confusion. A woman asked me if I was feeling okay. I pointed to the obituary and said, “I knew him. That doctor from NYU who’s been missing, I knew him. He was one of my teachers.” And I bawled openly amidst the embarrassed silence of the subway car.

  I escaped from the subway and walked the remaining thirty blocks home. Thirty painful blocks. Thirty blocks of remembering the comatose alcoholic with the shofar by his side and the twelve pints of Ben & Jerry’s ice cream for breakfast. Thirty blocks of remembering how Dr. Sitkin encouraged Lauren’s powerful song, and the way he always glanced at the Polaroid photo of Ms. Chen’s baby, taped to the railing of Bed 7. Thirty blocks of remembering how he made me laugh and how I actively struggled to dislike him and just couldn’t. Thirty blocks of remembering the tough work and the extraordinary payoff of earning Dr. Sitkin’s respect.

  Ours is a dangerous profession, I’ve often thought. There is the constant assault of physical and emotional challenges of taking care of patients, which is layered upon the already difficult task of conducting our own lives. It is no wonder that so many of us become overwhelmed at times and need some intensive care. For every Dr. Sitkin who eventually declares his pain to the world, there are probably fifty others who suffer silently, for whom the anguish burns slowly and excruciatingly. The medical profession has little room or patience for hearing about this. These feelings often get expressed as bitter, abusive personalities, or drug and alcohol addictions.

  The cliché says that doctors make the worst patients, that they are the last to seek treatment. We are always trying to help our patients get beyond their denial, but it seems that we use it the most for ourselves. Is that the Faustian bargain we make when we enter the profession? I don’t want to believe that is true, but for some it is apparently so.

  Falling Down

  SANDEEP JAUHAR

  On call nights, the ward was like a sleeping village, and you were the night watchman on patrol with your penlight and stethoscope. Senior residents were available for backup, but after 10:00 p.m. they were almost always admitting patients or at home sleeping. You could call them if you needed help, but few of us ever did. Not calling backup, I quickly learned, was considered a sign of strength, and for an intern there was nothing more flattering than to be considered “strong.” Once, I made the mistake of calling a third-year resident at her apartment in the middle of the night to ask for help performing a spinal tap. She roared at me on the phone for not taking care of the procedure earlier, before she came on duty at 10:00 p.m. When she arrived on the floor, she quickly saw my patient, told me a tap was unnecessary, and then berated me some more for wasting her time. I never called another resident for the remainder of the year, paging Rajiv instead (in the middle of the night, if necessary) when I needed help. If I could get so much flak asking for help managing a potential case of meningitis, I could only imagine the kind of wrath I’d incur calling about atypical chest pain or something equally benign.

  On night duty, it wasn’t the emergencies that overwhelmed so much as the little things, the minor issues—the insomnia, the constipation, the headaches—that the nurses had to make you aware of in the middle of the night. Even when the nurses didn’t call, it was impossible to enter any sort of restful sleep. The expectation of the pager going off was enough to keep you in a state of chronic anxiety. Sometimes I’d pace back and forth in the call room, or just outside in the corridor, looking out the window onto the East River and the points of yellow light dotting the skyscape, wondering what sort of calamity would next be visited on me. If I did fall asleep, I usually woke up with a drenching wetness on the back of my neck. Once, a nurse called to tell me that a young man, nervous about a procedure scheduled for the morning, had had fleeting chest pain. When I saw him, he was visibly nervous but otherwise fine. When I told the nurse that a twinge of chest discomfort in an otherwise healthy young man did not require an extensive workup, she made it clear that if I didn’t at least perform an electrocardiogram, she was going to file a complaint. So I went and got a machine and wheeled it to the patient’s room, but it was broken, and I went and got another one on a different ward, but it was broken, too, and by the time I performed the EKG forty-five minutes later, the patient was fast asleep and irritated at being woken and, of course, his EKG was completely normal.

  There were set times on call when you could expect a flurry of pages, like when the nurses checked vital signs at 4:00
a.m. That was when they called about fevers. Your response was always the same: blood and urine cultures and a portable chest X-ray to rule out pneumonia. But sometimes you discovered that a patient was already on antibiotics or that blood cultures had been drawn every night for the past week, every single one negative, and then you had to decide whether you really needed to stick him again, but most of the time you did so anyway, not for the patient’s sake but for your own, lest someone fault you in the morning for not doing it. That was the sad reality of residency: much of the time you were ordering tests to protect yourself. “The endgame of life is so depressing,” I wrote in my diary. “Look at Mr. Fisher. Successful lawyer, Goldberg patient. Now look at him. Sick, febrile, dying of who-knows-what: cancer, TB, sarcoidosis? If you think about it, it could make all of life seem unworthwhile if, in the end, we end up dying in the hospital, awakened at 4:00 a.m. by a stupid intern trying to draw another set of blood cultures.”

  Sometimes I worried about how I was going to get through another night on call, until I realized that my patients were helping me. Their bodies had homeostatic reserve, the capacity to self-correct, to compensate for my mistakes. In physics, an oscillator quickly returns to its equilibrium position after being displaced, and so it is, I came to believe, with the human body. Most of my patients were going to be fine despite anything I did, and if they were going to die—well, that was probably going to happen despite me, too. Health was like the wilderness: it could only be spoiled by human intervention. “We’re not saving patients,” Rajiv told me. “We’re just stabilizing them so they can save themselves.”

  I became awed by this concept, but most of my colleagues seemed indifferent to it. We performed our interventions with such confidence, such arrogance, but most of the time there was no way of predicting whether we were doing the right thing, or even a good thing. We’d give potassium for hypokalemia, or diuretics for edema, or nitroglycerin for high blood pressure—and we would overshoot. The diuretics would make our patients dehydrated or the nitroglycerin would lower their blood pressure too much—and then we’d have to give them intravenous fluid or raise their blood pressure with other drugs, and the process would start all over again. Sometimes we would give drugs just to treat the side effects of other drugs. Sometimes we would do illogical things like giving fluid and diuretics at the same time, and no one questioned it, including me. There was too much going on, too much complexity, to start asking questions. I wasn’t sure where to begin; I wasn’t even sure I knew enough to know what to ask. My energy was low, my enthusiasm flagging, and the system was in automatic drive anyway. The easiest thing to do was to get out of the way.

  When the nurses woke you in the middle of the night, you had to be prepared to deal with the unexpected. You knew that energy, clarity, fluent speech were coming; you just didn’t know when. One night, I was half asleep when I got paged. Must be blood culture time, I thought, reaching for the phone. In the dark, the receiver vibrated like an image from a jittery screen projector. When I called the number on my beeper, an urgent voice told me to go to Mrs. MacDougal’s room. When I got there, it was as if I had walked in on a play. Mrs. MacDougal was standing precariously in the middle of her private room in a puddle of urine. Bright ceiling lights were beating down on her like stage spotlights. She was an attractive woman, for ninety-one, with a sharp patrician nose and handsome cheekbones like Lauren Bacall’s. Her gown was open in the back, exposing her scoliotic torso, which was covered with age spots, like cow patties in a field. A nurse and two orderlies were circling her like muggers. They were trying to get her to go back to bed, but the old woman was insisting on going to the bathroom alone.

  “We’ll help you go in the bedpan,” someone said, grabbing her arm to keep her from falling.

  “I want to go to the bathroom!” she shrieked, trying to wriggle free.

  “We can’t let you walk there.”

  “I’m not going in the bed!”

  “You’re going to slip and fall.”

  “Leave me be!”

  I was trying to keep from falling over myself. I tried reasoning with Mrs. MacDougal, but she wouldn’t listen to me, either. After a couple of minutes of urging, I asked the nurse why we couldn’t just let her go to the bathroom.

  “She could break her hip,” the nurse said indignantly.

  “She could, but I don’t think she will,” I replied.

  “I can go by myself!” Mrs. MacDougal cried.

  “I know,” I said, “but let me walk you anyway.” I offered her the crook of my arm and, much to my amazement, this appeal to her ladylike instincts seemed to work. Off we went, with an aide on either side, to the toilet.

  An aide went in with her while the rest of us waited outside. “She’s sundowning,” the nurse said, clearly irritated, referring to a kind of nocturnal delirium often observed in nursing homes. “Before you leave, order restraints.”

  “Do you think that’s necessary?” I asked skeptically.

  “What if she sundowns again?”

  “Just call me,” I replied. People in the hospital were always obsessing about disasters that never occurred. I had seen it myself in the CCU, where nurses would use PRN (“as-needed”) sedative orders to keep patients groggy and cooperative through the night.

  When Mrs. MacDougal came out, I walked her back to bed. “You’re a nice young man,” she said.

  “Thank you,” I replied.

  “I like you.”

  “Well, I like you, too.” That was the nicest thing I had heard all week. I was going to show these nurses that a little kindness could go a long way. The next page came about forty-five minutes later. When I arrived back in the room, the scene was much the same as before, except now Mrs. MacDougal was standing in a slurry of feces. She was yelling some of the vilest obscenities—“Cocksuckers! Mother-fuckers!”—that I had ever heard from a nonagenarian’s lips. The stench was overpowering. I cupped my hand over my face, but the putrid odor still registered in my olfactory lobes.

  “Mrs. MacDougal!” I cried through my fingers. “What are you doing?”

  “Who the hell are you?” she screamed hoarsely.

  “Dr. Jauhar!” I said, incredulous. “Don’t you remember me? You promised you were going to stay in bed.”

  “I need to go to the bathroom.”

  I ordered her back to bed immediately.

  “You’re not my doctor!” she shouted. “Call Silverman. Tell him to get me out of here.”

  I told her that Dr. Silverman wasn’t available.

  “Get out of my way,” she cried, swinging wildly at me. She slipped and fell into my arms, rubbing brown excrement onto my scrubs. Steadying myself, I felt my right sandal slide a bit. The nurses were looking at me with I-told-you-so satisfaction.

  For a moment, I fantasized about putting Mrs. MacDougal into a choke hold and dragging her by the neck to bed, elbowing the nurse and orderlies out of the way, hissing, screaming at them to end this godforsaken shitfest. But, of course, that couldn’t happen; I had to deal with the situation calmly. “Give her five of Haldol and two of Ativan,” I shouted out as I tried to keep her from tipping over.

  “Yes, Doctor,” the nurse responded sarcastically before going out to get the medicine. The two aides and I managed to force her back to bed. When the nurse returned, she administered two intramuscular injections. Almost immediately, Mrs. MacDougal stopped struggling. Within minutes, she was snoring heavily. I felt momentary relief, until the reading from the pulse oximeter started to drop: 99 … 98 … 97 … Pretty soon an oxygen mask was plastered to her face and I was turning a knob counterclockwise on the wall. 94 … 93 … 92 … The brief calm quickly turned into another round of panic. Why had I been so impulsive? Was there an antidote for Haldol? Should I call an ICU consult? Where were the nurses now? For the next couple of hours I remained at her bedside, watching her snort like a pig. I stabbed her wrist with a needle to get an arterial blood gas, which revealed borderline oxygen and carbon dioxide levels. I p
rayed the drugs would wear off. Why had I allowed myself to be goaded so rashly? In an effort to protect her (or perhaps myself), I was afraid that I had killed her. It was an apt metaphor for my internship thus far.

  By the next morning, Mrs. MacDougal had returned to her sweet, great-grandmotherly self. At lunchtime a few days later, nurses, social workers, and people with nondescript titles like “coordinating manager” met to discuss patient “disposition”—who was going to be able to go home, who was going to require long-term care, and so on. Rohit told me to attend on his behalf. At the meeting, everyone seemed to be having a rollicking good time talking about the patients, exchanging gossip about family dynamics, and so on. The subject of Mrs. MacDougal came up. “Dr. Jauhar had a wrestling match with her a few nights ago,” a social worker said, and everyone laughed except me. Someone asked where Mrs. MacDougal was going to go once she left the hospital. Her daughter wanted to put her in a nursing home, but she wanted to go back to living independently. “No way that’s going to happen,” someone said with a certitude I found troubling. Someone asked me for my opinion. I had had so little interaction with her, just one unfortunate incident, that I wasn’t sure how to respond. I was wary of saying anything that could send her to a nursing home for the rest of her life. She had been delirious, no doubt, and a danger to herself, but she had also been in an unfamiliar environment with people she thought were trying to hurt her. Surely that had to enter the calculus for predicting future behavior. It was anyone’s guess what she would be like in a more familiar environment. Wouldn’t putting her into an institution just increase the likelihood of further sundowning? I thought of the Chekhov story “Ward No. 6,” and the incarceration of Yefimitch. I did not want to be responsible for institutionalizing another person. I had seen it before on the psychiatry wards. If someone said they were well enough to go home, we would say they lacked insight into their disease and keep them even longer. Where was Dr. Silverman? I wondered. We were discussing the future of a stranger over sandwiches and soft drinks. And that was beginning to seem normal.