Now, I had always been taught that “benzos” inhibited neural activity by raising levels of a neurotransmitter referred to as GABA (gamma-aminobutyric acid) and as such would make the patient less capable and even euphoric. With a sense of wonder, I ran to my resident and described my encounter with this obvious paradox of medical science.
“Raj, have you ever been really anxious and worried, so much so that you can’t think straight and are filled with all these unwanted thoughts? That’s how she feels every day because of her anxiety, and even more so by being in this strange, scary environment. When you gave her the Ativan, you helped her get rid of the anxiety and unwanted thoughts and to finally be herself. That’s why she’s so clearheaded now.”
It amazed me that all my years of preconceived belief were wrong—that here before my eyes was living proof that anxiety was indeed a real, inhibiting condition that caused actual medical problems that interfered with normal lives, and not merely the textbook justification for drug companies to make commercials featuring happy people running through butterfly-filled fields of daisies so that the companies could make outrageous sums of money. Here, before my eyes, was Mrs. Longwood.
I began to spend a great deal of time with her after this, so much so that I would check in on her almost every hour and use my free time to make sure she was OK. This mostly consisted of little things like getting her water, as the medications made her incredibly parched, and checking her pain levels and asking the nurse to give her more morphine when needed. But for the most part, I just enjoyed getting to know her family and listening to stories about Boston in the old days—a Boston that now exists only in history books.
Because of her anxiety, she often accused the nurses of neglecting her and making false statements, so they rarely ventured into her room unless absolutely needed. This didn’t bother me, though, because it just gave me more to do for her.
Over time, however, Mrs. Longwood began to think of me as her doctor, although I explained to her each time that I was only a medical student and that my name was Raj, not Ron. But eventually I began to enjoy being seen as a doctor—even though I had little real power over her care—and no longer minded when she called me Dr. Ron. She began to expect me to be with her, and I enjoyed being there.
But one day the cancer and radiation teams converged on her room with her family to explain that she needed to have her leg amputated in order to save her life. She began to cry. After all, who among us wouldn’t cry if we were to lose a limb, especially at her age, since it meant that she would never walk again? As her thoughts cleared, she refused the surgery and to lose her limb, despite discussions with her doctors and with her sons and husband.
I read every article I could find on osteosarcoma and paged all the members of her team to ask about alternatives, until the sad day came when I realized there were no alternatives. Radiation and chemo had been tried and ultimately made no difference. Her leg had to be amputated, and there was nothing else that could be done, not in the power of a medical student, and not in the power of a physician.
Her family sat with her one last time to convince her of its necessity, but she was a stubborn woman and refused. After her family left, on the last day the surgical team would take the case, I sat alone with her and explained the necessity of the procedure. I didn’t want to see her die of cancer. She was too wonderful a person for the world to lose, but more important, she was my patient. Others could ask for her consent and accept defeat, but I was Dr. Ron—her doctor. I sat with her on her bedside, held her hand, and asked her one last time about the surgery to save her life. She wept softly as we spoke, and I wiped her tears with my hand as she asked if anything else could be done. I told her with as much composure as I could muster that as far as I knew, from my reading and from speaking with others, nothing else could be done.
She looked at me. “I know you would never lie to me, Dr. Ron. You’re a wonderful person. God bless you.”
In Indian culture, the blessings of one’s elders are worth more than all the material success in the world and are in a sense a blessing from God. Elders are cherished and honored as the wisest, and it is the honor of sons or daughters to take care of their parents as they age and become less capable. Nursing homes do not exist in India—because no son or daughter would ever lose the honor of caring for his or her elders, especially a parent.
Here, as I sat with Mrs. Longwood, as she wept into my hands, I had received the blessings of my elders—the greatest gift I could possibly receive. In the morning, with her family surrounding her to steady her hands as she wrote, she signed the consent form for the surgery she needed to save her life. It was performed two days later without complications, and although she suffered greatly from the pain of a new wound, she was alive.
Her wounds eventually healed and she went back to the long-term-care facility where she normally stayed, but Mrs. Longwood is still with me. I think about her often, especially when I see an older patient, and I know that in these people lie the cherished memories of a life worth living—a life that history will record from a unique perspective that nobody else could have contributed in quite the same way.
I have begun my medical training—my indoctrination into a life of learning and of service—and I wonder how many more Mrs. Longwoods I will see.
III.
Easing Suffering and Loss
The first question which the priest and the Levite asked was: “If I stop to help this man, what will happen to me?” But … the good Samaritan reversed the question: “If I do not stop to help this man, what will happen to him?”
MARTIN LUTHER KING JR.
Not Since 1918
Kedar Mate
MR. BEACON IS SIXTY-EIGHT. I don’t know him well; in fact, before tonight I couldn’t really have claimed to know him at all. So unfortunately I can’t provide the gloriously succinct history of present illness that you’ve no doubt come to expect within the first few lines of anything written. Indeed, despite the fact that I have recently begun to seek out the “chief complaints” of all of my new acquaintances, I cannot claim to know much about Mr. Beacon’s.
No, Mr. Beacon, to me, was just a guy lying beyond two doors in a positive-pressure isolation room on the fourteenth floor of the hospital. He has, like many on the dreaded “Hiroshima” floor, leukemia of the adult variety: acute myelogenous leukemia (AML). All I knew about Mr. Beacon before tonight was that he had experienced some mental-status changes on my previous on-call night. When I’d gone to see him then, I’d found him lethargic, though awake and oriented, times an unfortunate two. I never pay much attention to “AAO × 2,” because I frequently forget where I am and what the date is, but in Mr. Beacon’s case, he’d forgotten his name. This earned him a neurology consult, and when the reflex-hammer jockeys (as my intern called them) emerged from the air lock all surgically capped and gowned and talking about pontine hemorrhage, we got worried. I quickly fled to the nearest computer before any questions regarding neurology were asked of me. My Internet Oracle informed me that said pontine hemorrhage was, indeed, a thing to be feared. Turned out that after much imaging, Mr. Beacon didn’t really have a pontine hemorrhage after all, just a “region of focal hypodensity” that didn’t amount to much. In the morning, much to our delight, he regained his sense of self.
That would have been the first and only time I met Mr. Beacon, except that last night, the Red Sox were playing the Oakland A’s in game five of the American League Championship Series. It was an unbelievable game, coming down to the age-old Little Leaguer’s mythical moment: bottom of the ninth, bases loaded, two men out, full count, and you’re on the mound. And so it was last night, when sometime after midnight Derek Lowe, one of Boston’s finest pitchers, threw a sizzling strike that ended the game and sent half of the fourteenth floor into arrhythmias.
Last night, Hiroshima, not to be crass, was on fire. Every ten to fifteen minutes, cursing and screaming would erupt from several rooms at once, sending the nurses scurrying to
check for possible codes, falls, sudden oxygen desaturations, or any one of an assortment of tragedies that may befall the hospitalized on a given evening.
I, for one, was paying extra-special attention to my three patients, all of whom were eagerly watching the ball game, regardless of how much they cared about baseball. One of my new guys, Mr. Storrow, is a soft-spoken young man with unresectable pancreatic cancer who’s got a wife and two boys, ages ten and twelve. His bowel was obstructed from the cancer mass, he felt nauseated, and he’d been vomiting every half hour to hour, but somehow he managed to stay riveted to the game, updating me on each pitcher’s pitch count every time I’d stop by. Mr. Vernon was watching the game over his hot-rod magazines. He likes to build cars, he’d told me earlier in the day. On one of my visits every fifteen minutes to check on his falling blood pressure and Pedro Martinez’s strikeout count, he offered to explain how to fix my muffler if the Sox won the game. Mr. Joyce, my last patient this evening, is a great old guy with lower extremity lymphedema from inguinal radiation therapy, which has now developed a cellulitis. Baseball’s not really his thing, but when you’re watching baseball with Mr. J., or anyone else who’s lived in Boston long enough, you feel like you’re sitting in Fenway Park in the 1940s with Ted Williams stepping to the plate.
While my beloved patients were relatively peaceful in their adoration for the famous Boston Red Sox, behind two airtight doors Mr. Beacon’s room was all kinds of chaos—ground zero for Red Sox fandom in Hiroshima. With every pitch erupted a chorus of expletives and cheers, better described as a collection of yips and yelps, emitted from a mucositic throat three times subjected to induction chemotherapy. A favorite refrain echoed out from beyond the doors: “Sit down, ya li’l pissah!” I was drawn to his room like a sixth inning fastball to Manny Ramirez’s bat.
Inside I found Mr. Beacon, propped up, wasted, his neck scaly, contracted, his tongue lounging at the corners of his drooping mouth. Eyes unmovable, affixed to the television set that hung from the ceiling. Had I tried to check his extraocular movements just then, he might have tried to do bodily harm to me. Accompanying Mr. Beacon was his wife of forty-three years and his son of thirty-five years, both fully dressed—beneath their yellow neutropenic precautionary gowns—in the fall line of Red Sox memorabilia. On their heads, as on Mr. Beacon’s head, sat Red Sox caps with blue surgical crowns. When I walked in and introduced myself, explaining that I couldn’t keep myself away from this boisterous inner sanctum of Boston baseball fans, Mr. Beacon’s wife quietly handed me a hat and told me to start praying. There we were, four loonies, awake and oriented to only one thing: the flickering TV that hung from the ceiling.
By the bottom of the ninth inning, the score was Boston 4, Oakland 3. Oakland’s batters were coming to bat, and when the first two Oakland batters were walked on base, Mr. Beacon was huffing and puffing, no longer able to communicate to us his lifelong frustration with the failure of the Red Sox. Any other moment, his hyperventilating might have caused some alarm; his oxygen saturation, which I quietly checked, was hovering between ninety-two and ninety-four—lower than it should be. When the Sox went to the bull pen, I asked him how he was feeling.
“Like hell,” came the gravelly reply, his eyes more alive than they’d been the last time I’d seen them. Confident he meant the game, we all turned back to it. Wife, son, and med student were now huddled around Mr. Beacon, hands clasped in some pagan ritual…. Two outs came swiftly, and life came to a standstill … all of our hearts pounding. Mr. Beacon’s monitor was showing some premature ventricular contractions—we ignored them. Two balls, one strike, one foul ball, and then Derek Lowe delivered the two-two pitch. We froze, Mr. Beacon held his breath, causing his O2 sat to dip past ninety to eighty-six, the monitor beeped loudly, and I had an undetected myocardial infarction … “STRIKE THREE,” came the call! The game was over; the Red Sox had won. We rejoiced.
Mr. Beacon’s sixty-eight years old, he’s got AML, and he’s been through several rounds of chemotherapy, relapsing consistently after each one. He’s on comfort measures only now. And most of the docs I’ve heard chatting about him wouldn’t give him much of a shot at seeing the Red Sox return next year to the American League Championship Series. I guess this makes me sad, but today, one day after that miraculous victory, I feel happy that Mr. Beacon could see that. Last night must have felt like living once again to Mr. Beacon. It certainly made me feel like I was living, and it made his family feel alive too. About a half hour after the victory, I stopped by to continue the postgame revelry.
“Not since 1918,” Mr. Beacon said, reflecting on the Red Sox’s last World Series win. “I hope I can hang on to watch them do it again.”
The Tortoise and the Air
Vesna Ivančić
CHAPTER ONE: FRESH AIR
This is the story of an old man who felt like a tortoise, or rather the back of a tortoise. Only it was his front that felt this way. His scarred, bloated, rock-hard belly felt exactly as I, an inexperienced percussionist, imagined a tortoiseshell would feel if you were to attempt percussing it. The analogy seemed no more unusual to me at the time than anything else I’d thought since entering the world of hospitals the week before. As medical students, we percuss all kinds of things and, to the great dismay of our clinical professors, extract just about as much information from the endeavor as you would if you attempted percussing a turtle. Besides, I’d been thinking about turtles lately.
Just that morning I had reluctantly taken the turtle off my necklace for the first time. It had been three months since we’d broken up—a breakup that was just as unexpected as the gift of the turtle on our trip to Phoenix the previous Thanksgiving. Three months apart after three years together, and I was starting a whole new life that week. It was obvious: the turtle had to go. I was a big fan of symbolism. I wasn’t superstitious; I just liked making connections. And so I unclasped the chain, and a shiny brown turtle swam jerkily down, landing tailfirst on a bookshelf. I sighed, realizing it was one of the bookshelves that he had put up in my room. What was the half-life, I wondered, for removing all traces of him from my system? Was I simply being romantic, or were such thoughts pathetic by now? I couldn’t decide, and either way, the turtle’s day had come.
CHAPTER TWO: WASTED AIR
An hour later, we were dutifully rounding on the list of patients assigned to the Red team. Most of our time was spent hunting for signs of infection. We scoured records of vital signs for fever, flashed light at wounds from every angle, and attempted to express purulence, otherwise known as squeezing to see if pus comes out. Then, of course, we’d reevaluate the appropriateness of antibiotic armaments assigned to each patient and coax them into admitting recent flatus or bowel movements. A positive answer relieved and delighted us, even at six in the morning, and we’d march off like a troop of white elephants through a sleepy jungle to the next room.
I don’t remember the first time we rounded on Mr. U. What first made him memorable to me was the day he set a trap for the herd of general surgeons stomping through the halls of the White and Ellison buildings. We were going along at our usual clip, en route, inexorably, to salvation: the operating room. I glanced at my watch—7:27. Not much longer now, I thought, until we will be scrubbed in, under the lights, over a prepped patient, beside the Mayo tray, and ready to do a satisfying colectomy. Mr. U. had a different morning in mind for us, and it all began when he politely refused his nasogastric tube.
It was my first week on a surgical clerkship, and I had already been taught that the NG tube, which sucked air and fluids out of the stomach, up through the esophagus, and out the nose, was, oddly enough, the exact way we treat people whose stomachs are as hugely distended and full of air as Mr. U.’s was. Apparently Mr. U. knew this as well. He’d had an NG tube before, and “No way, you can’t make me; I won’t have it,” was his response to a second encounter. My first reaction was in keeping with that of the other members of my team: nothing short of exasperation. I had never seen anyone
who needed an NG tube more. OK, so I had only seen a few people who needed an NG tube at all. But the guy’s tympanitic! I thought to myself—a word, not to mention an argument, I had never heard of one week before. Never mind that: it was obvious even to a layman that Mr. U.’s abdomen was all blown up and rock hard—turtle hard—or, as we medical students like to proclaim, this was definitely badness. Worse yet, his ostomy was kinked in exactly such a way that the distension was pushing his folded-up intestine against the wall of his abdomen, where it had no hope of uncoiling. His obstruction was getting worse. He needed desperately to be decompressed. In other words, the air had to come out of him.
And yet the only air that came out of anyone was the wasted breath of my senior surgical resident as he attempted to obtain Mr. U.’s consent for “snaking down the tube.” I especially noted the “Come on, let’s do this, we’re all on the same team” tactic—partly because it seemed, at first, to be working, and partly because, let’s face it, we may all be on the same team, but I sure as hell would rather be on the shove-it-in side of the NG tube. After what felt like an hour but was probably five minutes, my frustrated resident and intern left the room mumbling, somewhat rhetorically, “Why do these people come to hospitals if they don’t want to be treated?”
I stood there, confused, aware of the patient’s presence, aware of my team’s absence, upset by the conflict, seeing merit on both sides, and unsure of what to do next. In the months to come, I would realize that the way I felt at that moment was to become my usual state of being as a medical student. At the time, though, I was still naive and optimistic. I decided to try something that hadn’t been tried—the one thing even I, as a medical student, knew how to do as well as anyone else. I begged. I pleaded with him to let them put in the tube. I honestly trusted these people and fervently believed it was in Mr. U.’s best interest to have the NG tube if they said so. He, of course, said no to all my pleas. And just as suddenly as when you’re staring at one of those pictures that all your friends claim is actually a three-dimensional hologram, and all you can see is blue and gray sparkles until, abruptly and without transition, the other picture pops out at you, Mr. U.’s perspective popped out at me. Suddenly I believed he was perfectly right in refusing the NG tube. There were no guarantees it would solve all his problems. He had every right to refuse treatment. Besides, he swore he got this way all the time at home and was always fine by morning. Why should he believe this situation to be different? He didn’t feel any pain. “If there was something bad going on, I would know it,” he said over and over.
The Soul of a Doctor Page 7