Hospital

by Julie Salamon

  Eugene wished him good luck and turned to leave.

  The old man stopped him. “I don’t want good luck,” he said. “I would like to die.”

  No! said Lukyanenko—Eugene—and returned to the old man’s side. “That’s wrong. You’ll be fine.”

  The old man weakly shrugged and said, “You don’t want to listen.”

  The young man waited, and the old man began to talk.

  “My first thirteen years were in Germany under Hitler. At thirteen I came here. For forty-seven years I had a perfect marriage. I know you may think that is hard to imagine. But it’s true. Most people might argue over money or children. Children we didn’t have; money I didn’t worry.”

  The hum of the emergency room seemed to recede as the old man’s story gained momentum.

  “I worked at something that paid very well,” he continued. “Not that anybody needed it, what we made, but it paid well. At thirty-five I was making a hundred dollars an hour when people were happy to make a few dollars. I had a perfect life. I am eighty years old. In forty-seven years I didn’t say no to my wife once, or vice versa. If she wanted to do something I didn’t want, I just gave a look and she knew. And vice versa.”

  He watched me scribbling in my notebook and paused, maybe to let me catch up, maybe to catch his breath.

  “Children we didn’t have,” he repeated. “We had a house up in the mountains. A condo in Florida. Even though she was sick twenty-seven years, it was good. Four years ago my brother died, and then my wife died. I don’t want pain. I want to go to sleep and not wake up. It could be tonight. I wouldn’t mind.”

  Eugene said with sweet earnestness, “You have many good years ahead of you.”

  The old man shook his head. “You wouldn’t understand,” he said. “You don’t know how it feels to lose a wife. Children are even worse, I hear, though I don’t know. I never had any. I wanted to die the day after my wife. I had the pills. . . .”

  He stopped and looked at Eugene. “Are you Jewish?”

  The patient rep nodded.

  I didn’t know why it mattered until the old man continued. “I had the pills, but if I took them, I couldn’t be buried next to her. (Then I understood: Jewish law traditionally prohibits suicide, and those who commit it are not permitted to be buried in Jewish cemeteries, though rabbis make many exceptions, including suicide resulting from mental illness.) Before she died, she said to me, ‘I suffered with you thirty-two years, so I want you to suffer with me for eternity.’ So when I buried her, I walked out of the cemetery and threw the pills away.”

  He looked miserable. “I just don’t want pain,” he said. “I only have my niece who lives in Buffalo, a nephew who is good for nothing, and my other brother, in the hospital. So now, give me an answer, why should I live? Today I figure maybe today’s the day. I choked, I couldn’t breathe.”

  Eugene was studying to be a nurse, and he was young. The wish for death was anathema to him. In his strong Ukrainian accent, he said, “If you are Jewish, you know the rabbi said, ‘You must weep for those who are born and smile for those who are dead.’”

  The old man clucked. “You are talking to the wrong man,” he said. “I am an atheist.”

  Eugene smiled. “So am I,” he said. “But what the rabbi says is true. We must feel sorrow for our children at facing the difficulty of life.”

  The old man said, “I have a religious friend I gave money to say kaddish for me. I don’t remember how to say kaddish anymore. . . .”

  He waved his hand in dismissal. “He’s all right, but I don’t like most Hasidic Jews.”

  Eugene said, “That makes two of us.” Then he resumed his insistent defense of hopefulness. “You still have life ahead of you,” he said.

  “No, I don’t,” the old man said glumly.

  Eugene sighed and glanced at his watch. “While you’re here in the hospital, if you need anything, call me.” He gave his extension.

  As Eugene began to move away, again, the old man touched his arm.

  “You want to know something?” he said. “You’re the first pleasure I’ve had since I’m here.”

  They seemed to be somewhere else, no longer closeted in an emergency-room cubicle, separated from sick people on either side by curtains, yet still exposed. I, too, had drifted. Dan Sulmasy, Astrow’s Franciscan friend, told me about moments like this. “Sometimes I feel I should take my shoes off before I enter the room of some patients,” Sulmasy said, “because what’s going on there is sacred in a real transcendent sense. So much faith, so much hope, so much love. Whether they’re dying or going to recover almost doesn’t matter, because something bigger is going to happen.”

  On January 30, Lisa Keen, the social worker, brought a difficult case to biopsychosocial. She wanted information about a twenty-four-year-old woman, undocumented, unmarried, two children, Hispanic—we’ll call her Ms. Hernandez. Mendel Warshawsky, the third-year fellow and cancer survivor from South Africa, said he knew the background: An initial workup had shown a negative breast exam. This was not, as one might think, good news. The cancer had metastasized.

  “The prognosis in the case is dismal,” said Warshawsky. The sun shining brightly through the cafeteria windows seemed at first to mock this grim forecast but on reflection seemed the perfect backdrop for the specter of unseasonable death. Why was it sixty degrees in January? The persistence of unnaturally warm weather was creepy, a portent of doom, heralding the end of seasons as we had known them for the past many centuries.

  Warshawsky was still waiting to hear from Astrow about the oncology job and was angry about the delay. “Astrow doesn’t have the balls to make a hard decision,” he told me before the meeting. “I don’t know if he’s going to last here.”

  Warshawsky tried to concentrate on this difficult case, which left open many questions that he summarized for the group seated around the cafeteria tables they pulled together for the session, since there was no conference room for the fellows. Should the patient receive chemotherapy, which would not cure her and almost certainly make her feel sick but could prolong her life long enough for her to get her affairs in order?

  What did it mean to get her affairs in order? “We have an undocumented woman, limited English,” Keen summarized, challenge in her eyes, as usual. “Boyfriend of three months, the only one who knows she has cancer. She’s entitled to nothing, working as a cashier in a supermarket off the books.”

  Alan Astrow sat with his hands clasped on the table, his head slightly bent. “Probably not a big chain,” he said. “She’d have to have papers.” He seemed distracted. He had told me his mother had checked in to Sloan-Ketteringwith chest pain and was angry with him for not interceding with her doctor.

  “Probably an Indian store,” said Sushma Nakka in her lilting Indian accent, her makeup flawless and tasteful.

  Keen said, “We’re going to have to send her to Coney Island. Who’s going to follow her?”

  “Where’s the father?” Astrow asked.

  Keen said drily. “Somewhere.”

  Warshawsky finished his diagnosis. “She has metastasis to every part of her body.”

  Keen shook her head. “She doesn’t have a clue.”

  Warshawsky straightened the yarmulke on his hairless head. “Maybe we shouldn’t just talk about chemotherapy but that she should start thinking about taking care of her kids, about going home. If we start her on chemotherapy, she’ll be so involved with that, and then she’ll be so sick she won’t be able to do anything, and then she’ll die in the hospital. There isn’t that much we can do for it.”

  Sheldon Berman, the psychiatrist with the shaggy gray hair, several years older than Astrow, chimed in. “We know we have a young woman here. Mendel brings up the context of how we interact with the patient. How do you implement your plan? We have a patient we assume is going to die in the next year. I’m reading between the lines—physicians will talk about treatment without talking about imminence of death.”

  Jason Tac
he, another third-year fellow, always spoke as if making a conclusion. “You’re talking about prognosis,” he said.

  Berman shook his head impatiently. “No, not prognosis,” he said. “We’re talking about a young woman, limited English, how do we help her?”

  “Help” in this conference meant something different from in the interdisciplinary meeting.

  Berman was an old friend of Novetsky’s; they had developed the group-therapy style of this biopsychosocial conference together. Like Keen, he had a sensibility shaped by the 1960s, rebelliousness worn down to an attitude of weary cynicism, righteous fervor mellowed but intact. This would be one of his last sessions. He had told Astrow he wanted to leave as soon as another psychiatrist could take his place as provocateur.

  Berman repeated, “How do we help her? What do we do?”

  Keen laughed shortly. “Run away?”

  Tache sighed. “We are not prepared to give her the psychosocial treatment you are talking about because of the patient’s financial and social situation.”

  He looked at Warshawsky. “Has it spread quickly, or did she ignore it because she didn’t have the money? We can’t give her long-term care—”

  Astrow interrupted. “I thought she would be referred to Coney Island and a fellow will follow through.” The Maimonides fellows did rotations at Coney Island, a public hospital four and a half miles away.

  “They don’t have social services,” said Tache.

  Astrow nodded. “They don’t have a Nella.”

  Nella Khenkin was the cancer center’s social worker, who usually came to the meetings, but not that day.

  “They don’t have a non-Nella,” Tache replied. “There is no one to help with social aspects.”

  A woman in her forties, wearing a wig arranged with pageboy smoothness, entered the conversation. “She’s going to have to think about child support,” said Beth Popp, the hospital’s pain-management specialist, who was Orthodox and often wore headbands that matched her clothing over her smooth wig. She was eating oatmeal out of a Styrofoam container. She had told me she’d lost a hundred pounds before having her fourth child and was careful.

  “Giving her some suggestions about things she can do that are helpful is better than telling her she has terrible cancer and we’ll know how bad after the test results,” Popp said. “We should send off some warning shots, and it has to be done with social workers who speak her language.”

  Tache shook his head. “She has no insurance,” he said. “When she leaves this place, she has nothing.”

  Popp raised her voice. “But she’s here now!”

  Berman stepped in. “Listen to Jason’s approach,” he said. “He’s saying she is up the creek without a paddle.”

  Tache smiled. “I’m not saying she’s there, but she’s on the way,” he said. “I speak the language, and it’s common these people come here and have three, four children at home.”

  Keen stared at Tache. “Her mother is here,” she said.

  “Is she a responsible human being?” Tache asked. “You think she has two kids and someone has to tell her she has to take care of them? Why do I have to figure out what to do with her kids?”

  Astrow spoke. “No one is asking you to solve her social problem.”

  Exasperated, Tache replied, “That’s exactly what Lisa wants and Shelly, too,” referring to the social worker and the psychiatrist.

  Berman shook his head. “I’m trying to emphasize we are a team,” he said. “When you become an attending, it’s not just taking the temperature.”

  Astrow listened, his hands folded on the cafeteria table.

  “I agree with you, Shelly,” he said. “Let me reframe the question, because Jason has thrown down the gauntlet. People often want us to solve their social problems. Jason is suggesting it’s a limited role.”

  Tache shrugged. “I have a limited amount of time to expend my energy,” he said. “What’s the most useful way to do that? In our system I don’t see how to help.”

  Sramila Aithul spoke next. She was a second-year fellow who spoke with calm authority, a personality trait that had been reinforced during her tenure as chief resident. “Sometimes if you just talk to a patient in a way that gives them ideas of how to handle the situation . . . ,” she said. “You may not tell them what to do, but just talking to them, showing some compassion—”

  Tache interrupted. “With all due respect to Sramila, compassion is not going to raise her two kids.”

  Keen said, “I don’t have a problem finding services for people. My problem is dealing with a twenty-four-year-old who is dying. Somebody with two kids; my daughter’s age. I was half serious about wanting to run away. I need help.”

  Inna Sominsky, the second-year Russian fellow, said she had the same situation with another patient, a thirty-year-old with colon cancer, stage three. “Was told about her disease and prognosis by the surgeon, but she has never asked about the future,” she said. “She doesn’t ask any questions, and I am avoiding.”

  Astrow synthesized. “When a patient doesn’t ask,” he mused. “Sounds like this young woman—Ms. Hernandez—is not going to ask Mendel, and he’s raised some good questions. Does she want to go back?”

  Keen shook her head. “She doesn’t,” she said. “Her mother and sisters are here.”

  Astrow said, “Her country doesn’t have the services?”

  “It depends what kind of services,” said Berman. “Loving care, kindness . . . it may be better. For me the most significant thing is pain management and end-of-life care, which, God knows, we don’t do well. Let’s think of this as a team. We are totally impotent to be able to stop the disease. Death is going to occur. This has to be part of our thought. Everybody dies, including us. If our goal is to help this woman, let’s deal with the fact her kids are going to grow up without her, go to elementary school, to high school, get married, have children, and she’s going to miss all that. The most important thing for family members is to know that you are there. Have any of you sat by the bed of a family member when they died?”

  The discussion drifted in that direction for a few minutes, and then Astrow interceded. “The woman is not actively dying,” he said. “We haven’t finished the diagnostic workup. What is Mendel supposed to do?”

  Berman said, “I’m suggesting that part of what we do is to be a human being, to be there in the moment, knowing we can’t make it better other than to say, ‘I am here.’”

  Astrow tried again. “In the spirituality series, a priest talked about getting out of the fixing mode,” he said. “Instead of worshipping Jesus, he said, you should follow Jesus into the vale of tears. But before we follow this patient down the vale of tears, we have to help Mendel with the medical diagnosis and what to tell the patient.”

  There was more conversation, and then Keen said, “This has made me feel better. Being in the room and caring is the most important thing. We shouldn’t underestimate the power of hope.”

  Tache muttered. “Just don’t overestimate it either.”

  Astrow glanced at his watch. They were reaching the end of the ninety-minute session. “It is important to be aware of your feelings,” he said. “Not whether you like or don’t like the patient, but helping them figure out what’s best for them. Part of being a good doctor is self-awareness.”

  Popp turned to Warshawsky. “Think about this woman and having to face this huge challenge in a month or twelve months. She hasn’t had an easy life. Many of us have faced a number of challenges, but probably nothing like hers. She is twenty-four, doesn’t speak the language, eking out an existence while living here illegally. She has faced a bunch of challenges—yes, many of them of her own making, and of which we may or may not approve. But people like this often do better than middle-class people.”

  Astrow picked up that thought. “They don’t have the illusion that the world is there to please them.”

  Popp replied, “It doesn’t mean we shouldn’t do what we can do.”

 
; Astrow looked at Warshawsky. “When you go in to see her, Mendel, take Dr. Popp’s suggestion. Go in humbly. There’s a lot we don’t know about her. We don’t even know her prognosis. We think we do. We should go step by step. This person is not you. She’s had a different life. Maybe she wants chemotherapy. I know you see what’s down the road for her and don’t want her to make a bad choice.”

  Berman offered an example. “Choose chemotherapy when it might leave her unable to say good-bye to her children.”

  Warshawsky sounded exasperated. “I chose this specialty because I thought I’d cure cancer,” he said. “We treat cancer, but how often do we cure cancer? Almost never!”

  Astrow looked surprised. Warshawsky was a walking example of cure.

  “Never?” asked Astrow. “Why do you say ‘never’?” (Did he mean, How can you of all people say ’never’ ?)

  Warshawsky laughed. “I retract,” he said. “It’s just that when someone comes in with acute cancer, we rarely cure it. We’re not purveyors of medicine. We’re basically their doctor until they die, despite everything we do.”

  Astrow replied gently. “A lot of patients live,” he said.

  Warshawsky was combative again. “What cancer do we cure?”

  Guptay Ranjiv, another fellow, said, “We give them five years.”

  Mendel was impatient. “Colon? Lung? We don’t cure them. The focus can’t be on curing the disease. How do we make life better?”

  Time was up.

  Most of the 40,262 patients who were admitted to the hospital that year would leave alive, most of them in better condition than when they had entered. But more than 1,000 of them would take their last breath at Maimonides. The social workers and the chaplains tried to create the illusion of sanctity for families and friends, but it was difficult. The hospital was a pulsing organism whose reflexes were programmed to keep moving, the way a chicken continues to run after its head has been cut off.