Hospital

by Julie Salamon

  At the biopsychosocial meeting, Ms. Hernandez was back on the agenda.

  Astrow walked into the room carrying a banana for breakfast. As usual, he was last to arrive. The fellows looked at him expectantly.

  “We have a twenty-four-year-old with metastasized lung cancer,” he began. “Even if she smoked like a fiend, that wouldn’t explain this. She’s from Mexico.”

  “Dominican Republic,” said Keen.

  Mohammad Razaq spoke. “We gave her one dose of chemotherapy.”

  Razaq was the quiet Pakistani who had told Astrow, along with Warshawsky, that he would be interested in staying at Maimonides for a full-time position after his fellowship was completed that spring. Like Warshawsky, Razaq was growing impatient with Astrow’s slowness in making a decision.

  “Why is she still in the hospital?” Astrow asked.

  Sramila Aithal, a fellow, answered. “She doesn’t have insurance.”

  “She’s very sick,” added Inna Sominsky, whose blond hair was streaked slightly differently that morning. She looked tired. Her two young children seemed to wake up earlier and earlier.

  “Failing,” said Razaq.

  “At four we’re having a family meeting,” said Lisa Keen. “Her mother she hasn’t told, because the mother has high blood pressure. The father of the children, who has legal rights, is coming, supposedly.”

  Astrow nodded. “What is the patient’s understanding?”

  Keen replied, “That she has a limited time to live, but that God and a miracle will save her.”

  “Does she have English?” Astrow asked.

  One of the fellows nodded. “She does,” she said.

  Keen shook her head. “No, she doesn’t.”

  “She doesn’t have an understanding. . . .” Astrow seemed to be talking to himself. Then he looked at Keen. “What do you plan to say to the family this afternoon?”

  Keen didn’t directly answer. “Dr. Rubin said if she doesn’t respond to the chemotherapy, she’ll die in the hospital. If she does respond, she has maybe six months.”

  “What’s happening to the children?” Astrow asked. “Is the father involved?”

  Again Keen shook her head. “No, but the boyfriend and the grandmother are.”

  “The mother needs to understand she has to think of the welfare of her children,” Astrow said. “That has to be brought up.”

  “We’ve started,” said Keen.

  Warshawsky raised another question. “What happens if you’re illegal and suddenly the children come to the attention of the authorities?”

  “They are citizens by birth,” Aithal said.

  “Even if the parents are illegal?” asked Sominsky.

  “Born in the U.S.A. Yes,” said Astrow.

  Sominsky’s words sounded more cynical than her tone. “So everyone can come here and have children born here and apply for services?”

  Razaq returned to medical issues. “She became tachycardic,” he said. “Afterward I spoke to the sister. The patient knows she hasn’t got a good prognosis. I haven’t spoken to her about time.”

  Astrow asked, “How do you plan to talk to her about her children?”

  Razaq looked pained. “The children. The oldest is five years old,” he said. “Can you tell them?”

  No one answered.

  “The children are now staying with whom?” Astrow asked.

  Keen replied. “Mom and her boyfriend,” she said. “The patient’s boyfriend of three months.”

  “There’s a whole literature on how to talk to children about their parents’ illnesses,” Astrow said. “It would be good for us to review this whole topic.”

  “This meeting is to look at what the family dynamics are and how they can support her,” said Keen.

  “I’m going to tell the family they need to take responsibility immediately,” said Razaq. “Even if she survives a few months, she won’t be in shape to take care of children.”

  “How will she get to Coney Island?” asked Keen. If Ms. Hernandez got well enough to be discharged from Maimonides, her treatment would continue at the public hospital. Then the social worker moved from practical matters to spiritual. “She’s an ecumenical Christian and looking for spiritual support. We called around and found a priest who came over Saturday to pray with her.”

  Astrow asked, “Who do we have in this hospital for patients who aren’t Jewish?”

  “Deacon Tom,” said Keen.

  “Episcopalian?” asked Astrow.

  “Catholic,” said Keen. “We have all kinds of churches on call, and there’s a priest regularly on Wednesday and Friday. Jewish support is hard to get unless a patient is dead.”

  “It’s surprising in this hospital there’s very little religious support,” said Warshawsky.

  Astrow laughed. “I see all these rabbis floating around here,” he said. “What do they do?”

  Robert Rosenblum, another social worker, middle-aged with a beard and yarmulke, smiled slightly. “They float,” he said.

  Astrow was about to change the subject. He looked at Keen. “It’s very important for the mom to think about her children and how she wants them to remember her,” he said. “A fairly tough discussion.”

  At 3:00 P.M., the time scheduled for the meeting, Regina Tarkovsky was waiting outside Hernandez’s room. Tarkovsky, a Russian with pensive eyes and short blond hair, was a firm director like Gregory Todd, a full-time staff physician who had her own patients and, along with a nurse manager, supervised clinical care of all the patients on her floor.

  While we waited, Tarkovsky brought us up to date. “It’s a very interesting case,” she said. “She’s so young, and it is not likely for a young person to present this way, stage-four lung cancer. Plus, she has no insurance, and we’re all thinking, ‘What is going to happen? How will she get treatment?’ She looks better, she just got chemo. But the five-year survival rate is almost nonexistent.”

  God help the interesting patient. “We have teaching rounds at one-thirty; ten A.M. morning report on interesting cases,” she said. The floor was full of them.

  She told us about another patient she had, metastasis to the brain, no hope. Her group collected money to send him home to Ukraine.

  Tarkovsky sighed. “Sometimes I think there is too much teaching.” I noticed she wore frisky boots with skinny high heels and pointed toes, and I wondered how she managed to get around; the doctors never stayed in one place very long.

  “This patient can’t get treatment in our cancer center if she leaves the hospital,” said Tarkovsky. “She can go to Coney Island. The resident already talked to her about advanced directives, Do Not Resuscitate. But she’s in denial.”

  Tarkovsky explained that she was in charge of Hernandez but felt that the oncologist should talk to the family. Suddenly a dizzying smell oozed into the hallway from the room on the other side. Tarkovsky and Keen seemed oblivious to the stench and its source, an elderly man walking in small circles, and periodically lifting his gown, exposing his naked rump. He grabbed some plastic gloves from a container and leaned over to swipe at something on the floor but missed the fresh turd he had just deposited there.

  Tarkovsky finally noticed and called out to the nurse’s aide—the “patient-care technician”—a slender black woman walking down the hall. Smoothly the PCT shifted course and quickly cleaned the mess, while gently talking to the man.

  The Spanish-speaking student social worker couldn’t come to the family meeting Lisa Keen had scheduled because of the snow. Keen decided to proceed with another interpreter, a resident who spoke Spanish.

  The family arrived shortly after the hour. It was a modern family, nonnuclear, ordained by neither religion nor state, held together by blood, passion, children, culture, and now necessity: the patient’s sister and brother-in-law, the father of the children, and the new boyfriend of three months. They were young people, in their twenties, outfitted in jeans, a baseball cap, stylish boots, but apparently ready to assume this grievous responsi
bility.

  The resident who had offered to interpret appeared. It was David Kho, the Chinese resident born in Singapore, married to the half-Jewish Puerto Rican. Last time I’d seen him, he was interpreting for a Chinese patient. Now he was needed for the Spanish he’d perfected working with Dominican patients while a resident at Columbia’s medical school.

  While the group waited for the oncologist, Phil Rubin, Keen explained the purpose of the meeting. “Dr. Rubin is coming to talk about chemotherapy,” she said. “But the reality is, you have a limited time to be on this earth, and we want to help the family use this time in the best way.”

  Kho interpreted carefully. The sister began to cry, as did the children’s father. The boyfriend looked dazed. Only Hernandez herself, ethereal in her hospital gown, thinner and paler than when I last saw her, was composed, despite the breathing tube in her nose. She handed tissues to her sister and to the father of her children.

  Rubin arrived. He was a bulky, awkward Orthodox man whose yarmulke always looked ready to slide off his head. Bangs added to the impression of a big, gawky boy, even though his hair was graying. He was known for his thoroughness, an unwillingness to rush that contradicted every impulse of hospital momentum, and for a desire to cure so fervent that it compelled him to put a positive spin on the direst situations.

  He looked like he wanted to hide behind his bangs as he explained that the cancer in the patient’s lungs had spread throughout her body by the time she entered the hospital. Fluid around her heart had been drained so she could have chemotherapy, which had begun the previous Friday. “If no treatment was given, she would not be alive today talking to us now,” he said, looking at Kho, with an occasional sympathetic nod in Hernandez’s direction.“We hope the chemotherapy will fight the tumor around her lung and allow her to breathe by herself.”

  Rubin paused periodically, giving Kho time to interpret, in careful textbook Spanish. Rubin explained that the chemotherapy, which would be given intravenously once a month, was a poison, so it would affect healthy cells, too. It would take one or two weeks to recover her blood counts and at least two cycles of chemotherapy to test the overall effect.

  Rubin tried to use language that was hopeful. “If over the next week or so she has improvement in her breathing, that is a good sign and an encouraging sign,” he said. “She is not ready to leave the hospital until she recovers from the effect of the chemotherapy.”

  His young audience listened with petrified faces.

  Keen whispered something to Rubin.

  Dutifully he said, “The chemotherapy will not be able to get rid of all the cancer, but it can help her feel better and live longer. If it works, she can do as much as six cycles.”

  Keen interjected, “There is also the possibility she may not respond.”

  Kho interpreted. Rubin looked miserable. “Yes, as she says, you can only know if the patient will respond to chemotherapy by giving it,” he said. “It is possible she may not respond. If she responds, this may . . . it could give her many months, even years. The only thing to do is support her and see if she responds.”

  Once again Keen prodded. “We should mention the same people who follow her here will follow her at Coney Island.”

  Rubin nodded. “When she leaves here, that will be a good sign. Some of our doctors will follow her at our affiliate, Coney Island Hospital,” he said. “With God’s help we’ll pull her through this.”

  As Kho interpreted this, Hernandez smiled. Her sister continued to weep.

  Keen talked about the children and the need to make some formal arrangement for their care, even temporarily.

  Then, for the first time, the family spoke. The children’s father said, in English, “I can take care,” he said. “They ask mother if that’s what she wants. She says yes.”

  Keen asked Hernandez, “You don’t want them to come see you?”

  She nodded.

  The brother-in-law, leaning on the windowsill, volunteered to take her to and from chemotherapy at Coney Island Hospital, before and after work.

  Rubin said, “I hope it will only be a few times a month,” he said. “Two or three times a month. She has to be there five hours.”

  Keen asked about telling Hernandez’s own mother, but the brother-in-law said she suffered from high blood pressure. The news could be dangerous.

  Keen asked Tarkovsky, who had been standing by silently, to discuss the health-care proxy. They gave the sister brochures in Spanish from an agency that helps children.

  Keen said, “You can call on any of us for help. Me, Dr. Rubin, Dr. Tarkovsky.”

  Kho said, “And me,” reminding them he was a doctor as well as an interpreter. He then repeated in Spanish Keen’s offer to find someone to pray with them and stumbled on the word “religioso.” For the first time, Hernandez’s sister laughed, as she corrected his pronunciation.

  Keen looked at Hernandez. “We appreciate how brave and strong you are, but there will be a time you want to cry and carry on, and that’s okay,” she said. “At some point you’ll want to tell the kids, and if you need our help with that, we can do that.”

  February 15, 2006

  Daily Log—J.S.

  Three days after the meeting with the Hernandez family, my cell phone rings. It is eight-fifteen in the morning. I am walking home from dropping [my son] Eli at school. It is Lisa Keen.

  “Ms. Hernandez died,” she says.

  Once again that feeling of doom. Dr. Rubin was talking months and possibly years—everyone knew that this was overly optimistic, but I thought at least weeks. The family meeting took place on Monday, and now it is Thursday, and that young woman is dead.

  Why am I surprised? She was so wan. And the next day, on Tuesday, when Lisa Keen and Dr. Tarkovsky were going to meet with Ms. Hernandez again, she canceled the meeting because she felt so sick.

  Was it the chemotherapy or the illness? Lisa K. wondered.

  This is one of those cases, Lisa K. said.

  Her mother never saw her in the hospital, she said. Her children didn’t come.

  Lisa K. said Ms. Hernandez told the doctors she wanted to try everything to fight the disease. She wanted the chemo. Lisa K. was impressed by how earnest and responsible the young men were. Ms. Hernandez was not a beauty, but she had a sweet, eager smile—until she became too sick to smile. I remembered her pulling tissues from the box to hand to her sister, who was crying at the family meeting. The old woman in the next bed was hooked up to tubes.

  They had to intubate Ms. Hernandez, Lisa K. said. Like the old woman. But it was the young woman who died in the night.

  I told a friend the story of the family meeting, and she was touched, just as I had been. But did it matter to the family? Was that gathering—that acknowledgment of their collective and individual responsibility—important to them?

  What will happen to the Hernandez children? Will they remember their mother? Was some part of her, as Solzhenitsyn wrote, “indestructible, some tiny fragment of the universal spirit”? Had she become part of the soul of Maimonides? Does a hospital have a soul?

  Nothing—not even bad behavior or dirty floors—preoccupied Pam Brier Nas much as the area of patient care referred to as “pain management.” At Maimonides the pain program was combined with palliative care and directed by Beth Popp, who had trained in oncology at Sloan-Kettering. Helping patients deal with pain strained the budget. Anesthesiologists in private practice, with a different reimbursement structure, could make money at it, but hospitals dedicated to pain management were forced to treat it as a luxury.

  Alan Astrow often returned to the theme of the dictates of the payment system. “All the things that are really good—diabetes care, asthma care, taking good care of cancer patients—you don’t get paid for that, no way,” he often repeated in one form or another. “You get paid for radiating people, doing complicated surgery, giving them chemotherapy. That’s what you get paid for. You don’t get paid for taking care of people.” What set him off that time
was an article in the New York Times, about how diabetes centers were all going bankrupt. “Well, I could have told you that,” he muttered. “People think doing good will lead you to doing well. Absolutely not!”

  Brier and I had a long conversation about pain one day. It was a typical Brier tour de force, which began with a story about constipation. Specifically, she told me about a telephone call she’d made to Vincent Calamia, the endocrinologist who had taken on the thankless job of running Victory Memorial Hospital while the Berger Commission decided whether to close it. Calamia and Brier had a cordial relationship, quite different from the one she’d had with Victory’s previous chief executive.

  It was during this phone call that Brier declared to Calamia, “I want you to know I’m considered one of the great constipation experts in the borough of Brooklyn.”

  He was recovering from ambulatory surgery, which took place the day before Brier testified to the commission about the relationship between Maimonides and Victory. When she called to see how his recovery was going, he told her he wasn’t feeling well.

  “I presume, like everyone else in the world, you’re having a lot of trouble with your bowels,” she replied, and made a few suggestions on how to solve the problem (Metamucil regularly or Senokot-S; if more serious help was needed, “check with your doctor”). At the end of the conversation, he said to Brier, “I can’t tell you how much better I feel,” to which she replied, “Well, you’re a doctor, can’t you talk about this with your doctor?” According to Brier, he simply groaned.