Bloodletting and Miraculous Cures

by Vincent Lam

  “I imagined what would happen if I went over there. He would be fine, just a junkie on junk, but I’d be standing there all doctor-like and therefore unable to escape. Or, maybe he would be dead. Then I’d start CPR, although if he was dead all that time it wouldn’t matter, but if I was playing Mr. Doctor then I’d have to do something to make it look good, I’d have to do mouth-to-mouth and he would vomit in my mouth, and then whether he was okay or dead, by the time the ambulance guys came, either some homeless guy would have stolen my croissant and latte or it would be cold.”

  “But then…” prompted Chen, and he saw from Fitzgerald’s slump that the funny ending and heroic anecdote that these types of stories usually concluded with would not come.

  Fitzgerald said, “So the woman starts CPR. She hasn’t even checked for a pulse, and in fact I think I can see him breathing, so she would totally fail an ACLS course. Anyhow, she’s doing it like squirrel CPR. Boop boop boop on his chest. Must have seen it on TV. She’s got the two-hand thing going, elbows locked, but she’s barely touching the guy. I figured that if he was actually alive, her CPR wasn’t going to hurt him much, and if he was dead, none of this would matter. Then the ambulance came. I had to watch, because I was convinced that he was breathing, just to see whether I was right. Sure, they tubed him. I heard him sucking on the tube, and they weren’t pumping him. See? I knew he had vital signs.”

  “Sometimes you can tell from a distance,” said Chen.

  “Sure,” said Fitzgerald. A coughing fit. He wondered if he would have told the story if the ambulance crew had started CPR, if in fact the guy had died. No. He knew that he would have just kept it to himself. As it was, Chen was the first person he had told.

  “Did you go to Centre Island?”

  “Yeah, but that whole incident soured my day.”

  “It’s cute out on the Island, isn’t it? All the rides, and the kids in the swan boats, driving those little cars.”

  “I like it out there,” said Fitzgerald. Fitzgerald thought of a ferry trip to the Island with Ming before she met Chen, and was surprised that he could remember this without bitterness, without needing to know whether Chen knew that Ming and Fitzgerald had once spent a sunny afternoon on Centre Island. He felt good, that it was mostly a pleasant memory of a woman whom he now hardly knew, and of himself as a person remembered. A slight pang, of course, but after an unusual length of sobriety he was able to see that this was mostly a pang for his present aloneness, and that there was no truth to representing it otherwise. “Listen, if I go down the drain, and I think I will, I don’t want to be tubed or resuscitated or anything. It’s not worth it.”

  (Portion of progress note of Dr. R. Zenkie, FRCPC, dated March 20, 2003—excerpted from chart with permission of Toronto South General Hospital)

  …and as his clinical situation continues to worsen, Dr. Fitzgerald has indicated his wish to not be resuscitated should he deteriorate to the point that he requires intubation. He has told me that should this occur, he would not want to expose other staff to the SARS infection by performing such a high-risk procedure, since he judges that in this instance his chances of survival would be slim. I am inclined to wonder whether Dr. Fitzgerald may be suffering from an acute situational depression, and therefore may not be competent to make this decision. At this point, I am refraining from writing a DNR order, because of my doubts about the state of Dr. Fitzgerald’s mental health.

  Yours truly, Dr. R. Zenkie, FRCPC

  Consultant in Infectious Diseases, Toronto South General Hospital

  (NB: Also on March 20, Dr. Zenkie ordered diazepam 10 mg by mouth every one hour as needed by Dr. Fitzgerald to treat persistent tremor. No other explanation of this order is noted in the chart.)

  Dolores explained to the daycare director that she, herself, had no fever, no respiratory symptoms, that she was screened daily at the hospital and checked her own temperature at home at least twice. Certainly, her children were perfectly healthy. She had had no unprotected contact, she said, and could not be considered to be a suspect or probable case. The daycare director said that it wasn’t that she had any problem with the situation. No, it was just that the parents of the other children felt…uncomfortable. Dolores asked why those parents didn’t just keep their kids at home, then. Well, that would be unfair to them, said the daycare woman, and it wasn’t that she was forbidding Dolores’s kids from coming, it was just that maybe they should…think about things a bit. Already, Dolores’s children had told her that the other kids wouldn’t play with them, had been told not to by their parents.

  Dolores found a babysitter who could provide both daycare for the little ones and after-school care for Dolores’s older daughter. Dolores told her that she worked in the sanitation industry, and explained to the kids that they shouldn’t tell anyone that Mommy was a nurse. Why not? her daughter asked. Because people are silly, Dolores said. For how long do we keep it secret? her son asked. Dolores said that she wasn’t sure how long it would be. It might be a while.

  On March 21, Chen saw that Fitzgerald sucked on his oxygen with all the heaving muscles in his chest, that he ate ice from a cup next to him. Chen called Fitzgerald and asked how he was doing. Great, replied Fitzgerald.

  “Hey, you remember that guy, that old German internist, the one who did his residency in India? He would talk that crazy German-accented Hindi to all the Indian patients. They loved him. What was his name, Glug-something? Gland?”

  “Gerstein.”

  “Were you there when he convinced that woman she needed a spinal tap?”

  “Remind me.”

  “The one-in-a-hundred thing…”

  “Oh, of course,” said Fitzgerald. Both he and Chen began to laugh. Dr. Gerstein had been their attending when they were consulted about a patient with a headache. Her story raised suspicions of a subarachnoid hemorrhage, and the CT scan was negative. Dr. Gerstein explained to the woman, in the German-accented Hindi-influenced English he had learned in Bombay, that even though the CT scan was negative, there was a one percent chance that it could be wrong, and a lumbar puncture was necessary in order to be certain.

  “One percent,” she said. “I’m scared of needles.”

  “A subarachnoid could kill you,” Dr. Gerstein said.

  “But one percent. That’s one in a hundred. You would put a needle into my spinal cord for one in a hundred?”

  “Actually, into the spinal canal. We would avoid the cord.”

  “Maybe I’ll take my chances,” the woman said. “One percent isn’t bad.”

  At that, Dr. Gerstein made for the door, leaving Dr. Chen and Dr. Fitzgerald standing at the woman’s bedside. They did not know whether to follow him. They knew that this woman needed the lumbar puncture, and that sometimes Gerstein would abandon difficult tasks, such as convincing a patient of the wisdom of medical guidance, to his house staff. At the door, Gerstein turned, widened his stance. He made his hands into a pistol and raised them, pointed the two-fingered barrel straight at the woman.

  He said, “I just picked up one of a hundred Mauser pistols that were sitting here outside the room. One of them is loaded, and I don’t know which one. Regardless, the gun is trained on your forehead. I’ll leave it up to you. Would you like me to pull the trigger?”

  The woman’s eyes were fixed on the muzzle of Gerstein’s fingertips.

  “The safety is off, shall I pull the trigger?”

  Chen and Fitzgerald’s chests thumped in sudden fear. Gerstein stood absolutely still, stared down his gun barrel until he smiled—not ironically, not exactly kindly, but mostly with sadness at the reality of decision making.

  Fifteen minutes later, clear cerebrospinal fluid trickled into the needle embedded between that woman’s fourth and fifth lumbar vertebrae.

  “Like a gunslinger in a western,” said Chen. “High noon at the spinal tap corral.” Both he and Fitz were laughing.

  Fitz said, “You think we’ll die?”

  “Maybe.” The laughter continued
.

  “Me, more likely. I’m on a hundred percent.” He knew that Chen was only on four litres of oxygen per minute. “It’s not so bad,” said Fitzgerald. “If we die with only a few hundred others, we’ll be SARS martyrs. If thousands get it but they find a cure and our deaths help, then it’s worthwhile. If this thing just goes wild and the whole world dies by the millions, then we’ll miss the worst of it. See? Can’t lose.” By the time he had finished saying this, they were both sober.

  “When I try to remember, I can’t recall when I learned about death,” said Chen. “How it’s ordinary, but like a sudden hole in the world. I learned it, then I forgot, or maybe I just began to ignore it. Ming and I were talking about kids. Maybe next year.”

  “I’m a fuckup anyhow. Better for me to croak. You stick around.” The mention of Ming made Fitzgerald angry and sick with himself, his drinking, his aloneness. He told himself resolutely that losing her hadn’t influenced the shape of his life, but when he drank he did not believe this. When the bottle sank him below the comfort zone, Ming was one of the if-only-it-had-been-another-way things that became vivid. Fitzgerald decided from Chen’s comfortable manner with him that Ming had never mentioned Fitzgerald, and only once at a departmental party had they all been in the same room. He and Chen had never been very close, but when you do months of “team medicine” together, you end up acting like buddies out of necessity. Now, being in respiratory isolation together, calling each other on the phone, it was like those times.

  “Not what I meant,” said Chen.

  “That’s the way it is. I told Zenkie to write a DO NOT RESUSCITATE on my chart.”

  “You’re being crazy.”

  “Of course not. It’s just common sense. Look, everyone who gets tubed dies. While they’re getting tubed, the resuscitation team catches it. Then some of the people who tubed the guy who died get so sick that they need to be tubed. And so on. They should cut us off from everyone, like a leper colony.”

  “This is early, a new disease. There’re intubated people who haven’t died yet.”

  “Come on. You think we ever beat outbreaks? They run their course, they burn themselves out. It’s just a question of how many people get burnt up in the process. Spanish flu, forty million dead, more than the First World War.”

  “Something like that.”

  (Transcript of Dr. R. Zenkie, FRCPC, dictated March 22, 2003—never transcribed because of deviations from standard dictation format—recovered from electronic transcription system with permission of Toronto South General Hospital)

  ID: I am Dr. Ronald Zenkie, infectious disease consultant and avid nature photographer

  CC: Fever, shortness of breath, heightened awareness of societal paranoia

  (nervous laugh)

  To whom it may concern,

  (pause for coughing fit)

  I am taking the unusual step of dictating my own admission note. Today, I woke with chills and myalgias. My temperature, measured orally, was 39. Over the day, I have become progressively more short of breath, and have developed a cough.

  I think I have a cold, just a regular cold, but these days you never know.

  (pause for coughing fit)

  Erase last sentence, please.

  It is probable that I am suffering from a relatively innocent upper respiratory tract infection. However, it must be noted that I may be perceived as being at high risk for contraction of SARS, and thus it is appropriate that I mandate my own admission to the SARS unit in the interests of public safety.

  How about that, huh? Down with the ship.

  (prolonged bout of laughter and coughing)

  Shit.

  Erase last sentence and expletive, please.

  I have discussed my clinical responsibilities, which will be assumed by Dr. Waterman, who will act as the interim attending staff on the SARS unit.

  Yours truly, Dr. R. Zenkie, FRCPC

  Consultant in Infectious Diseases, Toronto South General Hospital

  (Addendum to SARS Bulletin 14, issued on March 25.)

  To All Staff,

  We are sad to inform you that after a short illness, Dr. R. Zenkie has succumbed to SARS. Our condolences to his family, and thanks for his twenty-six years of service to the Toronto South General Hospital. Staff members who have been in contact with Dr. R. Zenkie have been contacted personally, but are reminded that they are now on work quarantine. All such staff should leave their homes only to go to work, using a private vehicle such as a personal car or a taxi. Masks must be worn between home and hospital at all times. At home, all such staff are reminded to sleep in separate rooms from their spouses, to sit at a minimum distance of 1 metre (3 feet) from family members during meals, and preferably to eat in a separate room. There should be no physical contact with children or other family members. All staff on work quarantine should shower at work, or shower in a separate area of the home from their family members, because of the possible aerosolization of SARS infectious material within showers. Body temperature should be measured a minimum of twice per day, and any oral temperature greater than 38 must be reported immediately. Dr. Zenkie is survived by his wife, Amita, who is admitted in our SARS unit and asks that donations be made to UNICEF in lieu of flowers or gifts. The memorial service for Dr. Zenkie is indefinitely postponed, and we would remind staff that all gatherings of hospital staff outside of the hospital are forbidden.

  Yours truly,

  SARS Action Management Team

  The morning rush. The line behind the hospital trailed out of the tent and into the parking lot. There was an April drizzle but people did not huddle close to each other’s umbrellas. Those with umbrellas stood their ground, and those with bare heads stood at a more than socially polite distance from each other, and gradually became wet. Arriving for the day shift. Dolores eyed the boxes of masks to see whether the blue ones, which were the least constrictive, were available. There were no blue masks. Only the white, itchy ones.

  She saw that some people produced blue masks from their pockets and bags. They had hoarded the comfortable masks, she realized. Dolores had not done so, but decided that the next time she saw a box of the blue masks she would slip five or six of them into her purse. If it rained tomorrow, she thought, then she should bring an umbrella. Or maybe not. If she brought one, someone might try to stand too close to her.

  Ahead, people filed past the dispensers of antiseptic handwash, squirted the bottles, and rubbed their hands and forearms. They gathered up their daily bundle of isolation gowns and scrubs, stood one by one in front of the masked screeners so that body temperatures could be measured with the ear probe, and to answer the same screening questions asked the day before. Dolores saw that one man had his temperature taken a second time. He shook his head. Then a third. He protested. A fourth. A look of resignation. A screener pushed a second mask at him and led him out the side flap of the tent, to somewhere else. Dolores saw that there were security people at each corner of the tent. They did not move, but they, like Dolores, watched this happen. What was the difference between being led away and being taken away? None, she decided, when a security guard stood at each corner of the tent, when everyone had instructions to follow.

  Dolores began to feel warm. The line murmured, looked down, continued to move forward and present their ears for temperature measurement. Yes, she definitely felt warm. It was 7:20, and she should already be getting a signover report from the night shift, but she definitely felt a heat. Then she coughed. A cough. One, and was there another? It did not seem so, but her body temperature was intense, her heart beating. She was not yet inside the tent. She was still in the portion of the line that stood in the drizzle, that was still connected to the outside world of wind and water, a world that did not exist inside the hospital. Suddenly, Dolores wondered who would pick up the kids from the sitter and bring them home if she couldn’t? Their father now lived three time zones away, her closest family was two time zones distant. What would happen if she got to the front of the line and h
ad a temperature? They couldn’t live with the babysitter. They would end up in a foster home until she got better. 7:23. Or what if she didn’t get better?

  No one noticed, Dolores thought, as she ducked out of the line, as she made for her car. She did not look back to see whether anyone followed her with their eyes. Now, she had missed report. All the way home she felt hotter and hotter, more and more inflamed. A fit of coughing at a red light, but maybe she had just swallowed wrong? Told herself to drive carefully. She slammed the car door, rushed into the house in her wet shoes, made for the bathroom, and only once the digital thermometer was in her mouth did she think, But if I have a temperature, then I don’t want to be in contact with my kids.

  The metal wand under her tongue, she remembered with a panic the report she had read that speculated that SARS infectious material might remain contagious even for days outside of the body. What was she doing? What was she thinking? She was in the process of contaminating her children’s home. Whereas all this time she had been thinking only of the problem of picking up her children from the babysitter and bringing them home, now she wanted more than anything to keep them away from this place—this place that she was now transforming into a cesspool of disease. She felt a tickle, a scratchiness, needed to cough, needed to hold the thermometer under her tongue.