THE NEXT WAS A GUY on Acute Men’s, who according to the nurse had a temperature of 106.3. There didn’t seem anything else wrong, the report said, but the temperature was 106.3. This seemed unlikely, but if it was real it was probably the most acute thing on Joe’s list.
The patient was seated on his bed, hands clasped between his knees, head bowed.
“Mr. Bowen?” Joe called softly from the doorway.
The face turned up. It belonged to a thin young man who couldn’t have been out of his twenties. He looked at the doorway without much acknowledging us.
“It’s Dr. Bellagio,” Joe said in the same quiet tone. “May we come in?”
The patient made a series of spasmodic moves toward the wall that made me think of cornered prey.
“It’s okay, Mr. Bowen,” Joe said. “You remember me. I’m Joe Bellagio, one of the doctors.”
He stared at Joe.
“How are you feeling?”
“Okay.”
The matter-of-factness of his answer startled me.
“The nurse thought you might be running a fever.”
The patient looked past us to the door and shook his head, miming an obscure warning.
His voice dropped to a whisper. “It’s in my shoe.”
“Ah,” said Joe. He turned to me. “Mr. Bowen believes he has a transmitter in his shoe.”
Before I could catch myself, I looked at Mr. Bowen for confirmation.
“It’s not just a transmitter,” he said reproachfully.
“He believes it tells him things.”
Bowen’s expression was almost sullen. “It does.”
“Is it telling you anything now?”
Bowen cocked his head. “It’s listening.”
“To us?”
He shook his head.
“To you?”
Nod.
“And who do you think it is this time?”
Bowen leaned close to us, and after scanning the hallway behind us whispered: “NPR.”
In spite of myself, I laughed out loud. Bowen recoiled fully into his shell, and it took Joe a long minute to coax him out.
“He’s sorry. He didn’t mean it. He just—” Joe looked over his shoulder at me, pleading. “He just doesn’t understand.”
Now I was the recipient of the reproachful stare. “I’m sorry,” I said experimentally. Bowen dropped his gaze to the floor, where a pair of battered penny loafers lay innocently askew.
“I know,” he said wearily. The eyes flickered up at me, the expression almost pleading. “But it’s true. They do listen.” He looked at me for a long, searching moment before turning again to the floor. “They do.”
I would like to say that I said something in return that expressed my deep sympathy and understanding. That I said something that showed Mr. Bowen the error of his ways, and that through my insight he was cured. Instead I simply stared at him, feeling the empathy one feels for an insect struggling with some heavy piece of debris: cold, fascinated. A brief shiver of disgust—the same almost physical qualm I had felt on F-Max—made me turn away to Joe. I said, “Are we picking up signs of fever here?”
Joe looked startled for a moment, then recollected himself. “No. Sorry, I guess we’re not.”
The exam was unremarkable. Temp was 98.4.
A PATIENT ON GERO had vomited about an hour ago, which put him next on the list. At the nursing station, the unit clerk looked up from a stack of charts. “He’s in the back hall.”
“What happened?”
“He’s been eating garbage again.”
This turned out to be less figurative than I thought. The patient, an eighty-three-year-old man whose history was a scant catalog of ordinary ills ending with “frontotemporal dementia with behavioral disturbance,” had been deposited here several years ago, apparently after a scuffle in his nursing home. He had a court-appointed guardian and a habit of eating out of the garbage cans.
“What does he eat out of the cans?” I asked.
The clerk looked at me. “Garbage.”
I started to request specifics, but Joe explained, “We see this sometimes. It isn’t food, if that’s what you’re asking. It’s anything.”
“Anything?”
“Oh, honey,” the clerk said. “You don’t want to know.”
“Do I?” I asked Joe.
Joe shook his head. “It’s pretty nasty. There’s something about it—it’s not just random, because he doesn’t pick up stuff off the tables, you know? It has to be in the garbage can. It has to be—”
“Garbage,” the clerk cut in. “Last week he yacked up a ball of tinfoil, two bottle caps, and a latex glove. And before that?” She shuddered, rolling her eyes. “Oh, honey.”
“Coprophagia,” Joe explained.
We found Reginald Scatliff in a back hallway. He was slumped on a low bench, leaning over a basin; a nurse sat at his side. As we approached, he retched loudly and emptily over the basin.
“He okay?” Joe asked.
“Oh, he’s okay,” the nurse said. She stroked what was left of Scatliff’s hair back from his face. “He’s just feeling a little upset,” she crooned. Then, in a stage whisper: “Something he ate disagreed with him.”
“Do you know what it was?”
She looked at the basin, in which a thin yellow fluid was swirling. “Not yet.”
“Mr. Scatliff?” Joe called.
“Doc, you know he can’t hear you.”
“He can hear.”
“Yeah, but he don’t know what you’re saying.”
“Mr. Scatliff?”
The face turned upward. A few beads of sweat hung in the thin eyebrows. He seemed to look straight through us, then he rose abruptly from the bench. The nurse caught the basin as it slid from his lap. Without a backward glance Scatliff started shuffling down the hallway, stopping every ten feet or so to gaze right or left before setting off again.
We waited until he reached the next bench, halfway down the long hall, before catching up with him.
“Come on, Mr. Scatliff,” Joe murmured as we steered him toward the bench. “Let’s sit down.”
Scatliff stood by the bench, showing no inclination to sit.
“Please sit, Mr. Scatliff.”
He started off down the hall again. This time we pursued, and he picked up speed. Down at the far end of the hallway stood a trash can. We followed him as he homed in on it, his hospital-issue slippers scuffling faster as he approached his goal, his hands beginning to work at his sides. He let out a low, almost melodic moan.
He reached the garbage can and sank, painfully, to his knees.
“That’s enough, Mr. Scatliff,” Joe said, reaching to stop him as he groped within the can.
Scatliff glanced angrily at Joe’s hand, slapped at it. He seemed to think Joe was competing with him. The moaning became a series of staccato grunts.
Joe had managed to get a hold on both wrists and was turning him, trying to be gentle but increasingly struggling as Scatliff’s cries grew louder. Two aides appeared and began to lift him bodily off the floor. He milled his legs beneath him, crying out as the aides carried him to a nearby chair. When they deposited him in it he sprang up again, his eyes still on the can.
“We’ll need to restrain him,” Joe said. “That’s fifteen minutes of paperwork. Sorry.”
I watched as the aides levered him into a geri-chair. Scatliff looked hungrily past them toward the object of his desire, his head swiveling around as they turned the chair away. His mouth hung open, the tongue working over the toothless gums. In his eyes was a clear blue intensity that shone out for a moment, then was gone. He slumped back in the chair and let them wheel him toward his room.
In his room, held in bed by a Posey vest, he made no objection as we examined him. His mouth was empty, his breath foul, and from his abdomen we heard a series of booming gurgles. No response to deep palpation; no rebound, guarding, or mass. Benign.
Joe looked up at me. “Do you think we need to do som
ething?”
I couldn’t imagine anything medical that might help Mr. Scatliff. I shook myself, and made an effort to think of him as a human being who had accidentally ingested a foreign body.
“Start with a KUB,” I suggested, naming a standard X-ray view that would encompass most of his digestive system.
Joe noted this down, nodding to himself as he did. He looked up from his clipboard. “Anything else?”
I looked past him at Scatliff. He was looking back in my direction, trying to see past us. His tongue swept over his sunken lips and he writhed a little against his restraints.
“Could we try feeding him?” I asked.
“You think he’s hungry?”
“Worth a try, isn’t it?”
Joe looked back at me. “I don’t think it’s that kind of hunger.”
“We could try.”
I realized there was something a little off in my tone: I was pleading. With what or whom, I wasn’t sure. But I thought that if I could see Mr. Scatliff eating something besides garbage I would feel better.
“Never mind,” I said, and stood to go. I walked out into the hallway, embarrassed. I had been thinking of Joe as someone who naively misconceived the world we live in. I didn’t like revealing to him some need in me I didn’t understand. It made me walk a little faster toward the exit.
IT WAS MY PAGER that went off as we were leaving Gero. I recognized the number as 1 North, Acute Women’s. I traded my earlier embarrassment for pique. They shouldn’t be paging me. Pages go to the intern. I showed him the numbers on the little screen. “I think this is for you.”
It wasn’t. They had called me because Carrie B was complaining. Shortness of breath. Tingling hands. Dizziness. Her respiratory rate was thirty-two.
“How does she look?”
This is usually a good question to ask of an experienced medical nurse, but here I could never be sure if the person I was talking to was more trained in restraint holds. I asked anyway.
The reply was clearly skeptical. “She looks okay. I mean, her color’s good and all. I think she’s just hyperventilating.”
It seemed a good call. Of course, she could also be harboring a massive blood clot in her lungs. I tried to thrust that thought aside, even though I knew we were doomed to go through the full workup. Unless.
“Have you got a paper bag there?” I said into the phone. “Like a lunch sack?”
A long pause. “There’s the one I brought my lunch in.”
“Could you let her breathe into it? Just hold it over her mouth and nose for a minute.”
Something not quite voiced that I couldn’t hear. Then, “Yeah. I can do that.”
“Thanks.” I was pleading again. “Let her do that for a couple of minutes and see what her respiratory rate does.”
Joe was looking at me, one dark eyebrow cocked.
“It might work,” I said, the defensiveness tumbling out before I was aware. I caught myself. “New admit I worked up earlier. Carrie something or other. Did you hear about her?”
He rifled his sheaf of papers. “Uh-uh.”
“Internal stimuli,” I said. Joe just nodded.
“She’s hyperventilating. Let’s go down to X-ray. I ordered chest films.”
Joe followed me silently toward a stairwell.
“Any idea what I’m worrying about?” I asked him, remembering that part of my role here was his instruction.
“PE?”
“Yeah,” I said dolefully. Pulmonary embolism is something that happens to people after sustained inactivity, to women who are pregnant or taking birth control pills, and to people with cancer or some kind of inborn clotting disorder. It’s a common cause of in-hospital deaths, and because its presentation is often subtle any suspicion usually requires a full workup. And the workup is famously mined with false results. I was not happy to be thinking about PE in the context of strange little Carrie B and her internal stimuli. There was enough I didn’t understand already.
The radiology reading room was (as they often are) in the basement, where we found an empty, darkened room, with darkened view boxes lining the walls.
“Who’s there?” a voice came from beyond the far end of the room. Light leaked around a corner. Reggie, the X-ray tech, appeared, and suddenly the room was flooded with light. “Hey, Doc,” he said, hastily putting down a magazine. His other hand held an overloaded sandwich, which shed shreds of lettuce as he waved it in our direction. “I was just about to page you. Those films you ordered? Carrie B? You gotta see this.”
An uneasiness was gathering in my chest.
Reggie whipped a set of dark transparencies from a cubby below the counter and slapped them onto the view boxes, which flickered. Light and shadows snapped into shape.
The pair of films revealed the thoracic skeleton of an individual, young by the density of the bones, evidently female. Automatically I began to scan, following the protocol: name and date first, then bones, then—
We all involuntarily drew breath.
In half a dozen places, between the cursive sweep of the ribs I saw bright, impossibly straight fine lines, each two or three inches long. They radiated outward from the center, as if deep within the body some source of radiation spat out infinitesimal projectiles of energy. Then my perspective shifted and I realized that the objects I was seeing were pointing inward.
“Oh, my God,” Joe murmured.
They were needles.
“Pretty wild, eh, Doc?” Reggie said. He waved his sandwich again. “I counted seven. There’s one”—he leaned in closer—“you can’t quite see. It’s just about dead-on to the source. Posterior, I think. See? Right there.” The sandwich indicated a distinct hyphen of light tucked under the curve of the seventh rib. “I figure she must’ve—” Reggie reached with his sandwich behind his back, miming a difficult stretch. “Don’t see how she could’ve done that with all those others in there. Maybe she did that one first? What do you think?”
“My God,” Joe breathed again. He was looking at the lateral projection, in which the curve of the spine stood silhouetted, the arms held up to clear the ribs.
We all stared. The image seemed to be holding itself up for us, holding its breath just as we were, all four of us in the grip of something that could not release: the shadowy substance pierced by those impossible bright spines.
“What on earth?” I heard myself slowly—carefully—let out a long breath.
“Wild,” Reggie said again.
“My God,” breathed Joe. “An iron maiden.”
WE POUNDED DOWN the hallway to 1 North and fumbled for what seemed minutes with the keys before passing through both sets of doors. The strangeness of Joe’s words was echoing in the tumult where I was unable to think: I could only feel them resonating, an unease that kept pace with me as I ran down the darkened hallway. Iron maiden, I kept saying to myself. What a crazy thing to say.
The room was dark. On the bed within we saw a shape rigid as a crusader on a tomb. It made no movement as we hung in the doorway.
“Miss B?” Joe whispered.
Only the head moved, rotating slowly to face us. The eyes were open, wide and sharply focused, giving the impression that she had been lying there staring into the dark.
The eyes returned our gaze, their surface sleeked with light from the hallway. Something in the calm directness of her expression unnerved me again, stirring up once more the inward uneasiness that had been following me around all night.
“Miss B?” Joe whispered again.
The figure on the bed did not stir. She just held us in that steady, blank stare. Slowly, as if drawn, we moved closer.
Joe reached out a hand toward her. Almost imperceptibly, she shied away.
Silence gathered, pushing back at us.
My own voice broke against it in a harsh croak.
“We’ve seen the X-ray,” I heard it say.
The moment I said it, the tableau we had unconsciously formed began to dissolve. It was the wavering of her ga
ze that did it, releasing us all from the postures we had been holding. Joe and I audibly exhaled. Joe completed his gesture, his hand reaching her shoulder. “Don’t move,” he said.
A strange guttural sound, rhythmic and rising in pitch, emerged from deep in her throat. She was laughing. The sound rose to a high, tense giggle before cutting off with a sharp cry I could only recoil from.
I held myself carefully, suppressing the recoil out of professional habit: We do not reveal our disgust. Or fear. I kept my face as empty as possible.
“What are they?” I asked. She was taking rapid, shallow breaths, each inhalation ending in a grimace.
She took her time in answering. When she did, her voice was almost comically matter-of-fact.
“Needles.”
I expected something in her expression would change, her eyes to lower, a confession of something. But nothing changed: I stood riveted in her gaze until I looked away. I focused on the movement of her ribs as she breathed. That was scary enough.
“What sort of needles?” Joe asked.
A quick giggle, quickly cut off. “I got them. Here.”
“Like what the nurses use? For blood draws?”
“And injections.” She nodded owlishly at Joe.
“What did you do with the hubs?” I asked.
Her gaze swept back to me, her expression annoyed.
“Why do you want to know?”
Why did I? I considered a moment.
“I’m trying to figure out how to remove them.”
A smile: “I clipped them off. And pushed them. Deeper.”
Joe let out a sigh and turned to me. See? his expression seemed to say. I wasn’t certain I knew what he was inviting me to observe. Or understand. He seemed to have gotten over his astonishment. I was not any surer I understood anything.
AT A SAFE DISTANCE down the hall, Joe stopped and turned to me. He didn’t need to ask the question.
“How the hell should I know?” I said irritably. “This isn’t something they teach in medical school.”
“Do you think she’s safe?”
Internal Medicine: A Doctor's Stories Page 17