The Beauty in Breaking

by Michele Harper

  Finally, I headed to Room 18, to see Mr. Clements. As I approached his room, I saw a tall, lean man with long dreadlocks gathered into a trim ponytail grazing his waist. He appeared to be a remarkably youthful sixty-eight years old. With his hands resting resignedly in his linen pants pockets, he paced slow circles in his room, periodically stopping to look up at the TV screen in the corner. I walked to the room and knocked on the open door. I smiled and introduced myself. He extended his hand to shake and said, “I like your hair, Doctor,” indicating my own tied-back dreads.

  “Thank you. And yours as well,” I said, smiling. “Mr. Clements—”

  “Please, call me Joshua,” he interjected.

  “Joshua.” I nodded, smiling at him. “I’m so sorry for all the delays. I understand you’re waiting for a bed upstairs to find out why you have this lymph node swelling all over the place. I also understand you’ve had pain. Do you still have pain?”

  “I do, Doc. The pain is coming back. It’s not bad. It’s not like when I came in last night, but a little pain is coming back,” he said, rubbing the front of his abdomen to indicate the location.

  “Would you like more pain medication?” I offered.

  “I’ve never been much into pills. It’s just not the type of man I am, but yeah, today I’d like some.”

  “Of course. Let’s chat about your CT findings also. The doctor on overnight was telling me you have a history of cancer, many years ago?” I asked.

  “Yes, almost twenty years ago I had prostate cancer and two big tumors in my liver. I told them they could do surgery to cut them out. They wanted me to do chemo and radiation, too. The doctors kept pressuring me about that, but I didn’t do it, Doctor. I just couldn’t. So many people told me I was crazy, but to me, those supposed cures just felt like poison. Instead, I took herbal supplements and ate healthy. I went on long walks and felt good. That’s just my way, Dr. Harper. I prefer to keep things natural. I know it was a gamble no matter what I decided, but I’ve lived a healthy life and cleansed my body that way. Luckily, I’ve been fine ever since—well, until now. It’s just that I had some pain in my belly last night, so I came in to have it checked out.”

  The CT findings indicated a malignancy.

  This poor guy, I thought. There’s a macabre medical maxim that says that the good people get the worst diseases. If a person is generous of spirit and comes in with a nagging abdominal discomfort the week after she runs a marathon, we’ll discover she has stage-four ovarian cancer. The racist pedophile who drowns kittens on Sundays survives being struck by lightning and lung cancer as he chain-smokes into his nineties. I was almost certain—almost—that there was no truth to this rule, apart from it proffering an emotional cocoon for us to fold ourselves into during difficult conversations.

  I never liked being the doctor in the ER who, after knowing a patient for mere moments, and with only the benefit of a CT report and no definitive result such as a tissue pathology, had to introduce the word cancer into the discussion. But I knew it was cancer. I knew, too, that he wanted to know. I sensed that this man preferred the truth served up straight because it honored his right to choose.

  “I see, I see. Now, did the doctor last night tell you that whenever we see lymph nodes like this, we get concerned that it’s from cancer somewhere?”

  “Nah, she didn’t really tell me. She was kinda talking around in circles about swelling and nodes, but she didn’t say the word cancer. Honestly, she didn’t have to say it. I know what these findings on a CT mean. So, what’s happening now? What’s next? Will I just stay in this room all day?”

  “You know, Mr. Clements—Joshua—that’s an excellent question. Right now there are no beds in the hospital, and it looks like there won’t be any for a long time. Maybe not until later this evening or even tomorrow.”

  “Oh, Dr. Harper, I can’t stay here. I’m a vegan, so I can’t even eat hospital food. And I haven’t eaten since yesterday afternoon.”

  He was correct. This was no place for this man to use up more of his life, lying between bleached sheets, in a room with no natural light and no plants, forced to decline a breakfast tray of processed meat and eggs.

  “I’m sorry about that, about the delays and the food,” I said, then paused. “Joshua, I have to be honest with you. In your case, you don’t really need to be admitted to the hospital. A cancer workup is the kind of thing that is typically completed as an outpatient, and I really think you’ll be more comfortable that way. Of course, we can continue with your admission to the hospital as well. I’ll leave the choice to you. I’m just saying, why be cooped up here when you can be comfortable at home and outside in this beautiful weather? If you like, I can write you a prescription for pain medication to take at home, if needed, and I can call the oncology doctor now to make sure you’re scheduled for an appointment where the evaluation can be finished. The decision is yours.”

  He was a man who wore freedom more handsomely than any confine, so this idea suited him well. “Please, please. That sounds so much better. I don’t want to be cooped up here if it’s not necessary.”

  “Let me just call the oncology doctor now and see what they say, in case there’s any additional information they’ll need before you go. Is that all right?”

  He clasped his hands in front of his chest and bowed his head slightly as he looked at me. “Yes! You’ll come back and let me know?”

  “I’ll let you know. I promise,” I said, smiling.

  The oncology doctor called back and requested that I order a couple more blood tests as part of the cancer workup, including a PSA level and a chest CT for cancer staging. Her office would take Mr. Clements’s information and call him for an appointment within the week.

  Mr. Clements, apparently relieved by this expedited evaluation, agreed to stay to complete these studies. He then called his family with updates and asked them to bring him food, since he would be with us a couple more hours.

  As I finished placing these additional orders, the orthopedic doctor came over to let me know that he had seen Mr. Spano and drained his abscess at his bedside. He recommended that he be admitted to the Internal Medicine service for intravenous antibiotics, as we had discussed. He warned me, though, that Mr. Spano was refusing to stay.

  “What?” I said, baffled. “You’re kidding. He was just begging for us to save his life.”

  “Not kidding,” he responded as he left the department.

  I reviewed Mr. Spano’s results. His vital signs were now normal, and his labs were reassuring. His CT showed a superficial abscess and soft tissue swelling, but no gas formation—more good news.

  I hurried down the hallway to Mr. Spano’s room. He was sitting in a chair, shoving his feet into his sneakers. His brother had apparently already left, and he was now alone in the room with Carissa, who was trying to explain to him how important it was for him to be admitted to the hospital as planned.

  “Mr. Spano, what’s going on?” I asked, pretending not to know anything about his newfound urgency to leave.

  “I gotta get out of here,” he snapped. “I have things to do. I can’t just lie around here. I’m better now. I need to go.”

  “Mr. Spano, you’re better because we gave you a lot of very strong medicine to treat you. You’ll need more of that medication to ensure you continue to get better.”

  “Well, then I can just leave with this IV. Just give me the medicine and I’ll inject myself, or I can get my family to do it. I have family members who are nurses and doctors.”

  “Mr. Spano, you cannot leave with the IV. Your leaving with this IV would be against every hospital policy everywhere.”

  “Well, then just give me pills,” he said, tearing the IV out of his arm and throwing it to the ground. Blood dripped from his arm onto the floor, and he snatched a piece of gauze off the medicine cart next to him, held it to his arm, and then threw it to the floor next
to the IV he had already discarded. He stooped down to tie his shoelaces.

  “If you must leave, I’ll certainly write you a prescription for antibiotic pills to take at home, but Mr. Spano, remember when you came in just a couple of hours ago? Remember when you sat on that stretcher crying and begging us to save your life? Remember how I told you that you have an infection that could kill you?”

  His hands stopped mid-bow on the left laces. For a moment he looked at me, and seemed to follow my point reluctantly. He nodded.

  “Well, that is still the case. You still need that medication. You could still get very sick and perhaps die if you leave now without adequate treatment.”

  “Listen, there are other things I have to do,” he said, bending over to complete the last lace. He stood up again and walked over to the side table to collect his jacket and phone. “I can’t just sit here all day and night in a hospital. I have to finish paperwork for a job interview. I have a court hearing for custody of my son next week.”

  “If all goes well, you’ll be out of the hospital within a couple of days,” I told him. “That won’t conflict with court next week. As far as paperwork, isn’t there a way you could complete it here?”

  “Listen, I just have too much to do, so I’m leaving,” he said.

  After he left, Carissa and I looked at the trash on the floor and the trail of blood.

  “What a waste,” Carissa said, as she kicked the trash into a pile and threw a chuck (a large medical napkin with a surface to soak up liquids) over the blood. “I knew he was gonna do that from the very beginning. What a complete and utter waste of time.”

  Mr. Spano had left without his prescription for antibiotics, without the dressing changes for his leg, without his discharge instructions, and without follow-up appointments.

  I walked back to my station to scribble out some notes stating that Mr. Spano had left against medical advice. I forwarded the notes to his primary care provider and to Orthopedics, hoping that one or both services would try to contact him to make sure he was healing well.

  Within ninety minutes, a very patient Joshua Clements would also get to go home. Radiology called again, providing a reading of his chest CT that was much like the CT of his abdomen: “Nodules too numerous to count.” While the normal range for prostate-specific antigen is around 4, his level was over 200. I called Urology, who took his information for a walk-in appointment in four days to discuss what was certain to be a widely metastatic prostate cancer.

  I called back the oncology service, who appreciated the follow-up and reported that someone would call Mr. Clements later that day to set up an appointment. Then I went back to his room to find him flanked by a fortysomething couple; the man’s face was almost identical to his. The spirit in the room was aloft with laughter.

  “Hello, everyone. I’m Dr. Harper. I’m back to give you the most recent results before you get on with your day.”

  “Dr. Harper, this is my son, Reid, and my daughter-in-law, Tracy,” Mr. Clements announced, making his introductions.

  “Hello,” I said, greeting each of them. “So, Mr. Clements—”

  “Joshua,” he reminded me.

  “Oh, yes, sorry. I keep doing that! Joshua, I have two more results for you. Your PSA level, the level for your prostate antigen, is super high. You probably remember talk of this from your last bout with prostate cancer.”

  “Yes, yes, I do.”

  “Also, the CT of your chest shows the same thing as your abdomen: numerous nodules everywhere. The combination of all this information suggests that this is all coming from the prostate cancer we were discussing earlier.”

  “I figured, Dr. Harper. I figured it. Wow,” he said, looking at his children. “Wow, I feel fine!” He placed his hands on his chest and took deep, ample breaths as his hands expanded with each inhalation and contracted with each exhalation. “They’re all over my chest, but I’m breathing fine.” He looked at his children and continued to drink in the air. Lowering his hands to his lap, he said, “You know, Doctor, I’m not afraid. I’m just not. I’ve had a really good life.” And then he laughed—a joyous, relieved, contented laugh.

  His son looked at him and then at me. “You know, he’s right. This old man has had quite a run,” he said, chuckling. “Now I have to run around behind him like I’m the dad!”

  “Ah, then all is as it should be,” I responded, joining them in laughter.

  Joshua continued. “I eat clean, I live clean. After all this time, I can say I’m truly at peace with whatever is to be. I had cancer over twenty years ago, and they said I would die if I didn’t let them irradiate my body or fill me up with chemicals. I didn’t want that then and I don’t want it now.” He placed one hand on his chest and one on his abdomen. “So strange. I’m breathing fine. I’m feeling fine. I look fine, if I do say so myself!” He laughed aloud again. “But, no, I mean I just really feel fine,” he said, looking down at the body beneath his hands.

  He inhaled for two counts and exhaled for four, looking down at his feet at the edge of the bed. Switching his attention to me, he smiled and repeated, “You know, I’m just not afraid. I’ll go to those appointments, Dr. Harper, just so I know what exactly is going on. I won’t do chemicals or radiation, but I’ll get my diagnosis, then leave it be and feel this good for as long as I can.”

  His son and daughter-in-law looked at him, full of courageous love. In that moment, there was no doubt in my mind that this was the most peaceful room in the hospital, perhaps in all of Philadelphia. I wanted to stand there longer just to be with his presence. I wanted to exhale all my anxiety over the uncertainty of life and breathe in Joshua’s absolute faith in the universe, his absolute love for his body regardless of its tumors, his absolute comfort in his own skin.

  “Joshua, the oncology team will call you later today to schedule your appointment. I’ve already spoken to the urology team, and they want you to return for your appointment Friday morning at nine a.m. Will that work for you?”

  He nodded.

  I continued: “Of course, I’ll write you prescriptions for pain and nausea medications, should you need them. Do you all have any more questions for me now?” I asked.

  His children shook their heads. Joshua got up off the stretcher and put out his arms to signal a hug.

  I felt my back stiffen—a reflex. We emergency room doctors don’t get too close to patients. It could be a fear of bedbugs, contaminated blood, or maybe the sacred integrity of the boundary between doctor and patient, or even just a fear of getting too close to people we hand off to others. In the split second between his extending his arms and my lumbar muscle contraction, I considered the unwritten rule of maintaining at least a gloved hand’s distance from patients at all times. In the second before his warm embrace and his kiss on my cheek, I decided that sometimes these boundaries are more effective at keeping us caged in rather than at keeping others out.

  “Sis, I want to thank you for making me feel like a human being through all this.”

  “My pleasure. All the best to you all. All the best on this journey.”

  As Joshua and his family gathered his belongings, I returned to my station and wrote up the discharge paperwork for him and then checked the tracking board. I needed to follow up with my new patients from that morning and the ones who remained from the night before. Luckily, two of them had magically received beds. My colleague had finally arrived and picked up five patients—out of guilt, I was sure. I signed up for one of the remaining—a seventy-year-old man with chest pain and normal vitals who was currently pain-free and had a normal EKG. I put in all the typical orders, which would save time and buy me a solid forty minutes to catch up on the work from earlier.

  It was a good time to make a quick coffee run. I needed some form of caffeine to be able to do my work, but I needed the glimmer of sun and fresh air the ten-minute walk to Wawa would provide even more.
/>
  Later that evening, at home, I poured myself a glass of Côtes du Rhône and settled in to eat dinner, a healthy comfort meal I deserved. I was glad that I had treated myself to flowers two days before. Right then, there was nothing in the world better than sunflowers, peonies, and roses as the backdrop to my meal.

  I contemplated my time with Mr. Spano and Joshua. I marveled that Mr. Spano, who, once he’d learned that he wasn’t going to die that afternoon, had found the prospect of remaining in the hospital so unsettling that he had preferred to hobble out on a bloated red leg and risk dying a few days later, although he wasn’t yet thirty. I wondered what it must have felt like for him, without the haze of intoxication, to blur the relationship between himself and the truth. What was so terrible to face that death would be preferable? How might his inner contract read that he would be consumed with such a compulsion?

  I am not healthy and cannot commit to healing. I am not strong enough to heal. I am fearful, so I must run. I am not worth fighting for. I am not worth healing for. I cannot endure the pain of facing my life. Because I am afraid I cannot be here sober; besides, I cannot be helped. I do not love myself enough to take care of myself. I do not love myself enough to allow you to take care of me. I do not deserve wellness, so I return to what I deserve.

  What struck me powerfully was that Mr. Spano had honored every word of his inner contract. (Like everyone, he had this right of self-determination.) We do this when we select the partner who confirms our feelings of unworthiness, when we pick the job that pays us less than we deserve. It is all the same. It is all part of that contract that even if we didn’t write it for ourselves, we certainly co-signed.

  I wondered, too, about my contract with myself. I wondered why the behavior of this self-hating man would rock me for even a second. I thought about how I needed to love myself enough to allow others to fulfill their contracts with themselves, be it Mr. Spano, my ex-husband, my father, my mother, Colin, the hospital administrators, or anyone else. Mr. Spano’s contract demanded that he act in ways that were dismissive of my attempts to help him. A human being can never treat another person better than he treats himself. So, if he says things that are disrespectful, this is his contract. His contract has nothing to do with mine unless I allow it to—unless I uncover a clause, in minuscule print on page 5, a clause that I overlooked, that stipulates my need to be validated by the Mr. Spanos of the world in order to feel okay about myself. He was kind enough to prompt me to review that section again, to edit out that portion for good. In that way, he was an angel of the shift.