A History of the Present Illness

by Louise Aronson

  “Times,” Robert corrected. “Your time plus my time makes it plural, particularly since how we spend our minutes is so very different. Time is one thing I now have to spare.”

  Dr. Sung looked at him. “Do you?” she asked. “I mean, isn’t that what we’ve been talking about these last few weeks? How there’s never enough but also sometimes too much?”

  He placed his e-reader on the table and tilted his chair back onto its hind legs.

  The weekend she threatened to leave, Cate had complained that they didn’t spend enough time together to sustain a marriage. She also said—no doubt quoting Lenore—that she never reached the top spot on Robert’s to-do list, and he expected her to compete for his attentions with the sick and disabled.

  “Have you ever noticed,” Robert asked Dr. Sung, “how most of the time it’s much better to be the doctor than the patient, but occasionally there’s some little shift, a subtle alteration you didn’t see coming, and all of a sudden everything seems flipped on its head and you’re not so sure anymore?”

  He picked up his e-reader. “I may not have been the world’s best husband, but I guarantee you I was a damn good doctor.”

  Then he pounded on the door for the guard.

  The day Consuela Alvarez’s grandson had wheeled her into Robert’s office and lifted her onto the exam table, a fluke winter heat wave had begun that would bake the city for three days straight. Outside, people wore shorts and t-shirts. In Robert’s office downtown, the heater remained on, programmed at some mysterious central location. His staff opened the windows, which helped some but not enough. Robert sweated in his shirtsleeves, but tiny Consuela was burning up. Her grandson wondered about fever and infection, but Robert didn’t think that was the problem.

  When he told Consuela that he needed to send her to the emergency department, she refused.

  “You won’t have to stay long,” he argued. “It’s because of the Parkinson’s, because you can’t sweat.”

  Her grandson stroked her head. “Can’t you care for her here? Please?”

  Asking the grandson to step outside, he and his nurse undressed Consuela. As always, her fingers and jaw shook in short, rapid rolling movements, but they managed to tape ice packs and cool compresses on her forehead, neck, and wrists and cover her with a single thin sheet that he told her grandson to jiggle periodically, creating a fan. While he saw patients in the other room, the nurse gave him regular reports as Consuela’s temperature slowly decreased.

  Midday, her grandson went out to pick up lunch. In a low voice garbled by saliva and interrupted by coughing fits that left her red-faced and panting, Consuela told Robert that she needed his help.

  Robert said he certainly would help if he possibly could.

  Consuela spoke so slowly that several times he had to sing the happy birthday song in his head to keep himself from interrupting. She blinked once every forty seconds, and it took twelve blinks for her to explain what she wanted.

  That same day, Paul Massey, kept awake at night by the searing twitches of his right facial nerve, fell asleep at the wheel and drove his car into a stop sign, luckily with only minor injuries, though clearly he needed to be seen that afternoon. Serena Chang was in the ER seizing. Harry Cohen wouldn’t discuss how he was managing without the use of the right side of his body. Latrice Jones, only thirty-seven, had an MRI that revealed several new white matter lesions. Tom Julavitz needed a hospital bed, a commode, a night nurse, more medications, a shower chair, a wheelchair, a ramp for the front steps, a night-light, a pill cutter, and a new nervous system. Ten patients had been scheduled for Robert’s morning session, twelve for the afternoon. These figures did not include his hospital rounds or the urgent add-on of Paul Massey. There were also five messages on his voice mail, seventy-six e-mails in his in-box, three piles of reports for review, and—as Consuela described her terror at choking repeatedly on her own secretions so she couldn’t catch her breath and felt as if she were drowning—a courier waiting for him to sign for the divorce papers that had arrived by certified mail from Cate in Wyoming.

  Dr. Sung suspended their sessions. That week, Robert read Things Fall Apart, Gone with the Wind, Portrait of a Lady, Women in Love, The Awakening, and Beloved. The following week, the forensic pathologists hired by Nick Barton concluded that Consuela Alvarez had died of hyperthermia as a result of the unfortunate combination of her many well-documented medical conditions and the extreme heat, and that although the medications she’d taken in the day or two prior to her death might not have been the ones all doctors would have prescribed in that setting, the drug levels were too low to have killed her. The most they could conclude by way of accusation was that maybe Robert’s Spanish wasn’t as good as he thought and/or he hadn’t adequately explained what needed to be done in terms of ongoing cooling to her family. They couldn’t explain the initial conclusions of the local coroner, though one did note off the record to Nick that he always read the local paper when consulting in order to give his work a sense of context and he had spotted the coroner on the society page with two members of the Board of Supervisors reported to be against the city’s plan for a physician-managed universal health coverage system.

  “In light of these reports,” Nick said, “not to mention the recent hoopla over the low solve and prosecution rates for murdered black men in the Bayview and Hunters Point, I’d put money down that the DA will drop your case and you’ll be a free man by week’s end.”

  “That’s it?” Robert asked.

  “There will be paperwork, but yeah, basically, that’s it.”

  “My life has been ruined by . . . for what?”

  “It’s not clear.”

  “How the hell do you do this work?”

  Nick shrugged. “I could ask the same of you.”

  Two days later, Robert walked out of the county jail into an early-summer afternoon in San Francisco. He couldn’t see the fog—it wouldn’t come in for another few hours—but he could feel it. A cold wind blew through his shirt as he watched cars race down Bryant Street, honking and swerving in their haste to get to wherever they were going. He carried only his e-reader—he’d just downloaded Deliverance and In Search of Lost Time, Housekeeping, and Never Let Me Go— and a stack of letters he’d written to Cate. Having read Close Range and Bad Dirt, he knew that Wyoming was tough country but also quite beautiful in summer. He thought he might find out for himself.

  Heart Failure

  Two days before her father’s angiogram appointment, one day before her elder daughter’s disappearance, and just hours before a ragged ball of cholesterol and platelets stopped all blood flow through her father’s left coronary artery, Marta Perez-Barton prepared for her father and stepmother’s arrival for a family dinner. As she chopped and stirred, Marta’s three children loitered in the kitchen, supposedly helping but mostly snacking, when Jason, age eleven, the middle child and only boy, asked whether someday they would need to move to a house without stairs so Abuelita Mercedes could still come to visit. Marta realized then that her kids were worried about the wrong grandparent, so she sat them down at the kitchen table and started explaining about heart disease.

  Sophie pushed back her chair and stood up. “I’ve got homework.”

  “Later,” Marta said, using the calm, even tone recommended by their family therapist. And then she waited, as if she had all the time in the world. “Don’t let her provoke you,” the therapist told them week after week. “If you react, things escalate, and she wins.” Marta and Nick sometimes wondered why they paid to be told what was essentially common sense and what she as a practicing physician should already know, but they believed that seeing the psychologist meant they were doing everything possible to help their daughter. And they kept believing, even as Sophie’s anger deepened and she stopped accompanying them to therapy.

  Sophie slouched back into her seat. “Tic-toc,” she said. “Better clue us in before the geezers show.”

  Marta took a long, slow breath. In the Pere
z-Barton household, the children were allowed to swear, as long as they did so appropriately and infrequently. Words like geezer, by contrast, usually led to discussions on the nature of prejudice and the importance of language.

  “Go on, Mommy,” Olivia said.

  Marta shifted slightly to face her two younger children. “The heart is incredible. It beats one hundred thousand times a day, thirty-six million times a year. And it’s able to do this because—”

  She stopped talking. Sophie’s arms jutted out from her body, and she tilted her torso left and right in wide dramatic sweeps so the dozen black and white plastic bracelets she wore along her forearms fell against one another, clattering arrhythmically. In the sudden quiet, she lifted both hands above her head like an apprehended criminal.

  “Okay, Sophie,” Marta said. “Go do your homework.”

  Sophie’s lips curled into a tiny, satisfied smile. “And miss a chance to learn about the heart from an expert like you? No way, José.”

  Olivia’s eyes widened. Jason’s left leg jiggled under the table. Three more years, Marta told herself. Three more years and Sophie would leave for college. In the meantime, she would be a good mother and follow the therapist’s advice.

  “Livia,” she said to Olivia. “Pass me your crayons and a sheet of paper.”

  Using pinks and blues and purples, she sketched a cartoon of the blood’s path through the heart. Next, she drew a close-up of two coronary arteries, one clean and healthy and the other filled with thick yellow plaque, and then she explained about heart attacks, using a red crayon to clot off the diseased artery.

  When she finished, there was a pause, and then Jason said, “I don’t understand what this has to do with Abuelo.”

  Olivia let her bangs fall into her face. “Me either. Sorry, Mommy.”

  “Yawn,” Sophie said, and yawned.

  Marta pointed at her drawings. “This is what your arteries look like, and this is what Abuelo’s look like. That’s why he’s going to the hospital for a special test.”

  Jason said, “But they’ll fix him, right? And then he’ll be okay?”

  “They can help, angel,” she said. “But he needs to be careful. And that’s what I want you guys to remember tonight. Abuelo looks strong and healthy, but he might be really sick. More sick than Abuela Mercedes. So no games. No running around.”

  “Mommy,” Olivia said. “I still don’t understand.”

  Sophie picked at a pimple on the side of her nose. “Who cares? This is just another one of her ‘stuff you kids need to know because I’m a doctor’ talks so she can avoid telling you Gramps—oh, sorry, Ah-boo-eh-low—is a goner.”

  “What did you say?”

  “Uh-oh, kiddos,” Sophie said to her siblings. “Mom’s going deaf. Oops! I mean”—and here she perfectly mimicked Marta’s professional voice—“she’s developing hearing loss.”

  Marta stood up. “Don’t speak to me that way, Sophie.”

  “Or what, Mom? You’ll send me to my room, and I’ll miss the Dick and Mercy show, and then you think I’ll be all weepy and sorry like you if it’s sayonara granddad, time for the big nap six feet under?”

  “Get upstairs,” Marta shouted. “Now!”

  On her way out, just as the doorbell rang, Sophie turned. “Don’t worry, angels,” she said to her brother and sister. “Mom’ll make sure Gramps gets therapy or whatever else he needs so she can get on with her life.”

  Marta’s father and stepmother arrived fifteen minutes early for dinner that night as if, like a foreign country, the Perez-Bartons’ Glen Park home contained unforeseeable deterrents that might jeopardize their meal.

  “We’ll get it,” said Jason, tugging at Olivia’s sweater when the doorbell rang a second time.

  “Great,” Marta replied. After years of practice, she, Nick, and their two youngest had mastered the art of the rapid switch from private to public selves. Less than a minute after Sophie’s outburst, Olivia opened the front door grinning widely so her grandparents might notice her newly missing tooth.

  Ricardo Perez wore pressed jeans and a soft sweater the same backlit brown as his eyes. Well into his seventies, he still had the carriage of a military man or the leader of an impoverished but proud people, though he’d been neither, just a community general practitioner, evangelical about the role of the physician in society and the preservation of the city’s Mission District murals. After a quick hello, with blatant disregard for his cardiologist’s recommendations, he trotted back down the front steps to the driveway. “Was he checking to make sure we were home?” Nick asked while Marta watched her father’s comb-over fall into his face as he bent to open the car door for Mercedes.

  Overweight and a little breathless, Mercedes grasped her husband’s hand in both of hers, still fearful a year after her knee replacement. She wore a halo of tight copper curls—“Someone’s been to the beauty parlor,” Nick said—and what appeared to be a designer dress, far too fancy for a weekday dinner with the grandkids. Later, she told Marta that the dress was homemade, constructed over six months of Tuesday afternoons at the city college senior fashion class, and she wanted to show it off. Ricardo wouldn’t attend the Older Adults Department courses or the Lifelong Learning Institute at San Francisco State. He spent his time up at the University of California Medical Center instead, going to all the free lectures, his stethoscope tucked into his suit-coat pocket as if he’d just come from the office.

  Inside the house, Nick helped Mercedes with her coat while Olivia took her grandfather’s arm and led him into the dining room. Jason had disappeared after opening the front door. Now he moonwalked in from the den and tucked a small electronic device into his back pocket. He shook his grandfather’s hand, then circled Mercedes. “Hmm,” he said. “I bet I could rig that so it lights up.”

  Mercedes looked down in horror at her dress. It was red and covered with hundreds of tiny metallic disks she’d sewn on one at a time herself.

  Nick took Jason by the shoulders from behind and tilted him backward until they were eye to eye. “I bet I could rig it so you had to eat dinner in your room.”

  Jason grinned, shook free of his father, and kissed his grandmother. “I meant that as a compliment. No kidding. You look totally glam.”

  Mercedes smiled uncertainly.

  “Glamoroso,” Nick explained. “A good thing.”

  “Abuelo?” Olivia asked. “What are they going to do to you at the hospital?”

  Ricardo tucked an errant wisp of Olivia’s hair behind her ear. “They are going to take pictures of my heart and maybe clean out its pipes,” he said. “You remember last year when you stayed with us and we had to call a man to come fix the kitchen sink? What they will do to me is something like that, like Roto-Rooter.”

  “Roto-Rooter of the heart?” Olivia laughed.

  From upstairs came a stomping. The ceiling shook, then a door slammed.

  Nick said, “Why don’t we sit down. I’m starved.” He pulled Mercedes’s chair back from the table and pushed it forward again once she was seated.

  “Me, too!” Olivia said, waiting beside her seat.

  Jason and Marta went into the kitchen to get the food. Neither Ricardo nor Mercedes asked where Sophie was or why she wasn’t joining the family for dinner.

  A necessary barbarism. A mutilating assault for an undeniably good cause. In the years prior to Sophie’s adolescence, that was how Nick described his oldest daughter’s entry into the world to family and friends. For Marta, the birth by cesarean section had been like the Civil War surgeries she’d read about in medical school, chaotic and bloody and brutal.

  The epidural wouldn’t take. Frustrated, the anesthesiologist treated her as if she were a patient instead of a colleague. “Can you feel this?” he asked over and over, repositioning the catheter and poking her legs and pelvis with a pin. When she answered yes and yes, he tried again, but eventually he gave up, shaking his head in disgust, as if she were the problem. So when all the monitors alarmed, sign
aling fetal distress, and the obstetrician cut a long, horizontal window across her abdomen, Marta felt pain like an explosion that reduced her to a single inflamed sensory bundle. She smelled shit and blood and singed flesh, and she listened with a cringe to volleys of high, piercing sound she only later recognized as her own screams. She watched herself being filleted, and if the pain and the nurses hadn’t held her in place, she would have lifted herself up off that table and tried to kill them all.

  Perhaps for that reason, bonding with her firstborn hadn’t resembled the experiences described in her new-mother books. What, Marta privately wondered, was so terrific about a bald, blemished, inarticulate being who transformed one’s life using precisely the same techniques used to indoctrinate people into cults? For weeks that felt like decades, she resented the sudden and drastic change in the way she spent her time, the dietary restrictions and sleep deprivation, her relentless busyness and loss of privacy, the monotonous repetitive tasks, the forfeiture of her former activities and professional identity, and, most of all, other people’s assumption of her unconditional surrender to her infant’s needs, the universal belief of family members, friends, books, and health professionals that these changes constituted not only life’s greatest miracle but her own greatest joy.

  And then one evening when Sophie was two and a half months old, she began to cry and wouldn’t stop. Nick fed her and changed her diaper and walked her around and sang to her, all to no avail. Finally, he carried their wailing daughter into the bedroom where Marta was trying to nap and placed her on Marta’s chest. Sophie quieted mid-scream. Her eyes widened, and a few minutes later, they both fell asleep.

  That night, Marta began to appreciate her new role. She returned to work on schedule two weeks later but negotiated a decrease in her clinical responsibilities so she’d have more flexible hours and fewer ancillary demands. Four years and two miscarriages later, they had Jason, and three years after that—to their surprise—came Olivia. As Sophie reached her tweens, Marta watched as her eldest became increasingly strong-willed and serious, less family-focused than Jason, and more needy than her much-younger sister. Conveniently forgetting that Sophie hadn’t always been that way, Marta attributed those traits to genetics, birth order, and the unique individuality she and Nick tried to cultivate in each of their children. In other words, long after the signs of serious trouble appeared, she underestimated their significance. She made excuses. Like Nick, she repeated the story of Sophie’s beginnings to her friends, as if to say they’d been through hard times before with this kid and look how well things came out. As if the story offered more insight about her daughter than herself.