A History of the Present Illness

by Louise Aronson

  THE BEAUTY MYTH

  “Oh yeah,” my intern sneered when a dietitian walked by in a short skirt and three-inch heels and all the guys at the nursing station in the surgical intensive care unit turned to watch. “Yeah,” she repeated so only I could hear. “I could look pretty hot too, if I worked eight hours a day instead of twenty-eight.”

  This was at the university hospital on my obstetrics and gynecology rotation. The next day, I caught my first baby, a seven-pound boy. His father held him up, and everything in the delivery room just froze. It was like a medicalized and modernized religious tableau: the father—bearded and decades older than his wife—glowing, the child wailing above his head, the two of them bathed in fluorescent light.

  That month, I worked with my best team yet. The attending had won every teaching award the school had to offer and had allowed a medical student to deliver each of her three children. My senior resident, headed into gyn-oncology, was equally skilled in the most challenging surgical techniques and in giving bad news so the grieving could actually hear and make use of what she said. The intern had conducted groundbreaking research on domestic violence in the South Asian community while she was in medical school and had since published three research articles, the last of which had been picked up by the national media.

  That they treated me as one of them blew my mind. By the end of the month I decided on obstetrics and gynecology as my specialty. It was perfect: both surgical and medical, inpatient and outpatient, young patients and old. Similar to what the rest of my family did, yet entirely my own.

  Hank had finally decided as well. “Really?” said the future neurosurgeon when I told him my choice. “Everyone knows OB-gynies are lame. They’re like medieval with the scalpel. And anyway, what do you get to do that really matters?”

  THE FEMININE MYSTIQUE

  One night toward the end of our third year, Hank came home and called me a slob. I looked at his pants on the floor, at the piles of his journal articles obscuring our futon. For a while I’d picked up after him, but I no longer had the time or energy.

  “Sorry,” I said. “But I was under the impression I was your girlfriend, not your maid.”

  I’d just worked a sixteen-hour day and was expected at the hospital by five the next morning. I took a big mouthful of strawberry yogurt. A perfect pink circle fell onto my textbook. “Dinner,” I said. “Yum, yum.”

  Hank opened, then shut the empty fridge. I kept reading. I was on peds with Raj Patel, our class genius. If I wanted honors—and I did—I was going to have to bring my A-game every day. Besides, the more I knew, the more they’d let me do, and I wanted to do it all.

  Hank said, “We live like shit.”

  I looked up. “You haven’t shopped or cooked either, and you’re on an easier rotation.”

  “Then let’s go out for dinner.”

  I turned the page in my textbook, though I hadn’t finished the page I’d been reading. “I can’t. Sorry.”

  He knelt beside my chair, a position that would have raised my pulse and expectations just a few months earlier. “C’mon. My treat.”

  “I’ve got yogurt.” I wanted him to earn my attention, to beg for it.

  “That’s not dinner.”

  “It is for me.” I pretended to keep reading, noting with satisfaction that the hair at the far end of his part was thinning.

  “Well, that makes one of us, doesn’t it?”

  He went into the living room. I heard the sound of rustling paper and a while later the roar of our ancient vacuum. I returned to studying Ewing’s sarcoma. When Hank came back into the kitchen with my coat a half hour later, I shut the textbook and we went out for Chinese.

  THE BELL JAR

  Three weeks after Hank broke up with me, Althea came over. I hadn’t left my apartment except to go to work, and I’d been ignoring phone calls. In honor of my first full weekend off in months, I had decided to do nothing but watch sentimental family dramas on television, crying as frequently and noisily as I pleased.

  “Up,” commanded Althea.

  When I didn’t budge, she pulled me to my feet and led me into the bedroom. Then she tried to pull my sweatshirt up and off. I pushed her away. “What the hell?”

  “Don’t be stupid,” she said. “You are so not my type. But you do need to shower, and you need to do it now. I’ll be in the kitchen.”

  Apparently she’d brought groceries. I hadn’t noticed. As I showered, then dressed—“Clothes,” Althea shouted from the kitchen, “not pajamas”—she cleaned and cooked, transferring pots of food into labeled Tupperware, filling both freezer and refrigerator before moving to the bedroom, where she changed the bedsheets and straightened the closet, spreading my clothes beyond the half to which they’d previously been confined.

  I watched from the futon. She had muted the sound on the TV while I showered, and I couldn’t even be bothered to press the one little button that would have restored the current sound track of my life.

  Finally, she flopped down beside me. “What’s the difference between a family doc and a pizza?” she asked.

  I didn’t have a clue.

  Althea smiled. “A pizza can feed a family of four.”

  “Family?” I said, feeling interested in something other than my own misery for the first time in weeks. “You’re going to do family medicine?”

  “Ba-da boom!” She grinned, throwing her arms wide. “So I’m ordering pizza, and since you’ll make twice what I do at least, you’re paying.”

  While we waited for our vegetarian special, she organized my medical journals and textbooks, using little pieces of paper color-coded by organ system and enumerated by order of importance.

  “For the record,” she said, looking up from the New England Journal, “you’ve done nothing but complain about him for months.”

  “So?”

  “So, breakups suck. But (a) you might eventually be happier without him if you let yourself, and (b) you’ve worked too hard to blow it now.”

  REVOLUTION FROM WITHIN

  I did my emergency medicine rotation at San Francisco General over the winter holidays of my fourth year. Assigned to the night shift, and with all my friends working days, I developed a ritual of sleeping until midafternoon, then going for a walk to remind myself of things like fresh air and conversations that didn’t include words like pus, gunshot, pain, hemorrhage, or heroin.

  Outside Macy’s in Union Square on Christmas Eve, a homeless man in a SAVE THE WHALES hat held out his cracked palm. After deciding he was not the patient whose boil I had drained the previous night in the emergency department, I told him I gave at the office.

  “Where you work?” he asked. He sat on a filthy army-issue sleeping bag. At his feet lounged a gray-and-white pit bull wearing a red velvet collar studded with small silver bells.

  I told him.

  “I been there,” he said with a smile that lifted the right side of his face but not the left. “Okay, baby, you get a pass. Merry Christmas.”

  In the square across the street, a tree rose three stories above the crowd. Baubles hung from each limb, and a huge gold bow had somehow been fixed to the narrow top. People swarmed around it, holding hands, carrying packages, and pushing strollers. To me they all looked like patients or potential patients, people who didn’t realize that their lives could change, or end, in an instant.

  I crossed back to the Save the Whales man, handed him all the cash from my wallet, and went home.

  That night, the doctors and nurses in the emergency department all wore Santa Claus hats and red T-shirts under their green scrubs. The atmosphere was festive. Someone had loaded the CD player with Christmas music and pressed both the Random and Repeat buttons, so Christmas carols played all night long. Between patients, we drank hot apple cider and ate tree-shaped sugar cookies decorated with sprinkles. Except for the suicides, the shift was fairly quiet.

  BACKLASH

  I was on the gynecologic oncology service in February, when most of m
y friends, having submitted their residency match lists, were lying on beaches or doing “research” months in places like Kenya or Paris or Guatemala. Althea was in the Punjab at the Jawahar Children’s Hospital. Hank, I’d heard, was at Harvard doing an extra sub-internship. Me? I was hoping to stay in San Francisco for residency, and as my father reminded me several times a month, this was no time to let my guard down.

  I spent my cancer month going to work in the dark and coming home in the dark. In between, I devoted an absurd number of hours to changing dressings, hunting down fevers, and replacing the essential minerals that seemed to drain from the cancer patients’ bloated bodies like water through gravel. As if that wasn’t bad enough, I’d somehow decided that if I could deal with the sickest patients, I could handle anything, and so had set the personal goal of racing to the scene every time a code blue blared from the loudspeaker announcing some desperately ill person’s effort to die. No matter the hospital floor or medical service, seconds after the announcement fifteen or more residents, students, and nurses would pack into the patient’s room and vie for the chance to run the code, put in the breathing tube, or somehow otherwise appear useful. Usually I watched and handed people things. Then one morning I was the second person to arrive at the bedside.

  The first person to arrive, who later turned out to be a cardiology fellow named Sheppard, said, “You’re a student?”

  I nodded.

  “Then go to it,” he said.

  I started the chest compressions and felt the patient’s ribs shatter with my very first thrust. The cancer must have been all through her bones.

  Thirty-six minutes later, after Sheppard had made the official call that the woman was surely and irrevocably dead, he looked over at me and said, “Hey, stick around.”

  “Why?” I asked. There were low potassium levels in need of my attention.

  He grinned and whispered, “Because you’re gonna line her up.”

  I stared.

  “You know,” he added. “Put catheters in her.”

  I looked at the patient’s sunken, frozen face and all the tubes already hanging from her arms and neck. “But she’s dead.”

  Sheppard nodded. “Right. So she won’t mind.”

  I put in four lines that afternoon, one after the next, until I had the process down cold. I felt elated, especially when Sheppard said he’d never seen anyone get so good at it so quickly.

  That night, Sheppard and I went out to dinner to celebrate my new skill set. He held doors and chairs for me and insisted on paying the bill, but not on sleeping over. We dated for the next two weeks, until the night he took me to see a romantic comedy and afterward happened to mention that he’d never marry another doctor.

  “You can’t do work like we do and be a good mom,” he said. “There’s just no way. And I totally want to have a family.”

  OUR BODIES, OURSELVES

  For my final rotation as a medical student, I did anesthesia at the private hospital across town. This was late spring of my fourth year, when I’d already received my first choice in the match and knew I’d be staying in San Francisco. With no move to plan and orchestrate, I could focus on getting ready for internship. Anesthesia provided the perfect practice grounds, as it was all about doing procedures and giving medications.

  My first day on call, I got pulled off an elective gallbladder to help with a Jane Doe who’d been found crawling down the sidewalk on the block of Market Street where historic landmarks and prominent department stores gave way to discount retailers, gentlemen’s clubs, and bars. She had a business card for one of the private hospital’s doctors in her sweater, so the cops had brought her in to us. In the ER, they’d figured out that she’d taken a beating and also that Jane Doe was actually Joan Kendall, a former CPA who’d become homeless after having three or four glasses of wine at a party and driving her family into an oncoming semi in an accident that made local headlines for its six instant fatalities (her husband, their four kids, and the trucker) and one intoxicated but unscathed driver.

  The day I met Joan, the surgeons suspected that she had a slow internal bleed, and they wanted to open her up to find out for sure. I explained to Joan that she needed a second IV for surgery and that I was going to numb up the spot before inserting the needle. When I reached for her arm, she pulled it away and tucked it between her legs. When I tried again, after at least a minute spent reassuring and cajoling her, she howled. And when I moved to her feet, still looking for a decent vein, she kicked me in the chest.

  I told my attending that I thought it was time to move to Plan B.

  “No, please, no!” she wailed as I tied her arms to the bed-rails with soft restraints. “No. No. Noooooooo!!” she screamed, louder still, as I pinned her head and torso and my attending held a mask of nitrous oxide over her filthy, scarred, and screaming face.

  As soon as she was out, I put in the lines and we took her to the OR. I ran the whole case, the attending occasionally pointing at a dial or a drug but mostly telling me the story of his solo trip up Mount Whitney that weekend.

  “You’re ready, you know,” he said after we’d dropped Joan in the post-anesthesia care unit. “For internship, I mean. You don’t need this rotation. You should drop it and go on an adventure. Do something wild and crazy while you can.”

  I thanked him but didn’t take his advice. Putting people to sleep so they could be painlessly cut open and made healthier was wild and crazy enough for me.

  WRITING A WOMAN’S LIFE

  The Saturday before my medical school graduation was one of those perfect late-spring days in San Francisco when there’s no hint of fog and the locals who usually complain about the cold complain about the heat instead. Althea and I decided to brave the lines at the dive restaurant on the pier at China Basin in exchange for the pleasure of sitting outside by the water and the seagulls, drinking beer and eating oversize burgers. She too would be staying in San Francisco, doing the Family and Community Medicine Residency at SF General. We joked about how great it would be the day I delivered a baby and handed it off to her for its first full physical.

  We were well into our second beers and discussing all the weddings taking place in the two weeks between graduation and internship, when out of the blue Althea said, “Did you ever feel, you know, like you hated them?”

  “Who?” I asked.

  “Patients,” she answered into her glass. “The ones you were taking care of.” She leaned forward. “You know. All that whining and manipulation and wasted time. The way they made you look stupid and useless in front of your team when you were killing yourself just to keep going and learn and not hurt anyone.”

  Just then our dessert arrived. “Signorine,” said the obviously Latino waiter, with a small bow and an exaggerated sweep of the arm not laden with other customers’ dirty dinner plates.

  “Cappuccino? Espresso? More beer?” he asked without waiting for our answer.

  “Patients are sick,” I said. “Probably they can’t help it.”

  We’d been given a generous slice of tiramisu with three and a half ladyfingers along the edge and a decorative spray of shaved chocolate across the plate.

  “A work of art,” Althea said, pushing the plate toward me. “You eat. I don’t deserve it.”

  I eyed the cream bulging voluptuously between the thin layers of sponge, then moved the plate back to the center of the table. “Not all patients,” I said. “And not all the time.”

  “No,” Althea agreed. “Not even most of them. So why do I keep thinking of the hard ones?”

  A seagull landed on the railing beside our table, opening and closing his beak as if he wanted to join the conversation.

  “You know what Dean Rosenthal would say.”

  Together we intoned, “Focus on your strengths, and you are weak; focus on your weaknesses, and you get stronger.”

  I looked out at the bay. Three middle-aged women glided past the pier in bright orange kayaks. Farther out, a windsurfer struggled to remain u
pright in the scant breeze. The water wasn’t quite the blue green of the tropics, but it sparkled in the sunlight.

  And I had at least four more years in San Francisco ahead of me.

  Althea must have been having similar thoughts. “Mostly it’s amazing, though, isn’t it?” she said. “Medicine, I mean. Interesting, challenging, important—everything you’d want in a career. And we get to do it here.”

  I nodded. “And it probably gets better once you’re really a doctor.”

  “You mean the week after next?”

  We laughed and picked up our forks. The tiramisu was as good as it looked.

  After

  In the rehabilitation and Extended Care Building of the San Francisco Veterans Affairs Medical Center, where some people came and went but most came and stayed, Rodney Brown, a.k.a. A-Rod, nudged the Bible off the edge of his bed. It hit the floor with a slam, and across the room, K.C.’s eyes opened, scanned, then rolled up, and he said, “Shit, man, not again. What the fuck time is it anyway?”

  Rodney ignored K.C. and turned on his call light by slapping his left arm against the pressure-sensitive pad beside him on the bed. And then he waited, something he was getting good at, not that he had much choice, though at least he was better off than Danny Stockton, who had taken one in the head, or Pablo Villela, who lived two floors up on the ward where you didn’t have to do anything for yourself, not even eat, not even breathe.

  He listened for footsteps. Sometimes he could tell which girl was coming by the way her shoes touched down on the linoleum: Esther did a tap-shush, Celeste made a squeak-sigh-squeak, and big Grace—full of self-importance—sounded as solid and steady as a man. With Rita, his favorite, there was only the nearly inaudible brush of one nylon thigh against the other.

  Unfortunately, Rodney’s nose also worked well—too well—and now it was telling him that someone somewhere not far enough away was crapping himself. He hoped it was K.C. and not himself, since the hall was completely quiet, meaning it was still the night shift, the staff sacked out in an empty bed or in the med room or wherever the hell else they hid when you needed them most.