by David Watts
It’s not me, I say.
What?
Frank, go have your surgery. And blessings be upon you. For Christ’s sake, just do what you need to do. You’ll live longer.
He gathers up his rabbits and tucks them in his pocket. As I watch him, he looks like a man picking up chess pieces at the end of a bad game, not accepting the outcome.
Then he leans over the desk. Can we talk about this again? he says.
THE DOCTOR WITH FOOD ON HIS SHIRT
He was a doctor with food on his shirt, she said. You don’t like to see that, I said. You don’t like to see a doctor with food on his shirt.
And, she said, he put me in a room that wasn’t a room but open space with a curtain around it, short as a miniskirt.
You don’t like to see that, I said.
He said he didn’t know what Asacol was and why I was taking it. I said it was for my disease. He said he didn’t know why they gave Asacol for that disease. I said I’d been taking it for years — Hmm, he said — for my disease and I thought that everybody who had this disease took it. He said he noticed that I worked for that company that had the big scandal recently and what did I know about that scandal because he was interested in what did I know about it. And I said I’d rather talk about my disease, which was why I came, to talk about my disease.
You don’t like to see that, I said. You don’t like to see a doctor who doesn’t want to talk about your disease.
And people were walking up and down outside my curtained-off open space, which was not a room, talking loudly about weight-loss pills and which one worked best, and how Josie’s boobs really looked a lot better now that she’d got them fixed.
And he asked me a couple of questions which I don’t remember, but I do remember it didn’t sound like he knew very much about my disease, or maybe nothing at all, because he looked at me and said you look okay, you look okay to work—just like that—and I said aren’t you going to examine me and he said okay and put his hand on my belly. But I know you can’t tell the color of the colon inside by putting your hand on the belly outside.
He didn’t look at the disease, I said.
He didn’t look at the disease, she said. He might not have known where to look.
Maybe he’s a hired gun, I said.
What do you mean, hired gun?
Maybe he’s a paid killer.
What do you mean, paid killer?
I said, Maybe they have paid him to kill off your disability, the disability you paid into, working all those years at that company with the scandal and the days that made your disease worse, and paying in each month to social security and state disability, that money you paid, in case you needed it later and now you need it and they want him to kill it off.
But isn’t the system supposed to take care of you? she said. That’s what they said when they withheld all that money: The system will care for you when you need it.
I said, It’s cheaper for the system to pay a doctor who will file a report to kill off the disability I put you on and that you deserve because your colitis will not stay under control as long as you work for that company, cheaper than it is to pay your disability. It’s economics.
She said she could see that and it sure felt that way, but she didn’t understand the part about how a doctor could train under that oath to do —what is it? — do no harm? And then go around killing off her disability like that.
I said, Let me tell you a story. Suppose you’re a doctor whose practice is not going well and all the patients seem to be going down the street to the doctor who doesn’t have any food on his shirt. And every patient who sees him is one patient fewer who sees you, and you’re looking around for some way to pay the overhead and buy a biscuit for breakfast and the disability company sends you a patient with ulcerative colitis who can’t work anymore and you look at her and say, She looks like she can work, and they pay you for that. Pay you pretty well. For that. And you keep your office and your biscuit and maybe you know the principle or maybe you don’t know the principle, that if you say no to the disability company, they won’t be as inclined to send you any more patients, but as long as you keep saying “back to work” and things like that, they will keep you busy.
And she said, Oh.
And then she asked, What did he say in his letter?
And I read her the part about how she looked okay and he didn’t see why she couldn’t do some work of some kind.
And she didn’t say anything.
And I said, You could make an appeal, and she said, That’s the kind of stress that makes my disease worse and that I’m trying to avoid by all this, and I said, I understand, and she said, I’ll be okay. But I sure could have used some of that money.
I said I was sorry and then something about how you don’t like to see things turn out this way, and she said, Thanks, and we sat for a while not saying anything.
And then she said, You know, I found out he’s not a gastroenterologist. He’s a weight-loss doctor.
And I said, Was he fat?
And she said, Yes he was.
And what kind of food was it, anyway?
And she said, I’m not sure. It might have been tomato. Pizza sauce or something.
And I said, You don’t like to see that. You don’t like to see a doctor with food on his shirt.
ADVANCE DIRECTIVE
I’d like to be somewhere where the last word of every sentence is not ... Okay?
I laugh.
They’re always in a hurry to finish this and be on to that, she says.
I change the subject. You’re in pretty good shape for the shape you’re in, I say.
By this time I have tracked her down from ICU to the Step-Down Unit, then to the third-floor Radiology Suite. I can feel the pull of the highway that wanted to take me home thirty minutes ago. I am in no mood for delicate conversation. I am speaking to an eighty-five-year-old woman, lying on the X-ray table, her face still swollen with infection and antibiotics.
It is her turn to laugh. You have strange taste in women, she says.
I like feisty ones, I say.
And I know the issue: She’s just off the operating table for a perforated gastric ulcer. She has a big infection at the surgical site and has been refusing the central IV catheter that would give her nourishment, saying she just wanted to be left alone. Meanwhile, the prospect of another surgery looms.
At the ethics meeting yesterday they worried she wasn’t competent to make the heavy decisions of life and death.
I’m disappointed, she says.
Why?
Don’t you have a copy of my advance directives?
Yeah, but you didn’t die. Your directives say that if your heart stops or you quit breathing we do nothing. But you didn’t do that.
Too bad, she says.
And it brought us up square against the same old puzzle we struggle and struggle with but never solve. How can we? Here’s an old lady with a quirky, offbeat sense of humor who chides the medical system for being so impertinent as to cross the street before checking the traffic light. What appears to be confusion might just be the outspoken rantings of her seasoned personality.
It reminds me of my mother’s Winnie-the-Pooh form of understated intelligence, and how it disguised her competency in later years.
Are you competent? I ask.
Hell, yes.
Sounds good to me, I say.
What do you think I should do? she says. What if I need surgery again?
Well, you’re pretty healthy, I say. Just a little crabby.
She frowns.
But I take that as a good sign.
So you think I should do it?
She’s pinning me down, the old goat. Well, here we go.
There are three possible outcomes, I say. Two of them good.
Which two?
The first is easy: getting better. The others, staying the same or dying . . . well . . . for this I have to go back to what she’s thinking.
The ho
use staff said you were about ready to give up and check out, I say.
Maybe I was.
Time to push her a little. Well if that’s so, not making it through surgery is a good outcome.
Possibly. But what do you think?
I can’t answer that. All I can say is that if it were me lying on this table knowing what I know about my life, I’d have to go for it.
I expect a pause, a pondering, a rebuttal that says my life is not her life. But she bounces right back.
I’ll do it, she says.
Let’s be sure about this, I say. It seems we got to home plate a little fast. Does that mean they can start an IV?
Yeah.
Put in a feeding line?
Yeah.
Do surgery if it is required?
If it is required.
The orderlies come to wheel her back to the floor. She compliments them on how deftly they shift her to the gurney. Something has passed between us that feels like a clean base hit.
I turn to write the note in the chart that will signal her change of heart, and I wonder what the ethics committee would say.
Yes, I know all about competency testing. But that only tells us about the brain. The brain informs, but it’s the heart that makes decisions.
And her heart? Medically, it’s great. After all, it has survived this ordeal. But spiritually?
I don’t know if the decision we’ve made is right. But for her, and for me, and for the moment in which it was made, it was perfect.
SYLVESTER
Have you ever sewn anybody up?
Your first night in the ER, you want not to be noticed. A medical student in the ER is like an acolyte with a passport to the Basilica, accepted in the circle of the holy, keeping his ignorance under his vestments.
It was the resident who had asked, a Ben Casey, no-nonsense-type guy, all hair and body odor under his green scrubs.
The intensity of his eyes required a quick and precise answer.
No, I said.
Then come with me.
The resident pulled a chart—a clipboard with its billowing pages of paper— from the slot at the end of the triage desk and handed it to me.
Read it, he commanded.
I didn’t know where to begin, so I stumbled through name, date . . .
No, no, not that stuff. The chief complaint.
I looked at the line marked CC.
Laceration, scalp, I said.
What else?
Hit on the head with a bar stool. Said the guy just walked up and hit him for no reason. Brought in by police.
Fine. He’s yours. Call me when you get him in a room.
The resident disappeared as if possessed by his next location.
Before I had time to struggle with the idea of where the “room” was and what I was supposed to do when I got there, an ER nurse whizzed by and locked arms with me, and I found myself suddenly traveling like an echo down the terrazzo corridor to the waiting room.
Babies were crying, couples were holding on to each other . . . we seemed to have entered Albert Schweitzer’s holding area at Lambaréné. I was in the presence of misery, collective suffering on a scale I’d not seen before. Eyes rose to look at me — dispassionately, I thought, as if surveying intentions I could not even know myself—at my starched white student’s jacket with its shiny, hardly used Littman stethoscope curled crisply in the top pocket, my blue-and-white name tag, the book of diagnostic signs in my side pocket like a virginal peripheral brain, and the discomfort welling up like magma inside me.
Sylvester! The nurse shouted from a point that must have been two millimeters from my ear.
A tall, lanky, kind-faced black man I hadn’t noticed before stood and, clasping a bloodstained handkerchief to the dome of his head, faltered forward.
That’s me, he said.
Immediately we were in a treatment room, washed in a quality of light that penetrated every dark thing. Sylvester was lying on the table, head covered with orange suds—a mix of Betadine and blood and smutty Wildroot Cream-Oil—that dripped in a foamy collective, noiselessly, to the floor. The nurse, in her gloves, was scrubbing him into a froth.
Here, she said, handing me a saline sponge. Get your feet wet.
I reached for the sponge.
She drew it back. Wait, she said. Take off your coat, get on a gown, and glove up. What size do you wear?
I had no idea. She looked at my hands and pointed to the bin marked Large. Try these.
I scrubbed.
And because I suddenly remembered, I said, The resident said to call when we got—
The nurse just smiled. Scrub, she said. Five more minutes. And then—she placed a disposable razor on the Mayo stand — shave a two-centimeter margin around the laceration. I’ve got to start an IV next door, but I’ll be back.
Odor was rising from Sylvester’s body. It was a mix of beer and armpit sweat and yeast and Granger roll-your-own cigarette tobacco. And now Betadine, too.
Does it hurt? I asked.
Naw, he said.
Just let me know.
I scrubbed and shaved and scrubbed some more. So who got you? I asked. I was embarrassed by the obvious curiosity of the question, a detail that should not be important to a compassionate and experienced helper. But I was new and I was interested in everything.
My friend, he said.
The nurse came back, sloshed the wound with sterile saline.
Irrigation, she said, and sloshed until it lay gaping and exposed before us. It was jagged at one end, with three zigzags that made little triangular peninsulas of skin projecting from the side of the crevasse like stone platforms over an earthquake-shattered crust of earth. The bleeding had slowed to a trickle.
The scalp is a very vascular structure, the nurse was saying. Bleeds like stink, but because of that it doesn’t often get infected. Still, we need to observe sterile technique. You need to reglove.
My lesson was under way.
This is a suture tray, she said, plopping a cloth-wrapped package onto the Mayo stand. I open the outer layer, you open the inner one. Be careful not to touch anything outside the sterile field.
She peeled back the folded-napkin-like points of the sterile wrap.
Drape first, she said.
I draped. The wound lined up under the slit in the thick, heavily laundered cloth, the hems covering his forehead and eyes.
Well, you might let him see, she said. But don’t contaminate your field.
Syringe, she said.
A glass monstrosity with brass rings sticking out from the barrel like Mickey Mouse ears, and the plunger that perfectly fit inside it, lay side by side. The ground-glass surfaces slipped together like fuzzy paper.
Xylocaine, 1 percent. She thrust the bottle in my face. You need to always double-check the label to be sure. It’s routine.
I looked.
Well? she said.
Well, what? I said.
Say it.
Xylocaine, 1 percent, I repeated.
She squeegeed the rubber top with a cotton ball drenched in alcohol and pointed it to me. First draw 5 cc’s of air.
I did that.
Now, with the larger needle, poke the top, push in the air, and draw out 5 cc’s of solution.
It occurred to me that there was still a patient under all that wrapping we served over like a tablecloth. How are you doing, Sylvester? I asked.
You just do what you need to do, he said.
The nurse was peering over the wound. This will take about ten stitches—2-0 silk. He’ll probably take the full 5 cc’s.
I must have looked as helpless as I felt.
Switch to the 25-gage needle — that’s the smaller one — it doesn’t hurt as much. And always inject under the edge of the wound into the tissue. Fewer nerve fibers there. Make little welts of Xylocaine all along the edges.
She went away.
I injected. Am I hurting you?
Sylvester laughed. Am I your guinea pig?
I guess so.
Just make it pretty, Doc.
I raised little mounds and waited. I tried to visualize how the edges, now somewhat swollen with fluid, trauma, and my little injections, would ever go back together. I imagined little buttons and loops and wondered if I would get it straight or manage in my bumbling to hook the button in the wrong buttonhole.
Use landmarks. The nurse was back, standing over my shoulder. Start at the ends and watch how the edges come together with each stitch.
She opened into the space of air above my table and let fall from there a curved needle with a black, thick, silk thread attached to the back end. Grasp it firmly in the hemostat and curl it in with your wrist, she said. She demonstrated the deep curvilinear motion that would gather the planes of tissue, pull them from the top and the base of the wound simultaneously to align them like a sealed fault line.
I decided to start at the jagged end because the parts seemed like interdigitating puzzle pieces. I looped a point into a trough.
You’ll do fine, the nurse said. And disappeared.
I studied the wound. I visualized the pieces. I watched them come together several times before planting the suture needle, curving to its prescribed depth, matching that depth on the other side, then pushing the point through the volcano eruption of its own making on the other shore. I remembered the scene from the movie Kidnapped in which the pieces of the cup on the floor coming together was a visual trick used as a seduction into hypnosis. I snapped out of it and continued sewing.
I was three stitches in and feeling spunky. So how about this friend of yours? I asked.
What about him?
Sure it wasn’t an enemy?