Bedside Manners

by David Watts

  I murmur something, reach for the blood-pressure cuff, and begin unobtrusively wrapping it around her arm.

  Why are we keeping people around who really don’t want to be here? I’ve seen people at Laguna Honda who pray to be taken before morning. I don’t see myself there— I have no great pain at the moment. I don’t exactly have a son and I’d really like to have one to discuss this with. The household was the household. We must accept it as it is. We need to forgive each other. But I can’t.

  I release the cuff. Her pressure is higher than usual. I don’t report it and decide to chalk it up to the subject matter.

  It was almost unendurable, my sister’s death. They were talking only to my son. The heir. He was insisting on the operation, but I had the durable power. I knew what was going on between my sister and my son. They meant much to each other, but they would not let me see her record. My son read it every morning. It was a little difficult.

  But the doctors were kindly. They let me hole up in Bronson Institute, said I’d be perfectly safe so long as I kept the door shut.

  I have learned to schedule my visits with Millie when there is a terminus, in this case my patient with rectal bleeding eleven floors down on the endoscopy suite table, waiting for me. Lost, but recorded somewhere, is the assertion I made when I first entered the room that I had only a short time to be here. I call it forth now. She says fine, fine. But as I quicken my steps to the elevator I can hear her conversation still going like the horn of a diesel locomotive already passed, softening down the tracks in the distance. I will come back later. Or . . . not.

  As I wonder what will come next I reflect that she is too eloquent to be declared insane, too insane to be responsible, and too easily offended to adhere to a constant path.

  The next day I am in the middle of an endoscopy when Rich passes me a note. The way he does this is to crack the door, reach around the facing like an anonymous hand snatching a coin — only in reverse — and stick this Post-it to the door facing. It says MB on the twelfth floor has called. Her number is busy, so I walk up to see her.

  She is on the phone. Sees me and tells whoever it is she has to go.

  They are struggling with me, I know that. I didn’t intend to call you at the endoscopy unit, but your secretary insisted and Rich was very nice and said that it would be okay. They’ve been working on my constipation.

  Additionally, I think I’m bothersome by not taking all the medications all together as they wish me to. I like to space them out, but I try not to make too many difficulties. But they’re not sure if I will take over. I sympathize with that.

  I’m not trying to make a problem, I just would like to go home. It’s not UC, it’s the payment system. We know that. It’s a serious time. We should do better.

  And I’m trying not to get taken over in conservatorship. Because then I would be useless. So I’ve been talking to the State of California and have found a sensitive person in the Department of Health. I’ve lost all my file cards. But I have his name somewhere . . . so it’s . . . everywhere . . . nowhere . . . here somewhere.

  Oh, my!

  Yesterday they were going to get security and shove me in the vehicle. But now they seem to be doing it by the book. The first time they forced me home, they sent people in. They were making the bed up under me. It was a wild scene. But I put up with it.

  I haven’t got my calcium today, but some of the nurses have been wonderful. One has not. I like Russians. I even speak a little. Every time she enters the room she takes the curtain and throws it back. I could be sitting on the commode—whatever. So I reported her and she has, since that time, been difficult.

  I, adhering to my plan, have already started examining her legs.

  Because of the Raynaud’s I need an extra wrap. But yesterday I was uncovered to my knees for the longest time. It was the one on this leg—they removed the dressing. Finally I put socks on it myself. Eventually I did get the nurses and we are trying to find a robe to cover my shoulders and we haven’t achieved that. But that’s okay.

  It was Bill. No, that’s not quite right, it starts with an H. Okay. Well. He’s a very good physical therapist. He could see, contrary to the story “Well, you’re doing fine,” that not all was well. Because of the Lasix I was getting floods of water. So I got out of bed. But they stopped me. They put the walker in front of me. I had a terrible time taking a shower and my head was wet so I took this cantilevered light over the bed like this up against my neck to dry out my hair. That’s why we need advocates.

  You asked me would I go to Laguna Honda Hospital and I sure would. They don’t like me there. They know me: Millicent Barker, UC disaster. But I was there to help the lady with her leg cut off. The problem with the Mariposa is they order you around like cops. And the rooms are depressing unless you decorated them yourself. And the food was excellent, but I know that it is often excellent on the day you are there.

  And, of course, my property has gone whhpp fiitttttt with all this going on.

  When you’re in a wheelchair and you go to any desk like Neurology, that desk is so high you’re only seeing their nose, if that. I’d like to see that changed. Well, I was in a wheelchair and I had gone into the disabled bathroom—you couldn’t use it. So I called to have it fixed.

  And while she was speaking I confirmed to my satisfaction that the evidence of cellulitis was indeed gone. It was safe for her to go home. Well, as safe as it would ever be.

  We’re trying to quiet the wards. You can wear earphones. We’ve changed M-15. You know M-15. Oh yes. I know. It’s the admitting ward. Yes. It is transformed. It is as quiet as can be. And the voices of the nurses are different.

  I raised my hand.

  I know. You have to go. I just wanted to let you know how I’m trying to help out and bring you up to date. They say I’m diabetic. Have been since I hit the hospital. That’s news to me. I wish they’d tell me. But I assume you know that. I’d like to stay until tomorrow evening.

  Will you go and talk to her? To Doctor Silverstone? She wasn’t so nice on rounds this morning. She’s usually nice. She’s beginning to push. A little shovel action, I guess.

  I turn to the door, placing her request among those that get filled if the occasion to fill it comes along. It must be tough to be so concerned about issues of so little concern to most of us, even those who are in the business of care. I wonder how she persists in what seems to be an intensive, dedicated concern. Is she never lonely?

  I go to her chart. I want to see how the house staff is holding up. And I want to know about the diabetes thing, the subject of substance that finally surfaces after hours of fluff. And I read:

  Pt. eval yest. Rec short term SNF placement or d/c

  home c 24 hr home health & PT.

  afebrile. taking dicloxacillin qid

  S. feels not ready to leave hospital as “I need more

  Physical Therapy”

  c/o lump in throat. unsure if improves drinking fluid

  feels legs look better

  O. VA Tm 37 65-75 135-165/65-75 20 97% RA

  I/O good po

  Exam Gen 82 yo lying in bed awake . . .

  . . . medically remains stable for d/c Pt aware. Have

  arranged house PT. will discuss d/c w/SW

  [unintelligible], MS4

  Nothing about diabetes.

  Next day I call her room around noon.

  Oh, Doctor Watts, I’ve been trying to get ahold of you. I am thinking that the solution they have proposed is not the right one for me. Because it is a Somatocor organization. As you know, Somatocor has no use for Mrs. MB. Therefore, if I am a UC disaster . . . I don’t know. I don’t know what to do for the body.

  If you think it’s the best thing to do, I will do it. I thought you were in my camp and I want to go on thinking it. But there are people who are confusing and appear to want to be. And now I am told I am hostile, I am passive-aggressive. I suppose that is their last thing to throw at me. I don’t think that should happen.
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  The problem is the friendlies from Washington — and is there any way this can be used as an example?—I don’t think they want to hurt people. Of course we’ve got Bush now, don’t we. Yes. So there you are.

  This is not to my best liking, but I am told to be thankful and appreciative and gracious. And I will try to do so.

  We hang up. I am struck by the fact that in spite of her having finally consented to my request for her to go to the Step-Down Unit for extended care, I really have very little to do with how things have turned out. Instead of my usual role, in which opinions are listened to and often followed, in this case I am more like a stopover, a nesting box for geese in migration. Maybe it is not my role to alter the impact of disease after all; maybe I can only introduce a little sway in the hammer’s arc.

  Halfway down the hall my cell phone is ringing again. My receptionist will need psychotherapy when I get there. I will ask her to spend time on a project where there is some hope of a positive return. Require her to use her judgment. She will need to apply the graceful art of hanging up without offense. Learn to recognize, as best she can, the event or the trend of events that might be dangerous. Leave the rest to me. And to fate. It is all we can do. My receptionist is troubled. Maybe I will bring her flowers.

  Maybe some for Millicent, too.

  PART

  TWO

  WAITING TO BE SERVED

  The man with the beard, wearing tennis shoes, a ski hat, and a sleeveless red vest, escorts his friend to the car.

  The friend is stiff. He waddles and ooches in a way that I, having had various appendages of my own temporarily disabled, can understand.

  The man opens the door for his friend. His friend falls in. The car on cue bows in response. A cup of coffee in a Styrofoam container sits on the roof. In the moment that passes between equilibrium in the passenger seat and the instant the man reaches for the cup and hands it to his friend, there is, for the man, a little breath, in and out, and for his friend, anticipation, waiting to be served.

  I know about this. My mother, though she lived to be ninety, was always sick or on the verge of something or other. She created within this inhospitable geography of illness a realm of comfort by always recruiting little moments of service like these: my father, in the kitchen scrambling eggs, her boys bringing wildflowers to the bedside, everyone tiptoeing through the rooms in what came to be a ghostlike passage of childhood. We didn’t like giving service, but we got to be very good at it.

  I’ve even wondered if that’s part of the reason I became a doctor, and why, though committed to service, I resist behaviors that service generates. Be strong. Recover. Resist the idea of pain . . . the disease and the disease it makes.

  And it doesn’t make me tough on my patients. On the contrary, it gives me a basis for understanding where they are, and, out of that, more tolerance.

  Mavis calls, complaining of constipation. It’s seven thirty in the morning. The urgency is that she’s deathly afraid to fly and she’s booked on tomorrow’s plane to Hawaii with her husband. She wants me to tell her she can’t go. Well, I have layers of response to that, all the way from “It’s all right if you don’t go” to “Just do what you have to do and stop whining about it.” Well, I guess I wouldn’t say that. I’m too well trained.

  I know, I know, there’s a fuzzy sense of well-being that rises from attention received. It lights up faces. It’s an expression of affection, after all. And it does wonders. And I love doing it, but it’s tricky. The circumstance is born out of need, and need . . . well, need can always be questioned. So the server either has to commit to the legitimacy of the request or wonder if he’s being manipulated. It’s natural to doubt, to try to protect yourself a little. Yet when either the disease or the diseased is convincing, doubt, and all the self-protection it provides, is crushed.

  So the friend receives his coffee, but he is made to wait just a little. Mavis will be funneled into a pathway that takes her to the airport, but the ceremony will contain a few grumbles.

  The man is walking around his car. He is unlocking the door.

  I don’t know him.

  I know him very well.

  FLU SHOT

  She stood in my examining room unable to sit, pacing, then stopping tensely, as if paralyzed by the urge to Space. Three times she had made this appointment, three times a no-show. My secretary raised her eyebrow when she came in. But I had nothing to say.

  Now her eyes touched and glided, touched and glided over me like the scan of an electron microscope, programmed for the penetrating search.

  I fetched the vaccine, rended the silver packet for its sterile pledget, swabbed the red nipple of the rubber disk at the top, then plunged and withdrew just the right 0.5 cc amount. I had anticipated this visit.

  I asked if she was ready. She said yes. And now the killed virus I injected into the dense fibrils of her shoulder would evoke from the rangy lymphocytes their molecules of protection. She winced, turned to go, then turned back.

  Why did he have to die? And as she says this her body gives a little seizurelike lurch. Couldn’t you have prevented it?

  I was gathering the detritus I had left behind: the silver crimps of packet walls torn open, the needle guard, the soiled pledget with its spot of blood in the center, the dangerous needle I would place in the red plastic carton marked Hazardous. I remember his last office exam, sixty-two years old. Healthy. We focused on a few small problems with his cholesterol medications. As a part of his general workup I might have ordered a sigmoidoscopy. I did not. In my ear I could hear the admonitions of hospital lawyers cautioning me not to say too much. Don’t commit yourself, they might say. And I felt—what was it? — something like the shame of being caught doing something wrong. But in the cavity of that humiliation, finally exposed, I felt no desire to waffle or dodge. She deserved better than that.

  Yes, I said. The cancer might have been prevented. And then there was just me and her and the truth in the room.

  Strange, she said. All those years with you and with the doctor before you, nobody ever recommended a sigmoidoscopy. If that had been done the year before, would you have caught the cancer in time?

  The detritus was removed. The needle was in its safe place. I had no urge to fidget in the face of her question.

  It’s possible, I said, if it were still a polyp. Or if it hadn’t spread too far. And I realized that though this was true, it was a manner of deflection. I was drawn to return to the unadorned answer. It’s possible, I said. It’s possible it could have been prevented.

  She was silent.

  I was silent.

  She waited, then . . .

  I have no one. No children, no family. He was all I had.

  I nodded.

  She reached for her overcoat.

  You’ll probably have to do something about this or let it go, I said. All this hurt will come to no good.

  I would never do anything, she said. I like you. I think you are a good doctor. I want—I think I want— to continue to come and see you—but it will be hard.

  I’m sorry, I said. And I want you to know that I believe you should do what you need to do even if it means . . .

  No, no. Well, maybe. I don’t know.

  She left. And returned for her flu shot the following year, and the year after, never mentioning her husband, and then, eventually, for her own screening sigmoidoscopy, well in advance of its time, a request I filled as an obedient pharmacist might fill an unusual prescription, knowing it was too early, but conscious of the fear she was facing, conscious of the forgiveness she brought, coming to me for the help I might give, the test that might have saved her husband.

  THE MORBIUS MONSTER

  Billy Claymeyer had indigestion. For as long as he could remember, he had a burning sensation in his chest and throat, usually after eating. For years he had put off going to see a doctor, but the symptoms worsened, and he thought, still with some reluctance, it might be time.

  I advised the usua
l therapies: antacids, H2 blockers, elimination of coffee, chocolate, and alcohol from the diet—nothing worked. Because of the long duration of symptoms and the possibility he might by now have a more aggressive form of esophagitis called Barrett’s esophagus, a condition in which the cells of the lining begin a precancerous transformation, I recommended endoscopy.

  The idea of endoscopy is scary—a snakelike tube with a light for a mouth, pushed down your throat—but with a little information most people recognize that the fear is worse than the event itself, and generally the motivation to be free of annoying symptoms, or to avert danger, overcomes resistance. The reality is, it only lasts five minutes, and the patients are pleasantly sedated so they don’t experience discomfort. Considering what’s happening, it all goes remarkably well.

  But Billy refused.

  Patients know their bodies. They have a sixth sense I have learned to respect. So I am accustomed, without much dissent, to endorsing their wishes as long as they are not clearly harmful. In this case there seemed to be no urgency. That, combined with a look on his face I could only describe as untamed dread, made me let it slide.

  Billy was about thirty-five, a somewhat inward man with a tendency not to volunteer his thoughts or feelings. He was an accountant with a large number of clients who delighted in his intelligence and regard for duty. It seemed to me that his decision not to do endoscopy was inconsistent with his exacting manner in business. I concluded it must be for reasons not apparent on the surface.

  I prescribed a stronger antacid, advised him again regarding diet and activity, and asked him to return in one month.

  He returned admitting the symptoms were no better and that he had started waking up at night with pain. It sounded like he was now having symptoms of ulcer disease in addition to those he already had of reflux esophagitis. Diagnostic categories blurred. Choice of therapy would be impacted. Outcomes would become less predictable. I brought up endoscopy again. After long consideration, he agreed.