by David Watts
Let’s find out why.
I don’t know where to start.
Anywhere you like.
I took that Zelnorm—it was awful—it didn’t do anything.
That was for when you were having constipation. Maybe it caused too many contractions of the bowel?
Anyway, I took only four of them.
But why was it you stopped?
I can’t recall. Well, let me tell you what I did. I took the Metamucil, how much I don’t recall, and then I didn’t have a movement. I stopped it Sunday night. Definitely. I had made up my mind I would never take another of those Metamucil pills.
Why not?
Just let me finish. I had breakfast at eight a.m. And I took a suppository and had a little BM. But yesterday, two doses of Metamucil and that was it. Then I went out to dinner and did a foolish thing. I ate split-pea soup, and I had a wonderful salad of spinach, carrots, and a little butter lettuce. It was wonderful. What happened, really, I had the runs. I’m sorry, but really that’s what happened.
What caught my attention was her smile as she described the salad. Doesn’t sound like a foolish thing to me.
I have it here, and I definitely saw spinach.
She reached in her purse and pulled out a napkin wrapped in clear plastic.
It took me a minute to realize what was going on. I gathered my wits and took the specimen from her. I performed a little test for blood, which added drama to the situation and which was negative. Then I combed through it with a wooden probe and saw no undigested foods.
It seems normal.
But I get scared.
Let me examine your belly.
I did that. Her abdomen was soft and non-tender. There were no masses and no enlarged organs. The bowel sounds were normal.
Things are not going well, I said. I think we need to push further to see that we don’t miss something. It’s difficult to know what to do when the symptoms — and I paused to say that I did not blame her for this —when the symptoms are so nonspecific. I know you’ve had a colonoscopy within the last six months, but I propose repeating that and getting a CT scan of your abdomen.
Next day she called to say she couldn’t get to sleep the night before.
Why?
I don’t know why.
A harmless parasite appeared in one of her stool specimens. I discussed it with her and decided to give her medications for it on the off chance it might be responsible for some of her urgency at night. Likewise, we might try an antiinflammatory for the bowel. These were long shots, and I told her so, but maybe worth a try.
In three days she stopped both medicines because they made her feel strange.
I walked over to her primary doctor’s office, and I told him we weren’t making any progress and that I had decided to push out the perimeter of the workup to see if something else was going on.
We’ve done a CT scan and had a colon scheduled, but she canceled. I was beginning to worry that she was decompensating. Did she have a psychiatrist?
Yes. I’ll send her over.
CT scan. CT scan, I said to myself on the way back to my office. I couldn’t decide if I’d done it yet.
I checked the chart. It wasn’t there. Shit. I thought we’d done that two weeks ago.
Let’s schedule a CT, I said to my office staff, almost at the level of a shout.
Christmas was upon us. She called to ask if she could go to her sister’s in Sonoma for the holidays.
No reason not to, I said.
I gave her my number in case she got in trouble, and she called the minute she arrived.
I’m confused about my medications, she said.
Which ones?
All of them. I just can’t get it straight. When we were done I asked to speak to her sister to make sure someone knew what to do.
Back from the holidays, and a new set of lab tests was on my desk. The alkaline phosphatase was elevated.
Oh my God, I said. I’ve seen this before. Some sneaky something growing in the liver can elevate this enzyme.
I walked out to the front desk to tell someone to call her right away, and she was standing at my elbow.
I was wondering if I could talk to you for a few minutes, she said.
Yes, and right now. Come with me.
We went to the exam room. I told her about the test, and that I was worried something might be growing somewhere.
I have something to show you.
She lifted her blouse and pointed to a little nodule just above her belly button.
Christ, I said to myself. That’s the Sister Mary Joseph sign.
I hadn’t thought of that term in years, but I remembered the lecture in medical school. Sister Mary Joseph was a very wise and intelligent nurse who observed that patients dying of cancer sometimes had little hard nodules on their abdomens, in a curious location around the navel. These little stones accreting in the wall turned out to be cancer metastasis to the lymph node left behind when mother and child separated. It was a terminal condition. The good sister even developed a little reputation making dire but accurate predictions when she spotted her sign.
I called in my associate to confirm my opinion. He concurred.
I pictured a huge cancer socked in the pelvis, pressing on the bowel.
Because of the holidays, the CT scan hadn’t been scheduled until the following day, and the colon exam the day after. We gave her the detailed instructions, emphasizing the importance of following through.
I have to tell you this, she said. Maybe I shouldn’t say anything, but your receptionist always leaves me on hold for a long time.
This was a break into a new sense of camaraderie. She’d never talked about things like this before. She had been emboldened by our common and newly elevated concern for her welfare.
I was thinking of the five times she called each day and how this had the effect of exasperating even the best of us. I’m sorry, I said. We are all concerned about you and want very much to get to the bottom of this.
I noticed she wore a bright smile. Things were happening, activity was rising up and circling about her. She seemed at ease. She was being listened to.
That night I gave my wife an update.
This kind of story always makes you want to do every test imaginable, right off the bat, she said.
Right. And I had that impulse. But if I did that every time, I’d be ordering a lot of normal tests.
Neither of us was satisfied with that.
I tried again. If I put “I don’t feel right” or “I can’t get to sleep” as the reason for the test, the insurance company would bounce it right back.
What do they have to do with it?
Nowadays they insist upon granting prior authorization for a lot of tests. Primarily the expensive ones. You have to say the right buzzword or it won’t happen.
Can’t you just do it anyway?
It won’t get paid for. And that’s a powerful, all-but-absolute deterrent. Besides, Radiology won’t even schedule a CT scan without a prior authorization number.
During the silence that followed, I was thinking that a few weeks one way or the other would probably not affect the outcome, but still, we all could have been on the right track a lot sooner.
And I tried to imagine what it must be like to announce your difficulty and not be heard. It reminded me of the Stevie Smith poem “Not Waving but Drowning.” Signals offered in the wrong language. Meaning lost in the interpretation.
Why do you suppose you didn’t order the CT scan? my wife asked.
I don’t know. And I shook my head with a little chuckle of admiration for her marksmanship, always landing squarely upon the issue.
Part of me would say I was distracted by the camouflage.
Go on.
Part of me says the system wouldn’t have allowed the right tests anyway.
My wife just watched me squirm.
Yeah, right. It’s a signal that I didn’t take her seriously enough.
Neither of us
needed to talk about outcomes or the anguish my patient felt, not waving but drowning. We knew which could be helped and which could not. There was just a little moment in which we thought good thoughts for her, almost like the quick breath of a poem or a prayer. Then we picked up our forks and finished dinner.
ANNIE’S ANTIDOTE
The fear that thumps us down. That’s what made her wait so long. Annie, the mild-mannered piano teacher, was fearful, so fearful that everything concerning her health required negotiation. In the moment when her clear thinking told her what to do, she lost courage, as if friendly forces suddenly withdrew to a foreign country.
Fear sucked her energy like a power outage. Mention the word endoscopy and she turned pale, her eyes drifting off like somebody unplugged.
Three months already, we should have done her endoscopy. First-choice treatments have their reasons. When fear takes them out, we drift into seconds, hoping the difference is not so great as to mislead or, worse, do harm. So we shifted back to medicines instead, added some alternatives, switched around the timing . . .
Fear fought us even there. Just the thought of side effects made taking medicines seem like injecting poison into the body, a grave contamination that could upset the fragile balance of life, or what passed for life, clinging to the narrow edge.
Through all this, the pesky symptoms stayed on, and on. It was they that finally forced us to stare into the face of fear.
I guess we all have fears: flying thirty-seven thousand feet over the Atlantic Ocean in a bullet-shaped projectile with wings glued on, propelling straight up a small chamber sixty stories to your accountant’s office, driving over countless tons of steel delicately suspended, God knows how many feet over the tidewaters of the Golden Gate, to get to work every morning—it’s a wonder we don’t all run around in a state of abject terror. Most of us have developed ways of not thinking about it. We can’t afford to, in a life that requires one long, continuous leap of faith.
So we make peace with fear. Or we reach a point of necessity that says, Screw it, just do what you have to do.
But sometimes the weight of the hammer that breaks us free has to be pretty great. So I’m not too surprised when people put off coming to see me. All too often it requires something drastic, an uncle dying of stomach cancer, a young friend. Then comes the realization: Well, maybe I’d better go get that endoscopy.
But Annie was in that phase where everything negative was magnified, empowered. Anxiety like this changes the playing field. Great terrors rise to besiege and paralyze— something as simple as a dental appointment or crossing the desert by car—an event that to others might seem ordinary can send the anxious to apoplexy.
We had postponed ourselves into a tight spot and quite possibly transformed a simple disease into a complicated one.
She realized, eventually, she couldn’t afford her fears. So with great courage she accepted the reality that this thing was going to happen, scheduled an appointment, and made herself go. Made herself actually show up.
But as we were waiting to begin, she freaked.
She had brought her Walkman and her favorite music to calm her, but it failed. Now, she trembled on the table as if shot through by voltage.
I can’t do it, she said.
And everything stopped.
I knew better than to force it. So we just waited, sitting around, trying to decide what to do, me on the little stool with wheels, the nurse leaning against the cabinet on the opposite wall, everybody taking a little time to breathe.
Some time went by.
She seemed to struggle with her body. It wanted to leave, lurching occasionally as if to leap from the table in a brief outburst of force that was just as quickly neutralized or tied down by the counterforce of her will.
Finally she said, You’re a poet, aren’t you?
I was startled. Where had that thought come from, and what was it doing here? But I didn’t dare question anything that might move us along some new path, any direction from where we were.
Guilty as charged, I said.
She laughed. The tension in the room seemed to relax. Maybe if you said a poem to me, I could go through with this.
It was an opening, however unusual. And a spell was weaving around us in which it seemed we had started working together on something, a project perhaps, something that sapped the spotlight from its fixation upon impasse.
I think so, I said, and flipped through the pages of my memory. But I’m afraid I only know one poem. It’s one of my own I memorized to say at a poetry festival a long time ago.
Could I hear it?
I leaned back, took a deep breath, waited long enough for my head to shift over into a different world, and recited:
My son brings me a stone
and asks which star
it fell from. He is serious
so I must be careful, even though
I know he will place it among those things
that will leave him someday
and he will go on gathering,
for this is one of those moments
that turns suddenly towards you, opening
as it turns, as if we paused
on the edge of a heartbeat and then pressed
forward, conscious
of the fear that runs beside us
and how lovely it is to be with each other
in the long resilient mornings.
In the silence that followed, it was clear to me that whatever power I had to change anything about this situation had been spent. Our direction had been cast, only as yet it remained unknown to me. Whatever was to happen, I thanked my good luck that the only poem I knew by heart seemed to suggest a certain resiliency of the human spirit that rose from—from what?—perhaps just from the companionship we share in the face of joy . . . or loss. Companionship. Well, at least we’ve got that.
She was silent. She seemed about to speak several times before she finally gave us a start:
I’m ready, she said. And lay down.
I moved quickly. Five minutes and we were done. The procedure went without a hitch. The biopsy from the edge of her ulcer revealed the infection, Helicobacter pylori, and some antibiotics cleared up the whole thing. Her long and troublesome struggle with symptoms became a thing of the past. Nice outcome. Nice and timely accomplishment for her. She triumphed — and it felt that way to all of us concerned. Thereafter, she seemed charged with a higher wattage of confidence. Her posture improved.
And I wondered what exactly it was that called off her demon, or at least stunned it long enough for us to do our thing. What turned her from wuss to warrior? Something told her that hidden within the hearing of a poem was the thing she needed. Was it a message of hope? Of resiliency? Of an experience that somehow shone through a rude reminder of mortality? Maybe the music was strong enough to soothe the rhythms of the body. Maybe she just felt more confident knowing her doctor was human.
I don’t know. But she found a little something to put in her pocket to place the monster on hold. And on top of that, no side effects. What drug could be better?
I’ve thought about it, but I’ve given up trying to figure it out. I realize it’s mystery, and love the word. And love that mystery still works in our lives.
MRS. ROBINSON EYES
He said he was sorry to disturb me at 2:00 a.m., but he thought a faculty member should be involved. James was one of our better gastroenterology trainees, and I always figured he could handle most anything.
Why do you need me?
Because my patient is my colleague. She’s a third-year surgery resident.
He told me that she was getting ready to go on a back-packing trek and at the last moment her girlfriend finked out. Danielle was home packing by herself when she started to vomit blood.
Hematemesis is a sign of a major problem—ulcer, perhaps, or severe gastritis. Still, James could have handled it— except for the colleague thing. It meant I had to travel across town in the middle of the night, but I
saw the need. I said I’d be right there.
We did what we are trained to do: sedation, endoscopy, the search for the source. All went well except that no sign of bleeding was found. Blood, yes. But no bleeding—and no ulcer, no varix, no gastritis . . . nothing.
It happens like that sometimes. Wouldn’t you know, it would have to be another doctor. All the same, this one, like all the others, would sort itself out in time.
She was transfused, she recovered, she reentered society, that is, what passes for society in a surgical residency. And we heard nothing more until a couple of months later.
Same drill. This time occurring in the wake of her mother’s visit. Blood transfusions, lab tests, X-rays — and no source found. Things were looking strange. I reminded myself they often do, when dealing with members of the medical profession.
There was talk of surgical exploration. The interns were restless. The attending physicians were uncomfortable with the uncertainty of no diagnosis in someone who continued to have episodic bleeding. I was impatient, too, but I told them I don’t do fishing expeditions. And on top of that, no answer pre-op is better than no answer post-op.
She seemed to thrive in the hospital. She endeared herself to the medical staff, who generally felt sorry for her, but she managed to alienate the nurses with her high-maintenance demands — long talks, the insatiable need for the little things.
I was not pleased. The momentum was building for surgery. Even the consultants felt it might be a means of examining parts of the bowel that our proddings and zappings had left uncharted.
I said no surgery until I get psychiatric clearance, and I brought the best psychiatrist I could find. He reported that she was an attractive, intelligent young woman with no psychiatric problem.
We went to surgery.
The surgeon removed part of the upper small bowel because that was the area most under suspicion. On pathological exam, everything was normal. I was beginning to think we had created our own worst nightmare. The old surgical adage popped to mind: Whoever creates a monster has to take care of it. But then surgeons were notorious for not following their patients. The monster gets passed back to the internist.