That’s what would happen to Mrs. McCoy. And there wasn’t much we could do about it. Which is not to say that we wouldn’t try, or that we hadn’t tried, as was evident when I sat down to go over her records in detail.
Between January and June of that year, she’d had thirty visits to the emergency room, and two long admissions to the County, the most recent being, presumably, her last. She was fifty years old and a widow with four children, but only two sons were still in contact with her. She lived, when she wasn’t in the emergency room, in an SRO, or what used to be called a cold-water walk-up flat, and Mrs. McCoy’s was in the Tenderloin. If it was like all the other SROs, it would be a room with a dusty twill bedspread on a single bed, the smell of mildewed carpet, a scuffed chest of drawers, and a shared bathroom down the hall.
All thirty of her emergency-room visits had been for alcohol. During visit number fifteen, she had almost died from a blood infection; and during number thirty, she’d gone into a coma from the alcohol. It had taken the County a month to sort things out. They dried her out, and she woke up, but because her liver wasn’t working, she was still confused. It was during this visit that her sons had agreed with the doctors that, in view of her terminal condition, “a natural death should be allowed,” and so the doctors sent her over to us to die. Although not without exercising their best efforts to improve her medical condition. They had put her on thirteen different medications—medications to dry her out, medications to support her blood pressure, medications to calm her, to stimulate her, and to treat the diabetes from alcohol’s toxic effects on the pancreas. They’d done a good job. She was, after all, still alive.
I sighed. I wrote her orders, handed the complex list of medications to the nurses, and went about the rest of my afternoon.
By the next day, Mrs. McCoy was not dead, although she wasn’t any better. In fact, she was worse. She was yellower and nearly comatose; her belly was bigger and tight as a drum; and she was beginning to moan. Her belly was so big from fluid that I would have to drain it.
Now, I don’t like to do this much, although it isn’t a difficult procedure. A thin tube with a needle at either end is used. After the skin of the belly is numbed, one of the needles is inserted into a vacuum bottle, and then the other needle is put into the belly; a vacuum is created, and the liquid inside the belly is drawn into the bottle. The belly decreases in size, and the patient is more comfortable, but only for a few days, because, since nothing else has changed, the belly fills right back up again. So the procedure has to be repeated within a week.
But there was nothing else to do. I walked over to Central Supply, which was a Dutch door behind which were the wooden shelves of the hospital’s supplies. Leaning on the shelf of the open door, I filled out the two-line request form, and the attendant gave me the two quart bottles, the needles, the catheter, and the bottle of numbing medication I’d asked for. I took everything back to Mrs. McCoy’s room. By this time she was moaning and nearly unconscious. I cleansed her belly, numbed the skin, inserted the needle, and, sure enough, honey-colored fluid began to flow. The first bottle filled, and then the second. Her belly deflated quite a bit, and she stopped moaning. I withdrew the needle, bandaged the site, cleaned up, and made ready to leave. But I didn’t leave, not immediately. I sat for a while.
I sat next to Mrs. McCoy, who was now sleeping, and I looked at the yellow liquid in the bottle. The afternoon light was coming through the window, and it came through the liquid, making evident by the swirls that this liquid was not just yellow water. It was not nothing—something to be thrown away, as I would do shortly. This yellow liquid was life. I could see that its consistency, as well as its color, was like honey from all those important proteins. It would taste like honey, too, sweet from the sugar in the blood; and it would be sticky, like honey, from the clotting factors wasted, and the enzymes needed for life. It was just too bad, I thought, that we couldn’t, somehow, put this fluid back into Mrs. McCoy’s veins. But, even if we could, it wouldn’t stay in her veins. There was not enough pressure inside the veins, and the fluid would flow right back into her belly. What Mrs. McCoy needed, I mused, was some way to push this magic yellow fluid of life out of her belly and back into her veins.
I wondered, as I sat there, how Hildegard would have thought of Mrs. McCoy’s disease, and what she would have done. Clearly, the element, Water, was in the wrong place. Then I recalled that humoral medicine had used physical techniques more often than we do today. One of its techniques was wrapping an abdominal binder, a kind of girdle, around the belly, in order to press fluid from a swollen belly back into the veins.
It was worth a try. If any place would still have an abdominal binder somewhere on its shelves, it would be our central supply. So I ordered one up, and, sure enough, it came. It looked like a wide ACE bandage—its only modern touch a Velcro closure. The nurse helped me wrap it around Mrs. McCoy’s somewhat deflated belly. It didn’t seem to make her uncomfortable. She continued to sleep, and I left the room.
The next day when I went by to see her, Mrs. McCoy was still not dead.
She wasn’t even worse. She was the same or, perhaps, a bit better. The abdominal binder was still around her, and her belly was no bigger than right after the procedure. That was significant. Although the liver cannot perform its functions if less than 5 percent of it remains, if just a little more than 5 percent is working, then the downward spiral begins to reverse. With just a little more, the liver can produce just enough more protein to increase the blood pressure a bit, and this allows the kidneys to start excreting excess fluid and toxins. The doctor can then start to use more medication for stimulating the kidneys, and fluid will start to go out of the face, arms, legs, and belly, which revert to their normal size. Because the patient is more comfortable, pain medications can be decreased, and the patient will wake up and start to move around, mobilizing still more fluid.
And this was what was happening with Mrs. McCoy. She wasn’t worse. That meant she was better—she had a chance.
By the end of that week, she was opening her eyes at the sound of my voice and even at the sound of my footsteps. The abdominal binder was still on, but it was loose; her face was beginning to acquire a shape, and when I sat down in the chair by her bed, she looked at me. Not only did she look at me; her eyes looked into mine with recognition and love—a particular kind of love. Not the love of a parent for a child or a lover for the beloved, but of a subject for his ruler—trusting, all will resigned. I recognized the look. It was the transference.
The transference is the name that the psychiatric profession, Sigmund Freud in particular, gave to the emotions that the patient transfers to the doctor during treatment. It is the love that he or she felt for his or her parents—not the rational love, but the irrational love for the all-powerful father/mother in a three-year-old’s life. This transference was the key to psychic healing, the key to psychic change, Freud wrote, because it made the doctor what the doctor was not—all-powerful. After the transference, the words, the nod, the blink of the doctor’s eyes would be all-important to the patient, would mean acceptance or rejection, pride or guilt, self-love or self-hate. And Mrs. McCoy, I saw by that flicker in her eyes, had fallen in love—which is what the transference really is—with me, her doctor. Not, of course, with me, the person; but with Me, the doctor-being sitting in the chair by her bed.
It’s a lot of power, the transference. Mrs. McCoy’s transference to me meant she would wait, during the day, for my footsteps; she would stay alive for that reason. Her transference to me meant she would hang on my every word and try to please me. If I asked her, she would bestir herself; she would make an effort. She would sit up in bed and feed herself; she would exert herself and get stronger. She would go without complaint to rehabilitation; she would take her first steps, to please me. She would be pleasant to the nurses; and, if her sons came to visit, she would impress them, she would smile and talk to them. She would participate in the life of the ward. Her transf
erence to me meant she would live and not die.
And that is what happened. After two weeks the abdominal binder was no longer necessary. The fluid in her belly had just about disappeared, as had the swelling in her face and arms. She had had no infections and no bleeding; and she had woken up. Her liver was improving. So the nurses moved her out of the quiet semiprivate room into the noisy communal open ward, and there she stayed for weeks. I saw her almost every day.
One day I noticed that she had a photo—one photo, saved from the wreckage of her life—above her bed. Black and white, yellowed and faded, shiny and creased. It was the photo of a dog. Who was the dog?
“That’s my dog, Spreckles,” she told me. “I had him for a long time, but when I moved into the SRO, they didn’t take dogs so I had to give him away.” She fell silent and then added, “Dogs are just like people, only they have four senses instead of five. They can’t talk, that’s all. They understand everything, though, everything. They just can’t talk.”
“Even politics and religion?” I teased.
“Everything!”
Not too long after that conversation, she appeared at the door of the doctors’ office. Our door was always open, partly because it was such a small office, but mainly because that way we were an integral part of the ward. We could see and hear the scene: the comings and goings of ambulance drivers and family members, nurses and volunteers, and, especially, patients—shuffling, wheeling, lurching, occasionally falling, occasionally running—as well as the crashes, shouts, spills, giggles, whispers, and, once in a while, the silence of the ward. Nevertheless, the custom was to knock on the open door, which Mrs. McCoy did.
“Dr. S., are you busy?” she asked.
I looked up from my desk. It was the first time I’d seen Mrs. McCoy standing. She was short and square. Her hair was dark brown and straight; her skin beneath the resolving jaundice was also brown; and she had the warm brown eyes of her Mexican heritage. There was a cane in her right hand and a potted plant in her left.
“I have a present for you, Dr. S. I potted this plant for you, on Saturday, in the greenhouse.”
I walked over and took the plant. There wasn’t much of it. Two leaves in newly potted dirt. “Thanks.” I put the plant on my desk.
“Make sure you keep it moist,” she said. “It’s easy to care for; you’ll see. Just make sure it’s watered.”
A week or so later, Mrs. McCoy was transferred off the admitting ward. I didn’t see her again for almost a year. But one day, as I was making my way through the smokers and poker players in the large hall, she limped up to me, cane in hand. She looked quite good, quite normal, quite like a stocky fifty-year-old Mexican woman.
“Dr. S., they want to discharge me. They want to send me back to the SRO.”
I looked at her. I looked at her cane, and I looked at her. I thought about the thirty emergency-room visits and the two monthlong hospitalizations she’d had in the six months before she came to us. I thought about the abdominal binder and the two bottles of honey-colored fluid I’d taken from her belly. I thought about the spark in her eyes.
“You know,” I said, “they can’t discharge you if you can’t walk, if you are in a wheelchair because of that bad knee.” (She had a bad left knee, which is why she used the cane.)
She looked at me, and I looked back at her. Message sent, and message received.
It was almost a year before I saw her again. She came to my office, this time in a wheelchair.
“They’re discharging me tomorrow,” she told me.
“How can they discharge you if you can’t walk?”
“They know I can walk.”
We both sighed, and we shook hands. For form’s sake I went over to talk to the social worker who was discharging her. Mrs. McCoy no longer had a physical need for hospital care, she explained, and hospital care was expensive, so she had to go.
But what about all the emergency-room visits, the expensive ICU hospitalizations that she hadn’t had during the years she’d been with us? I asked. The social worker agreed. It was a pity; it was just too bad; it would be more expensive in the long run; but there was nothing she could do about it.
I never saw Mrs. McCoy again. But I did watch the computer for her next admission to the emergency room at the County Hospital.
For months there was nothing. And then, about six months after she left, there it was. An emergency-room visit, but—ominously—only one. She was not admitted to the County Hospital, and there were no subsequent emergency-room visits. Was it her last emergency-room visit because the paramedics had found her dead on the streets? Or was she doing well, and it had been an emergency-room visit that anyone might make for something trivial—a hangnail, a cough, a cold? Or was it the emergency-room visit that convinced her not to drink again?
I never found out.
But I’ve thought of her often since. Because the plant she gave me did survive, though not thanks to me. Although I was in the midst of discovering that premodern medicine had the garden as its main metaphor, where the patient was plant and the doctor was gardener, I had a difficult time remembering to water that plant. It did not, in my hands, do well.
But it did do well in the hands of Larissa Russof, our Russian nurse who’d been a pediatric neurologist in the USSR. She was a good nurse, and the struggle of Mrs. McCoy’s plant in my forgetful hands pained her. One day, standing at the open door of the office, she offered, “Dr. S., that plant is dying. It needs to be watered.”
“I know.”
“I’m going to take it and help the poor thing.”
“Okay.”
So she took the plant away. I don’t know where she took it, maybe home for a few days, and when it returned, it was better, much better—green again and cheerful.
Over the next many years, Larissa continued to take care of Mrs. McCoy’s plant. It stayed green, and it grew very well—up over my desk and along the wall above my desk, then over the top of the window and down along the side of our computer. It was just beginning to grow around the corner and up along the wall of Dr. Jeffers’s counter desk when one day, unexpectedly, the consulting firm of Dee and Tee, Health-Care Efficiency Experts, arrived.
Three
THE VISIT OF DEE AND TEE, HEALTH-CARE EFFICIENCY EXPERTS
THE CONSULTING FIRM of Dee and Tee, Health-Care Efficiency Experts, did not, however, knock on the door of the admitting ward or on the door of the doctors’ office. Nor did administration, not even Dr. Major, announce their visit to the staff. Instead, we learned of it from Larissa, whose information came from her extensive network at the hospital, which was made up mostly of her Russian connections.
Although we had hundreds of staff from all over the world, only a few were from Russia, and the Russians were particular. In Russia they’d been professionals, and they brought their skills and knowledge, prejudices and irony, with them when they came to America. There was Head Nurse Raisa, for example, who in Russia had been an oncologist, and there was Fedorov, the electrician, who’d owned a factory. Although they were few, the Russians knew when to listen and when to hold their tongues; and they knew an evolving secretive bureaucracy when they saw one. So they were useful to Larissa up to a point. But it was the mafia of Russian ambulance drivers who were her best informants because they went all over the city, delivering patients, pizza, and clandestine goods—and picking up gossip and rumor.
However, Larissa did not limit her network of intelligence to the Russians. One day we ran into each other. Being herself doctor and nurse, Russian and American, Russian Orthodox and Jewish, she excelled at crossing boundaries, and almost everyone liked her and passed information to her—doctors, nurses, therapists, janitors. It didn’t hurt that she was intelligent and charming, humorous and well-groomed, with a touch always of something European—a thin gold bracelet, an Italian scarf—to show that she had not given in completely to American ways. Larissa, consequently, knew just about everything at the hospital and would divulge some of what
she knew in exchange for what she didn’t know, or sometimes just to oil the wheels of her machine.
She knew all about Dee and Tee’s visit, and, standing in the doorway of our doctors’ office, she told us with a satisfied air not all but some of what she’d heard.
The city had hired Dee and Tee to help solve its health-care budget problems, she said, and they were expected to be at the hospital for months. They would be paid 10 percent of any cost savings they came up with, although—here she smiled—they would not be responsible for any cost increases their recommendations might create.
How would they go about their mission? we asked.
She hadn’t yet heard. So far they were talking to senior management and looking at the payroll, especially at the laundry and the nursing department. At this, she gave us that meaningful look I’d come to know from all the Russians, told me that my Mr. B. had a bladder infection and needed antibiotics, smiled again, and went back to her job as nurse. We—Dr. Jeffers. Dr. Fintner, Dr. Romero, and I—looked at one another and then we, too, went back to our work.
By this time, Dr. Romero had finished her second residency, this one in internal medicine, and she had returned to the admitting ward. She took the place of Dr. Rachman, who’d finally paid off her hundreds of thousands of dollars in student loans and left to start a family.
Dr. Romero moved into Dr. Rachman’s chair at our rickety wooden desk, and there she would stay for many years. And it was true, what Dr. Rachman had told me on my first day, Dr. Romero did have two sides: witty and cynical inside our little office; openhearted and even unctuous—adjusting bedclothes, chucking the homeless under their chins—outside it.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 6