They had had no idea. Not an inkling. A whole continent. Huge, as vast as the world they knew. A new world was out there, but not for them.
I wondered what it had been like, to hear about this new, undiscovered world that no one had even imagined. It was the biggest difference between me and them, I thought. Everything else that had been interposed between me and the medieval experience on our pilgrimage—airplanes, electric lights, cell phones—would not have surprised them so very much. They’d imagined all of it: flying carpets, magic light, invisible voices—their magicians could do such things. But that new world was completely unimaginable and unimagined. I knew it was there, and knowing it was there in their future made it impossible for me to imagine it not being there, to imagine their world as they saw it.
It made me wonder especially, what new world was in our future, unimagined, unimaginable, and completely unexpected?
When I returned to the hospital, having completed my vow of pilgrimage, I felt somehow carefree. Perhaps it was all those days of walking and watching bad turn into good and good turn into bad, or perhaps it was burning that black card of worry. At any rate, I felt carefree. Whatever was going to happen would happen, according to its time and the seasons. Which was a good way to feel, because the real and irrevocable changes at the hospital were beginning.
Dr. Dan stopped the admission of new patients. With no new patients, the admitting ward was not needed, and Dr. Dan closed it. He moved himself into Dr. Major’s office; he moved me into the doctors’ offices downstairs, and he sent Larissa and the other nurses to other wards. While I was away, he packed up my things—papers, books, and index cards, including Mrs. McCoy’s plant, which he tried to prepare for its move. He took it into his special room, pruned it, and watered it, but when I got back from the pilgrimage, it was dead.
That seemed symbolic because Dr. Dan was not closing the admitting ward temporarily but permanently. He was not going to reopen it in the new hospital. It was too inefficient. In the new facility patients would be admitted to the wards where they would stay, and the doctor of that ward would admit them, so from the beginning the doctor would know his or her new patient well. In theory. But in practice, admitting patients on other wards would be stressful, another duty to add to what everyone already had to do. The other wards were not prepared for the patient who was much sicker than billed; who had to be sent back to the acute hospital right away; who had the wrong diagnosis or was on the wrong medications. The admitting ward was an investment that paid off in correct diagnoses and discontinued medications and in the diminishing of stress throughout the hospital.
The admitting ward was also a symbol of medicine’s place in the hospital. Dr. Curtis used to call it the brain of the hospital, because if you had a question about a patient, all you had to do was ask the admitting doctors. The admitting ward was where you would go for a second opinion on a patient, an X-ray, or a lab test, about a difficult family or a confusing diagnosis. Without it, I wasn’t sure that medicine would have a central place in the hospital any longer.
Perhaps Dr. Dan felt the same way.
Now I began doing something I’d never done before: I was what physicians call the “covering doctor” and what nurses call a “floater.” I held the hospital beeper, I ran the Code Blues, and I floated on the tide of every day to whichever wards lacked their sick or vacationing doctor.
I liked my new position a lot. I saw patients I’d admitted long before and how they were doing. I visited all the wards in the hospital and learned how unique each one was, despite their superficial similarity.
I had many adventures. I diagnosed a case of pseudopseudohypoparathyroidism, that bizarrely named rare disease I had vowed to diagnose at least once when we learned about it in medical school. I explored the obscure wing of the hospital where the podiatry students still lived, receiving board and room in exchange for their services as had been done for a hundred years. I discovered Room Eleven. But above all, I met Mr. Meng Tam and experienced what resuscitation really means.
Even now, years after his Great Event of Death, Meng Tam remains a mystery to me. Like the Cheshire Cat, his smile is all I know of him for sure.
It’s a sweet smile, though slightly askew now from his recent stroke. It’s a wide smile, for Mr. Tam still has all his teeth, and a wise smile, with eyes crinkling down at the corners. It’s a shy smile, a child’s smile or a bodhisattva’s smile, and behind it is a whole life and chosen way of being, though to this day I don’t know what that way of being is.
Here’s what I do know about Mr. Meng Tam.
He was picked up by the paramedics and brought to the County Hospital for the first time after he totaled his new white Toyota Camry. He wasn’t admitted, but that is how he got his social worker. It was she who noticed how neglected Mr. Tam’s basement apartment was and decided he must be moved into a board-and-care home. In the meantime, she found him a new apartment. He moved into it on the first of April, and on the second of April the paramedics found him wandering in the rain.
So they took him to the County Hospital for the second time. In the emergency room, he told the doctor he was just trying to get back into his old apartment because he couldn’t get into his new one, and a neighbor had called the police. The doctor thought Mr. Tam seemed fine enough but, while arranging to send him home, asked him a few more questions, and discovered that Meng Tam did not know his address or his phone number, his doctor or where his family lived, except that they all lived in China. Further questioning revealed that Mr. Tam did not know the day, date, or year, or where he was. So he was admitted to the hospital to find out why he was demented and whether he could still live alone.
He was given a complete dementia workup, with all necessary blood tests and X-rays, and he was evaluated by a psychiatrist. The blood tests were fine; the brain scans showed a lot of little strokes; and the psychiatrist decided that he was demented and possibly psychotic, because Mr. Tam told him that he was a professor of literature and had come to this country for his PhD and to inform people about counterrevolutionary activities. Psychiatric testing confirmed that Mr. Tam could no longer manage for himself, and so he came to us.
This was before the admitting ward was closed, and when I met him for the first time, he was sitting in the chair next to his bed. He had a full head of graying hair and a calm, proud demeanor, and he looked like the professor he’d said he was. An easy smile lit up his otherwise stolid and forbidding face, which, with just a wisp of added beard, would have been the classic face of a Chinese sage.
But he was certainly demented. When I asked him who was governor, he said “Reagan,” and when I asked him who was president, he said, “Reagan, too.” He took a long time to answer the simplest question, if he answered it at all. Worst was when I asked him to draw a clock, which is a usual question in the mental-status exam. I watched as he laboriously drew a circle with a center, put in lines that went out from the center, and then connected them to one another like a web. It was a bizarre clock and the sign of a severe dementia.
What was the cause, or causes, of his dementia? I found the signs of untreated high blood pressure when I looked in his eyes, which would account for the little strokes on his brain scan, and pointed to multi-infarct dementia. His walk was shuffling and wide-based, which meant some additional neurologic condition, perhaps B12 deficiency, which can also cause dementia. His stolid face and slow movements suggested Parkinson’s dementia, Lewy body dementia, or depression. So most likely Mr. Tam’s dementia was multifactorial: three parts stroke, one part depression, one part Parkinson’s, one part Alzheimer’s, and one part … something else. There must be something else, I thought, because the course of Mr. Tam’s dementia had been so rapid. After all, two months before he’d been well enough to buy a car and drive it, albeit into a wall. So Mr. Tam was a mystery.
This being Laguna Honda, however, I had the time to wait and see—for family and friends to show up and fill me in on the details; for Mr. Tam to get
better or worse or stay the same; for a trial of medications to treat his possible depression, Alzheimer’s, Parkinson’s. In short, for Slow Medicine to do its job.
I would begin by tapering him off all the medications he didn’t need. Then I would give him an antidepressant, an Alzheimer drug, and a Parkinson drug, one after the other, and we would see.
But we didn’t see, because a few days after he was admitted, a bed became available out in Clarendon Hall, and Mr. Tam was transferred. Nevertheless, over the next year and a half he did get a trial of antidepressants, an Alzheimer drug, and a Parkinson drug. But nothing worked, and he was worse. He stopped talking and walking; he stayed in bed and refused medications and blood tests. Sometimes he spit at the nurses. And no friends or family ever showed up.
He was so demented that he was assigned a public guardian to make decisions for him, and she was able to find out more about him. Much of what Mr. Tam had told the psychiatrist turned out to be true. He had come to this country for his PhD, although she couldn’t confirm his counterrevolutionary activities. He did become a professor at the university and, until two years before, had been investing in real estate and the stock market. His dementia, therefore, was quite rapid, and it was all the more remarkable that during the year and a half at Clarendon, it hadn’t progressed very much. He should have been way worse than he was and probably dead. So Mr. Tam was still a mystery.
But Dr. Dan was emptying Clarendon, and Mr. Tam was transferred back to the main building and into the care of Dr. Mack.
I liked Dr. Mack a lot. He always reminded me of a television doctor, but in a good way. He had thick, short, silver hair parted on the right, a tanned face, and a smile that creased the corners of his blue eyes all the way down to his cheeks. He usually carried a stethoscope and wore a white coat, white shirt, and silk tie. He was polite but ironic, widely experienced, and a good doctor; and Mr. Tam’s rapid deterioration worried him. So after he met Mr. Tam, he went over all of the records, examined him, and then began fussing with the colorful bunch of medications that Mr. Tam had collected over the eighteen months of his hospitalization.
Which is how I met Meng Tam for the second time.
It was late in the afternoon, and I was covering the hospital. It was quiet, and I was in my office reading medical journals when my beeper went off. It was Dr. Mack.
“I have a patient who is dying,” he said. “He’s a Do Not Resuscitate and, don’t worry, you won’t have to do anything; I’ll stay with him until he dies, which should be in about twenty minutes. But he’s going in and out of ventricular tachycardia and has an intermittent pulse and no blood pressure, and I thought you might be interested.”
I wasn’t sure why Dr. Mack thought I’d be interested. Perhaps he’d read one of my essays on the care of the dying or perhaps he knew I was always ready to see something I’d never seen before. Or perhaps there was some other reason. It didn’t matter and I told him I’d be right up.
As I climbed the stairs, I went over what I knew about ventricular tachycardia. It’s a tachy cardia—a fast heart rhythm—from the Greek tachys, meaning fast, and kardia, meaning heart; and it comes from the ventricles, the heart’s main pumps. It is usually a predeath heart rhythm. Normally the heart beats in its steady, organized way because of a few hundred cells in the sinus node of the heart. Those cells have a specialized membrane that slowly leaks out calcium and sodium. That leakage decreases the voltage inside the cell; and the moment that voltage gets down to a certain level, those cells twitch; their membranes open up in the opposite direction; and the calcium and sodium flow back inside. That twitch is what sends an electric current through the heart, and that current is what causes the heart to beat.
Those cells start their leaking, twitch, and electric current when we are fetuses of forty days, and they continue to twitch once a second or so for the rest of our lives, unless something goes wrong—a heart attack, an electrolyte imbalance, a drug toxicity. When they stop twitching, we die, unless a different group of cells somewhere else in the heart takes over. If that group of cells is in the ventricles, it produces a “ventricular rhythm”; and if that rhythm is very fast, it is a “ventricular tachycardia.”
But ventricular tachycardia is not a stable rhythm. It is too fast to pump the heart properly, and after twenty minutes or so, it usually deteriorates into “ventricular fibrillation,” a disorganized wiggling of the heart muscle that does not pump blood at all. A few minutes after that, the heart stops.
There are, however, treatments for ventricular tachycardia. Often a simple electric shock or certain intravenous medications will convert it into a stable rhythm. Of course, as Dr. Mack told me, his patient was a “Do Not Resuscitate” (DNR): in the event of a cardiac arrest, he was not to be resuscitated. But did that mean that we were not to try to convert his predeath ventricular tachycardia with electric shock or medications? Dr. Mack was a good doctor; more important, he was a wise doctor, I thought as I walked into the ward, so there must be a reason why we were going to simply wait for his patient to die.
It was early evening and the nursing station was cool and empty except for Dr. Mack. I sat down and he handed me the EKG and rhythm strips he’d just obtained. Mr. Tam was a new patient to him, he explained, and over the past month, he’d been decreasing Mr. Tam’s medications, many of which were not needed. He had monitored the functioning of Mr. Tam’s liver, lungs, and heart as he did so, and they had all been fine. So he couldn’t understand why Mr. Tam, that afternoon, went into this predeath rhythm of ventricular tachycardia. Was it one of the changes he’d made in Mr. Tam’s medications? Was it some obscure interaction among his many medications? Was there something he’d missed?
“Most likely he just had a heart attack,” I reassured him. “He’s the right age.”
Then I spread out Mr. Tam’s EKG on the counter. His EKG was impressive. The shark-tooth line of ventricular tachycardia was there, although it was a healthy and strong ventricular tachycardia, with sharp QRS waves marching across the grid of the EKG paper. It wouldn’t be so crisp shortly, I knew. Even now those sharp peaks of Mr. Tam’s heart rhythm must be starting to sag, getting rounder and shorter, faster and less regular, as the life force they were sparking dribbled out of them. Soon, like mountains wearing down into foothills and then into flat land, they would begin to merge with the flat line of death. Looking at the EKG, I imagined how Mr. Tam’s pulse would feel, bounding up for a few beats, then stopping, then sputtering up again, like a car running out of gas. Sometimes even after a patient is dead, you can feel an occasional beat of pulse or see a blip on the EKG strip.
It was quiet in the nursing station, with that particular quiet and calm you expect as night begins to fall. It was so quiet that it disturbed me, and I lifted up my head from the EKG. Almost everyone had gone home. The day nurses and nurses’ aides, the social workers and utilization review managers, who all, somehow, found a place in that small nursing station during the day, were gone, and the cacophony of voices, buzzers, and beeps gone with them. The charts of the ward’s patients were all back for the night in their rack. Only Mr. Tam’s chart was not back where it belonged, where it would never be again; it was open on the desk in front of me. My attention fell back to his EKG, and I wondered if he was dead when Dr. Mack asked, “Would you like to see him?”
I would, so Dr. Mack and I walked through the ward. We came to the second-to-the-last bed on the right, and there was the body of Meng Tam. His head was propped up on several pillows, and his face was the sallow gray of no circulation. His eyes were half closed and rolled back so that the whites showed, and his mouth was beginning to tighten into the risus sardonicus—the twisted smile—of death. The nurse had pulled the sheets up to his neck and tucked them in around him, and when I pulled them back, they were wet and cold from some last sweat.
I touched the body. It was doughy, clammy, and cold as ice—colder than ice really, because ice is, after all, still alive in its own way—it melts and changes, it w
arms and flows. But the flesh of the dead body is thick and doughy, cool where you expect it to be warm, doughy where you expect it to be resilient. The body was still as well as cold, and when I felt Mr. Tam’s clammy wrist, there was no pulse.
I looked up at Dr. Mack, who was standing on the other side of the bed. Behind him was the evening nurse, who was watching the scene while he handed out medications to the other patients, waiting for the signal to cover the body and call the morgue. But just at that moment, out of the corner of my eye, I saw a movement from Mr. Tam’s body.
It was his chest, rising and falling. Although he had no pulse and no blood pressure, Mr. Tam was still breathing. Quite evenly, as a matter of fact. And when I looked back to his face I saw that, though his eyes were rolled back and only the whites showed, they seemed somehow aware of me. I stared at his chest and so did Dr. Mack. How long would it keep moving?
I thought about the ventricular tachycardia on the EKG strip in the nursing station. It would be so easy to just shock that ventricular tachycardia back to life. All it would take was a little jolt of electricity. There would be the shock of the shock; the body rising out of the bed, then falling back; then the flat line of the EKG, signifying death, but only for a few seconds. Suddenly would appear those little marching soldiers of a normal sinus rhythm, in calm order, once every second from those amazing sinus cells, and the corresponding steady pulse, blood pressure, and circulation of the living.
But Mr. Tam was a Do Not Resuscitate, a DNR. He had an order that he was not to be resuscitated and Dr. Mack had interpreted this to mean that in the event of a cardiac arrest, which this was, Mr. Tam was not to have any defibrillatory shock. And so I stood by the bed, holding his cold wrist, staring at his stiffening visage, and waiting for his breathing to stop.
As I did so, I realized that Mr. Tam was no stranger to me—he was Meng Tam, who’d wrecked his new Toyota Camry and who thought he was a professor, and I knew him from the admitting ward. I tried to think how his DNR had been obtained. While he was at the County Hospital, on the basis of medical futility? I didn’t think so. In the months after he left the admitting ward? I didn’t know. Had his mind cleared enough to voice his wishes? Had his public guardian decided on the DNR?
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 32