Volume 20, P. 425
What a difference a day makes. On Friday, March 31, I was useless. Supernumerary. Tits on a boar hog. Which is to say, a medical student. The next day, the state of California gave me a license to practice medicine, and the Santa Clara Valley Medical Center issued three starched white jackets with DR GAMEL stenciled in blue ink over the heart. Immediately beneath, in the more durable medium of embroidery: INTERN. The pockets held my stethoscope, reflex hammer, tuning fork, and visual acuity card – gifts Eli Lilly hoped would encourage me to prescribe their excellent medications. Now I could sign my own orders. When a patient stopped breathing, it was my problem.
I had finished medical school three months early, planning to lie around and drink a little beer until my internship started in July, but an intern in the class ahead of me had skied into a tree during his vacation at Tahoe, landing himself in the intensive care unit and leaving Valley Medical Center desperate for a fill-in. A phone call from the hospital director caught me in a weak moment, lounging on the dilapidated porch of my rented cottage, halfway through a seedy joint cadged from my next-door neighbor. The director gave me a sob story about how hard everyone had to work filling in for the missing intern. A few days later, optimistic and well-rested, I shook hands with Harvey Fitzgerald, my chief resident, a scrawny man with a narrow jaw, caved-in temples and wild, straw-colored hair. There were dark circles under his eyes. He looked me over, taking in my fresh face and my fresh white jacket.
“God, you look good,” Fitzy said. He laughed and patted me on the shoulder. “That won’t last long.”
* * *
The odor given off by an E. coli abscess leaves a greenish-black licorice taste in the back of the throat. A number eleven Bard Parker blade is razor sharp, angled for deep penetration, encouraging the puss to pour out in warm yellow dollops. I trotted down the world’s longest corridor to the staff restroom, leaned over the toilet, vomited copiously, spat, coughed, cleared my throat. I turned around to find Fitzy standing behind me.
“So, kiddo,” he said, “maybe you should be a drug rep.”
I turned back to the toilet and spat two or three more times. When I finished, he handed me a gauze pad from the pocket of his white coat.
“Got some on your tie.”
Fitzy’s humor never let up. He made an amusing but stunningly crude remark when the pendulous breast of a corpse flopped over the edge of the gurney as it bumped its way down to the morgue. He poked an overweight OR nurse in the umbilicus and asked when the baby was due. He gave nicknames to everyone in the hospital. Two jaundiced patients on B Ward became the Little Lemon and the Big Lemon; both were wasted from liver disease, with bony chests and rail-thin arms and legs, but the Big Lemon’s ascitic belly was swollen to the size of a beach ball. On the private wing, we had two GI hemorrhages, the Good Bleeder and the Bad Bleeder, distinguished one from the other by their skill at using a bedpan. The four Frat Brats were scattered around the surgery floor – two in the SICU, one in the TCU, one on the ortho ward. They had ended their spring break from Chico State on the Bay Shore Freeway, tucked under the rear axle of an eighteen wheeler.
Two Frat Brats departed during my first week. Brat One, a pin in his femur, stretched himself out on the back seat of his father’s Lincoln Town Car, while Brat Four rattled down to M ward on a gurney with the sheet pulled over his head. Fitzy said, “One gone high, t’other gone low.” Under the sheet, Brat Four looked pretty good – a little pale, a blood clot in one nostril, an NG tube dangling from the other. The chief of pathology always insisted we send our corpses down with every tube and catheter in place; perhaps the patient had died because we poked something into the wrong organ. That left us with Brat Two’s persistent coma and Brat Three’s collapsed lung.
Then there was the Bone Woman. Cancer patients tend to waste away, but her body was a walking skeleton even before she began coughing up blood. Every two hours, she made a pilgrimage down the hall, shuffling along at a snail’s pace, her various attachments – the cast on her arm, the saline bottle, the IV pole, the drooping IV line – all rocking back and forth with the rhythm of her feet. Her floral print gown hung open. On her chest, above a useless brassiere, she bore the mark of death – a radiation portal tattooed in red ink. Even an intern could read the story: lung cancer had spread to her arm and cracked the bone. She smelled like an ashtray. I stared in fascination at the tar-stained fingers, the wasted legs, the tiny, eager steps that inched her toward the smoking lounge.
Passing her room one afternoon, I heard someone sobbing, “Oh, mother . . . please . . . please . . . ” Through the doorway, I glimpsed a red-faced man leaning over her bed. Apparently he convinced her that she might recover if she quit smoking. At rounds the next morning, she thrust her bony hand under the bedrail to grab Fitzy’s arm.
“Doctor, I’m gonna quit, ” she said. “Tomorrow for sure. I swear. The whole carton in the trash.”
Fitzy squeezed her hand, looked her in the eye, gave his warmest smile. Her coarse hair was dyed dark brown, with gray roots an inch long. Her face showed every hollow and ridge of the skull beneath. The eyes lay deep in their sockets.
“No ma’am,” he said, holding her hand with both of his, leaning down until their faces almost touched. “That won’t be necessary.”
The Bone Woman died five days later. The next morning, her room lay clean and fresh, the bed sheets drawn tight, waiting for Spinal Beauty to arrive.
* * *
A day goes on for a long time. Twenty-four-hour shifts followed eighteen-hour shifts. We walked down corridors filled with shadows and faces – vivid faces, bloated or wasted, jaundiced or cyanotic or bone white, each according to their disease. We walked on coffee-colored linoleum, beneath naked overhead pipes – red for steam, blue for water, black for sewage that gurgled every time a toilet flushed. We walked alone, or in slow, murmurous, down-gazing teams. Venetian blinds covered the windows of the charity ward. The private ward had pink drapes, the overhead pipes hidden behind white ceiling tiles. Every night janitors mopped the floors. At one, two, three o’clock in the morning, I heard the clank of their buckets, smelled the pine scent of their detergent.
“Doctor Gamel, I have a patient for you.”
It was Mrs. Stizel, the bed-control supervisor. She sat alone, exhausted, the peak of her white cap showing above the B ward counter. Her face was pale and soft. Untidy gray hairs curled from beneath her cap. Fitzy called her Grandmamma. Her voice was throaty, deep as a man’s. “The blue team is overloaded,” she said. “We must ask that the red team accept a transfer.”
She forced a smile. Her hand rested on a thick chart. Tabs divided the pages into sections: history, physical examination, laboratory reports, progress notes. On the front, in bold black letters: CATHERINE MARY KOHLER – VOLUME III.
In what had been the Bone Woman’s room, I found a girl with a twisted torso, her sternum thrust up like the prow of a ship beneath her flannel gown. Her nose and mouth were covered by the clear mask of a nebulizer that delivered oxygen and moisturized air. These things I had expected. The chart said a seventeen-year-old Caucasian female had severe kyphoscoliosis with secondary pulmonary compromise. The lungs don’t work when the spine is bent like a pretzel. Now she had pneumonia, hypoxia, tachypnea – thirty respirations a minute. But her face. The chart said nothing about her face.
What was Cathy’s secret? Was she beautiful? Not really. She had a long nose, a little broad at the tip. Except for the nose, her face was angelic, expressionless as a doll’s, framed by carrot-colored hair that lay spread across her pillow. Mist from the nebulizer settled in fine droplets on her cheeks and eyelashes. She had bluish lips, translucent skin with the dusky hint of suffocation. Mostly, though, I think it was the eyes – pale green, wide-set, elusive. A desperate child, struggling for breath every moment, but her eyes never pleaded. They never looked at me. They never looked at anyone.
“Hello,” I said. “I’m Doctor Gamel. You’ve been transferred to my team. How do you feel tonight?”
Nothing doing. Her eyes remained fixed on the TV screen above the bed. A minute went by, her gaze flicked over, took in my white-jacketed form standing by the bed, flicked back to the screen. The room filled with laughter as Lucy swung a rubber chicken over her head and chased Ricky around a grainy black-and-white kitchen.
The next morning, Fitzy and I stood beside Cathy’s bed while he asked the usual questions. How had she slept? Did she have any pain? Was her breathing better? Each reply, muffled by the nebulizer, gave off a puff of mist: “fine . . . no . . . yes . . . ” Fitzy pulled the curtain around the bed while I untied three bowknots down the back of her gown, exposing cyanotic skin, a spine that curved and twisted, thrusting her right shoulder into a pale blue hump. Her breathing was rapid, strident, almost frantic. With each inspiration, the skin on her flanks sank into furrows between the ribs. Her breath sounds came through my stethoscope as from a great distance, the whisper of a desperate, faraway struggle.
I laid her down and palpated her abdomen, the narrow, scaphoid abdomen of a girl, hardly wider than the span of my open hand, with iliac crests that rose like fence rails on both sides of the pelvis. A tuft of pink lint nestled in her umbilicus. Her eyes never strayed from the screen, though most of it was blocked by the drawn curtain. Back in the hallway, Fitzy said, “Stubborn little brat,” but he was the one who named her Spinal Beauty.
Later that night, I stopped by Cathy’s room, clutching a thin chart labeled CATHERINE MARY KOHLER – VOLUME IV. The lights were on, the TV droned, but she was asleep. Beneath the plastic mask, her parted lips showed the gleam of white teeth. Tiny droplets clung to her long, innocent lashes. She smelled like baby powder. Her arms, covered with downy, copper-colored hair, lay folded on her chest. I turned off the lights, turned off the sound on the television, leaving the screen alive so she would have something to look at if she woke in the night. The bluish-white glow played across her face. Her struggling breaths rose and fell over the hum of the nebulizer.
* * *
The interns’ call room was lighted by a dome in the center of the ceiling. I pulled the string, lay on the bunk, dropped into sleep like a brick down a well. A man who craves sleep craves nothing but sleep, envies no one but the peaceful, comatose patient. Sometimes the phone rang four or five times before I could figure out where I was. One night a Filipino nurse shouted, “Doctor, doctor, come quick, patient dying!” and hung up. Five wards, a hundred odd patients under my care for the night, and my only clue: “Doctor, doctor, come quick, patient dying!”
Surgical ICU – a lucky guess. Frat Brat Three sat bolt upright in bed, a beautiful boy with wide-open eyes, bushy dark hair, a halo of sun-bleached ends. Blue lips. Blue fingernails. Rapid, frantic breaths. The boy was suffocating, terrified, his eyes following my every move as I stripped off his pajama top and pressed a stethoscope against his dusky chest. The left side was silent. The overhead lights pierced my eyes. I struggled against the stupor of darkness and sleep. My mind said pneumothorax, but that was the end of it. Pneumothorax. Pneumothorax? How long did I stand there looking into those wide-open eyes, eyes that said, This isn’t nice, doctor, not nice at all – no matter how fast I breathe, it doesn’t help.
I watched my fingers peel a bandage from his flank, exposing a clear plastic tube threaded between his ribs. The tube was clamped shut, streaked with bloody serum. The day before, Fitzy had decided the boy’s punctured lung was healed and ordered a nurse to disconnect the tube from the vacuum pump. Fitzy was wrong. My fingers removed the clamp and connected the pump and flipped the toggle switch. I was startled, wakened, by a wet, glutinous sucking sound, the rhythmic glub-slurp-glub-slurp-glub-slurp of a gigantic infant nursing a gigantic teat. Unseen, deep in the boy’s chest, his lungs filled with air. He sighed. His breathing slowed. The dusky color faded from his skin. Under the bright fluorescent lights, his bare chest and arms glowed with an olive tint. He slumped against the pillow, closed his eyes, sighed again. I pulled the covers up to his chin. He turned on his side, smacked his lips. His lips were red and dry. He slept.
A few days after the boy’s discharge, I got a impassioned letter from his mother. The postmark was Malibu Beach. In elegant script, she thanked me for saving her son’s life, all but weeping on the perfumed vellum page. By that time, I had forgotten his name. To tell the truth, I had probably never known it. The fruit of his mother’s womb, more precious to her than life itself, but to me he was Frat Brat Three – a nineteen-year-old Caucasian male with a traumatic pneumothorax, sent home with a thumb-sized scar between his left fourth and fifth ribs. Some day a girl, caressing the smooth olive skin of his flank, will feel the scar beneath her fingertips. Oh, my, she will whisper, her breath warm in his ear, where’d you get that?
* * *
The Big Lemon died, followed three days later by the Bad Bleeder. Frat Brat Two finally came off the respirator and was dispatched to a nursing home for the remainder of his comatose life. Fitzy celebrated the Little Lemon’s birthday by hauling the old woman out of bed, then summoned every nurse and orderly on the ward, put his arm around her shoulders and led the group in singing “Happy Birthday.” Early the next morning, the Little Lemon began screaming her head off. She screamed for six hours, the arching spasms of a woman in labor, until the gallstone no one knew about passed out of her common bile duct. Her jaundice cleared. Four days later, on her way to the discharge desk, the scrawny, nut-brown old woman jumped out of her wheelchair and grabbed Fitzy around the neck, kissing him on the lips until he broke her grip to keep from suffocating. This was his payback for the Happy Birthday.
* * *
Fitzy’s touchy-feely routine fell flat with Cathy. She didn’t pull away when one of us took her hand, but the hand just lay there, cool and damp, lifeless as a dead fish. Our gentle touch, our kind voices, our caring smiles – all came to naught. Her eyes never budged from the TV screen. Nothing more than a grunt or a single syllable ever came out of her mouth. That twisted body had twisted her psyche: ignored, rejected, taunted for years, she had hardened her heart against human touch.
But I didn’t give up. On rounds one morning, I took a gauze pad from the pocket of my white jacket. Every time Cathy exhaled, mist from the nebulizer settled in fine droplets over her face, her lashes, her lovely red hair. While Fitzy went through his questions, I dried her face with the gauze, then gently brushed the strands of damp hair from her forehead. It worked. Those pale green eyes, glued to that wretched screen for a week, were mine at last. She looked at me. The room seemed to flood with light. My reward had come – a gaze so piercing it took my breath away. Cathy lay silent, entranced, while Fitzy’s questions fell on deaf ears. A torrent of meaning soared through the empty space dividing me from this lonely girl, a torrent that spoke of pain and cruelty, of a fathomless need that had lived for years on end without hope or a single tender moment.
Fitzy saw what was happening and winked at me. I had made contact. As we turned to leave, I heard a faint voice behind us. Perhaps it said, “Thank you,” or, “That was nice,” but by the time I turned around, it was too late. Ted Mack’s Amateur Hour had sucked those pale eyes back to the screen. At rounds that evening, I would discover them fixed, glued, stuck to that execrable TV with more tenacity than ever, as though my precious breakthrough had only stiffened her resolve.
But in the hallway, fresh from our moment of victory, Fitzy choked up. He put his arm around my neck and whispered in my ear. Had I seen volume one? No, I hadn’t. What volume one?
“You lucky bastard,” he said, his voice quavering with emotion. “I wish I’d never looked.”
He led me to the deserted B ward counter and hauled it out of a drawer – VOLUME I of Cathy’s chart, a bound stack of papers four inches thick, filled with nursing notes, lab reports, physician’s orders, vital signs, all recorded during her early admissions for asthma and pneumonia. Near the front, Fitzy showed me ten black-and-white photographs, each calibrated by a vertical ruler along the left side.
The first photograph showed a little girl standing naked beside the ruler with her back to the camera. She was four feet, three inches tall, her buttocks white between crisp tan lines. Someone had parted her long hair down the middle and pulled it forward across the shoulders to expose every square inch of skin, then marked the vertebral points along the spine with thumb-sized black dots. The dots showed a mild S-shaped curve that ran from her cleft to the base of her skull.
The second photograph showed a child four feet, seven inches tall. The curve was steeper, but only a bit. To the unlearned eye, Cathy would have seemed a healthy child, but year by year the curve grew steeper, until the last photograph showed a cruel black snake tilting the pelvis, contorting the ribs and shoulders into ugly, painful angles. Her skin, hidden from the public eye, was pale, unmarked by tan lines. Her hair was ragged and badly combed. No one pets a twisted child.
Fitzy and I sat side-by-side at the ward counter. The lights dimmed; it was ten p. m., the ward silent except for the distant hum of a refrigerator in the drug room. Beyond the counter stretched the faint yellow glow of two corridors dappled with shadows, lined on both sides by the doors behind which our patients slept. I caught a whiff of pine oil. An unseen mop clanked against its bucket.
I closed Cathy’s chart. Fitzy burst into tears, pressing his hand against his mouth to keep from making too much noise. He cried for a long time, slumped with elbows on knees, blowing his nose on gauze pads and lobbing the soggy pads into a trashcan. I put Cathy’s chart back in the drawer. Neither of us spoke. We stood up and went our separate ways.
I had lost my heart to Cathy even before Fitzy showed me VOLUME I. It happened soon after her transfer to my team, when I entered her room on my final rounds for the evening. Here was the bouquet of hospital life – Lysol, isopropyl alcohol, the urine of the diapered alcoholic lying comatose in the room next door. I turned off the overhead light, turn off the sound on the TV, leaving the bluish-white light of the screen to play across Cathy’s sleeping face. As I watched the rise and fall of her chest under the flannel gown, there came a special treasure – she began to dream. Her eyelids quivered. Her legs twitched. The sheet fell away, exposing a pale, slender foot. She whimpered, tensed her body, pulled at the oxygen tube, lifting the nebulizer to show for an instant the full indigo blush of her lips.
What colors fill the dreams of this blighted child? Does sleep show her wildflowers, dark, secret pools, the icy flakes of a winter storm? Do minarets rise up to pierce a morning sky alive with butterflies and iridescent clouds? Her vulnerability, her precious need for care – oxygen, epinephrine, antibiotics, endless attention to detail – weigh upon my shoulders like the cloak of a king. I shelter her. I sustain her. This is what I live for.
* * *
I can’t name the magic that binds a doctor to certain patients. Something happens, an emotional spark not unlike the spark that binds mother to child. Of course, we doctors try to give our best to everyone, but some patients are special. They worm their way into our hearts.
An eighty-year-old Caucasian female, pale and hairless as an egg, awaits the final stage of her pancreatic cancer. While I sit at her bedside filling her chart with my left-handed scrawl, she reaches down to touch my shoulder and whispers, “They’re not teaching you young doctors a damn thing nowadays.” When I ask what she means, she replies in a voice so faint I must cup my hand to my ear: “You’ve got that pen in the wrong hand.” Her tremulous smile, fragile as the wings of a fairy, has stayed with me to this day.
A ninety-four-year-old Filipino veteran of the Spanish-American war lies in the Palo Alto Veteran’s Hospital. In his room, I find a wasted lump buried under the bedclothes. He seems comatose, so I speak to the woman standing at the foot of the bed, a dark-eyed Filipino beauty who doesn’t look more than twenty-five.
“Are you his granddaughter?” I ask. My guess is a great- or a great-great-granddaughter, but I’m playing it safe.
“Oh, no,” she says, “I’m his wife.”
“His wife!” My voice is loud, almost a shout.
“Yes, his fifth wife.”
“His fifth wife!”
During the silence that follows my outburst, a laugh ascends from the lump in the bed. A muffled laugh, faint but full of life, full of a final, glorious triumph that will shine forever in my memory. A few days later he is dead.
But however much we love them, sooner or later our patients always leave us. I lost Cathy to the knife. The first hint of what awaited her came when Fitzy got in a shouting match with Ernestine Shoemaker, the chief of physical medicine and rehab. I saw the two of them striding toward the PMR conference room, both frowning and red in the face. After the door slammed shut, I couldn’t hear what they said, but they made lots of noise.
Later Fitzy told me the story. Shoemaker was an excellent doctor, adored by her patients, but with colleagues, she had a clangorous way of making her point. Fitzy nicknamed her the Linebacker. A short, stocky woman, she wore her dark hair cut like a helmet, and her shoulders bulged under her white coat. Fitzy said it was all flab, but an orderly on PMR swore he had seen her heft patients onto an examination table with her bare hands.
Shoemaker wanted some big cheese up at Stanford to cut on Cathy, slice her back open and implant a titanium rod to straighten her spine. Fitzy flew into a rage. The operation sounded like a horror show. We hunted down the chief ortho resident, a big Dutchman named Jansen. He showed us a horrible picture in The Archives of Orthopedics – skin flayed, muscles stripped down to the bone, the spine a row of white knots. The next page was worse – pliers, screwdrivers, huge gloved hands, a titanium rod running down the middle of a bloody mess.
“My god,” Fitzy said, “they’ll kill her.”
“Well, yeah,” Jansen said, “that happens. They lose tons of blood. Sometimes the spine breaks, they have to abort the procedure. They did the first few cases in Paris, and a couple of patients ended up paraplegic. It just depends.”
Shoemaker wouldn’t listen to reason. The battle raged all the way up to Valley Medical Center’s chief of staff. They even called Jansen to examine Cathy, and he jumped ship: do it, he said – it might kill her, but it might help. What nonsense. Nobody asked me. I thought the debate would go on for weeks, but three days after it began, Mrs. Stizel called to me from behind the B Ward counter.
“You missed the show.”
“What show?” I asked.
“The big hullabaloo. About an hour ago, two guys in funny uniforms” – ambulance attendants sent from Stanford, as it turned out – “trotted down the hall with a gurney, grabbed Cathy and hauled her off. You would have thought she was being abducted. I followed them down to the discharge desk, and when the supervisor tried to hold things up because of a problem with the paperwork, Cathy sat up on the gurney and cursed her like a sailor. Holy heaven, I never thought I’d hear words like that from a grown man’s mouth, much less a girl’s. They finally got things straightened out, but just as they wheeled Cathy off to the ambulance – I swear, you wouldn’t believe it – she spat at that supervisor. Just puckered up and spat, her eyes so full of hate you would have thought that woman was the devil himself.”
The news enraged me. My poor Cathy, the soul of innocence, had cracked under the strain, suffered a psychotic break, and still they sent her off to get sliced up like a side of beef. A few hours after the operation, I called Stanford hospital, introducing myself as “Doctor Gamel, Catherine Kohler’s attending here at Valley Medical.” God forbid they should know I was a lowly intern. Stable – that was the only word I could wheedle out of that stupid clerk.
A few days later, I got an afternoon off and drove up the Bay Shore Freeway, only to find Stanford hospital even more of a madhouse than usual, with teams of interns and residents and medical students swarming every corridor. The first floor of the west wing was closed so NBC could film a special on Norm Shumway’s heart transplant team, and I had to take the freight elevator up to west 3A. Cathy’s bed was empty. Her roommate lay reading a magazine, playing with her long brown hair, rubbing the soft tassels against her lips.
She said, “Cathy’s gone for a walk.”
The words gave me a shock. Cathy lived in a bed, now and then in a wheelchair or on a gurney. I had never seen her walk. I wandered down the corridor, around the corner to West 3B, across and back down West 3A. After two circuits I was about to reverse my direction, when – my god – there she was. I had passed without recognizing her.
Cathy walking, that astonished me, but . . . she was . . . so tall. Upright, ramrod straight, her head rising above my shoulder – almost as tall as I was. And painfully rigid, her eyes showing the agony of every step. An IV pole bobbed along beside her, dangling a bag of blood and a loop of IV line that ran beneath the collar of her pink quilted robe. The blood in the bag and in the line was dark, almost black. Beneath the robe, her modest breasts showed perfect symmetry. The titanium rod had uncoiled her into a woman.
It couldn’t be, but it was – Cathy. Yes, the green eyes, the hollow cheeks, the long nose, a little broad at the tip, the neck and face pale against the pink robe, and yet . . . something was wrong. The dusky hint of suffocation had vanished. It was an ordinary face.
I spoke to her. “Yes . . . Fine . . . No . . . ,” she said, answering my questions as reluctantly as ever, but now she looked me in the eye. A steady gaze, her face still flat and inexpressive as a doll’s. And ordinary. I couldn’t get over that – such a pale, common face. Perhaps I missed the color, the indigo tint of asphyxia. Now her skin was dead white, palely translucent, like a polished wafer made from ivory or bone.
The loss of that tint carried a terrible meaning: she didn’t need me. I was delighted, of course. Absolutely delighted. About as happy, I would guess, as a mother who finds that the precious child she once held in her arms is now six feet tall, with hair on his chest and a face full of pimples, a sullen adolescent who gags at his mother’s touch. Those who claim they never want to go back tell a terrible lie. All precious things have their moments, and that moment is never – never – the last. The last moment is death.
Cathy’s suffering would soon fade, the agony of each step healed by quick young tissues. Those green eyes had held no secrets intended only for me, no craving to be understood, no longing that could be served by innocent hands. She didn’t want a man to stroke her brow or balm her soul. No, she wanted a surgeon – a man with a knife who could fix her body. Fitzy and I were nothing but eunuchs, pathetic wimps who had nursed her down a painful road to nowhere.
She was not my patient. Soon she would be nobody’s patient. I had come to find the new Cathy, carved from old flesh by a surgeon’s knife, but in the majesty of her pain, I saw that she was lost to me forever.