A History of the Present Illness (9 page)

When we arrived at Hank and Ted's apartment, they were talking about the lecture too.

“Can you believe that asshole?” Ted asked. He opened a bag of chips and threw it onto their kitchen table, where we'd be studying.

“Lazy prick,” Hank agreed. “Like being hot stuff in the lab entitles him to give an incomprehensible, piece-of-shit lecture.”

Althea and I looked at each other and burst out laughing. It had never occurred to either one of us that the problem might lie anywhere but within.

In our second-year physical exam course, we were sometimes sent to practice our fledgling skills on real patients. When I met Jake C., he was twenty-two years old and panting like a dog. Reverend Frank sat beside him, holding his hand and whispering in his ear. He told me that Jake had had sex only once. The other guy was older, Frank said, told Jake he was negative, showed Jake a lab slip even, then swore on his mother's life and begged to ride bareback. “Live a little,” the guy had said. Reverend Frank closed his eyes and shook his head.

A photo of a handsome young man in a suit and tie hung at the head of the bed. On the white pillow below, Jake's nose, lower lip, and cheeks had been replaced by bulbous purple tumors.

I had learned from the chart that Jake had steadfastly refused antiretrovirals. He believed that he'd acquired the virus through sin and stupidity and intended to let God's will determine his fate.

It was Reverend Frank, a teacher at the small local college where Jake had studied until he became too ill, who had called 911. And it was Reverend Frank who, obviously in love with his former student, had pleaded with the doctors to do everything necessary to keep Jake alive.

I touched Jake's shoulder and asked if I could examine him. His oxygen mask fogged and cleared, fogged and cleared. He nodded.

I followed the sequence I had memorized the night before, starting with blood pressure and the other vital signs. When I finished with his chest, I lifted Jake's gown to examine his abdomen. His belly was covered in tiny, glistening pearly growths, and a few inches to the left of his belly button there was something that resembled a moist purple slug.

The nursing notes in his chart said that Jake's family never visited and that Reverend Frank never left Jake's room.

It was impossible to look at Jake's torso and not think plague and curse and infestation and death. But it was equally impossible to imagine how people could stop seeing, touching, and loving their son.

Feeling righteous, I reached forward to examine the scooped-out expanse between Jake's ribs and hips. Reverend Frank stopped my hand in midair.

“Doc,” he said with a nod at the box of gloves on the wall above Jake's head. “Haven't you forgotten something?”

Our medical school had a two-plus-two format: two years in the classroom followed by two years in the hospital. The demarcation zone consisted of a month in which we crammed facts into our brains for the first of the many board exams designed to certify physician competence. Hank and I had moved in together by then, and in the days leading up to the test, mugs and bowls and plates, papers and highlighters and books migrated onto every surface of our apartment.

“How old do you think this is?” I asked him late one day, holding up a half-eaten sandwich. We'd been quizzing each other on microbiology for almost five hours, working our way through hundreds of viruses and bacteria, protozoa and fungi. I was starving.

Hank moved from his perch on the futon toward where I sat on the floor, placing his feet carefully in the tiny lacunae of visible carpet. He lifted the uppermost slice of bread to reveal wilted lettuce smeared with mayo and mustard.

“Bacteria responsible for food poisoning,” he said.
“Salmonella
and
Staphylococcus aureas. Clostridium perfringens. Campylobacter. Bacillus cereus . . .”
He put the sandwich back on the seat of the armchair where I'd found it. “Come with me,” he commanded. He pulled me to my feet and led me on tiptoe through the drugs and bugs section of our living room to our bedroom, where the shades remained down and the sheets hadn't been washed in nearly a month.

“But I'm hungry,” I protested.

“The ability to focus despite distractions is a key attribute of the competent physician,” he said in the exaggerated cadences of our clinical-skills professor. “I think a change in
topic will help you regain your focus. Let's review some anatomy.” He pulled off his shirt and pointed in turn at his nipple, the paired muscles running down the center of his abdomen, and his belly button. “Areola,” he intoned. “Rectus abdominus. Umbilicus.” His pants and boxers came off in a single surgical motion. “Your turn.”

I took my time unbuttoning my shirt and unhooking my bra, then stood on tiptoe to unzip my jeans and leaned forward. Hank's pulse was visible in the arteries of his neck.

“I have an idea,” I whispered, my lips just a millimeter from his ear. “Let's switch to physiology instead.”

Neurology was my very first rotation—the start of the second half of our two-by-two curriculum. I was finally in the hospital, finally a third-year medical student. Finally, sort of, or almost, a doctor.

On my first call night, just after midnight, the intern and I went down to the radiology department. We needed to check on an urgent head scan we'd ordered first thing that morning. Though the scan had been done hours earlier, we hadn't had a chance to see it. Busy with a steady stream of admissions, we hadn't gone back to see the patient either. That seemed strange to me, but I figured the intern knew what he was doing, and I kept my mouth shut.

I followed the intern through the mystifying maze of hallways and doors that was radiology at San Francisco General. At regular intervals, open doors revealed darkened rooms with giant machines and glowing view boxes. Making a sharp left, we passed a guy lying on a gurney. Two steps later, the
intern stopped walking. I stopped too. And when the intern turned back to the patient, I turned back too.

I thought the guy looked sort of funny.

“Oh fuck,” said my intern. “That guy's dead.”

Except for Cherry and the other cadavers, I had never seen a dead person before. It turned out that they looked very much like alive people, only completely different.

“Call a code,” shouted my intern as he lowered the side rail and began chest compressions.

I scanned the walls, looking for a button or switch.

My intern slammed his arms down onto the dead man's chest. “Phone,” he said, and slammed again. “Operator,” he said, and down went his arms. “Now!” he yelled.

Since this happened during my first night in the hospital, I really appreciated that my intern took the time to introduce me to such an important diagnosis, even if we didn't also have time to discuss who the man was, or how he'd died, or why he was lying alone and dead in the radiology hallway in the middle of the night, or why we called a code and then did a full resuscitation when the intern had known the patient was dead from the start.

Walter was a cowboy and Vietnam vet with a failing heart. I took care of him on internal medicine at the veterans hospital, my second rotation. He was from the Wild West somewhere, a place with lots of rivers and streams. He called me honey or sugar, never doctor or doc, wore a bear-tooth necklace with his hospital gown, and taught me to start IVs. “Try again, honey,” he said when I missed. “I got plenty more.”

I saw Walter several times a day, not only because he was so sick but also because, even though my team had fourteen other patients, being a newbie student, I'd been assigned only Walter. Also, I liked him. From Walter I learned that moose shed their coats late each spring and for months look like mangy dogs, that the best protection against a bear is to sing at the top of your lungs, and that a single elephant turd can weigh eight pounds or more.

“Elephant?” I asked. Even a city girl like me knew that the only elephants in North America lived in zoos.

“Read that one,” Walter admitted.

He also admitted that he hadn't killed a bear to get the bear-tooth necklace he wouldn't remove.

“My daughter found it,” he said. “Gave it to me for Christmas the year she was six. The next week, her mama packed them both up and took off back to her parents in Phoenix.”

“Where is she now?” I asked.

“Dunno, sugar,” he said. “She got poisoned against me a long ways back.”

Ten days after his admission, on a sunny Wednesday morning when our team was doing morning rounds, Walter announced that he felt better. “Seems like maybe the old ticker isn't used up after all,” he told us, sucking air through dusky lips pursed to a crenellated O.

The real doctors on the team nodded and murmured, weighing the pros and cons of sending Walter home. When the senior resident gave his okay, with the usual caveats and warnings, Walter smiled. As the others filed out of the room, I squeezed Walter's hand. It felt cool and limp, like a fresh-caught fish, and I wondered whether his heart, though improved, was doing well enough to keep him going outside the hospital. I told Walter I'd be back later to do his discharge
paperwork, and then I hurried off to catch up with my team. Walter winked and said, “Catch you later, sweetheart.”

But he didn't.

When I got back to his room, a man bright yellow from jaundice lay sound asleep in Walter's bed. I raced to the nursing station, sure that Walter had died, but he hadn't, he'd gone home. The senior resident had done the paperwork while I was at a student conference.

“Hey,” said a nurse, holding out a wadded piece of tissue. “He wouldn't leave unless I promised to give you this.”

Inside the tissue was the bear-tooth necklace.

“So creepy,” said the nurse.

I held up the worn leather strap. Most of the huge tooth was a yellowish brown, lumpy and ridged, but the tip was pale and worn, with a chip at what should have been the pointed end. I tucked it into the top pocket of my white coat, safety-pinned it in place, and headed down to the emergency department to meet my next patient.

During the first months of our third year, despite the long work hours, Hank and I felt thrilled to be in medicine and happy to be together. I pranced in my rubber clogs. When Hank put on scrubs, he swaggered. No matter how late at night we got home, we lay in bed and presented our accomplishments to each other like gifts in a game of escalating munificence: I did a spinal tap, he caught a baby; he stapled a wound, I did an intubation; he put in a central line, I sutured a laceration.

Since the start of medical school, Hank had debated the pros and cons of each type of surgery: heart or brain, colorectal
or transplant, plastic or orthopedic. I hadn't wavered from general surgery, sure that it alone would allow me to indulge my broad interests, play to my strengths, fulfill my family's expectations, and prove my grandfather wrong.

That fall, I began my general surgery at the university hospital with a team considered one of the ten best in the country. Unlike my earlier rotations in neurology and medicine, my surgery team didn't spend half the day talking to patients or one another; we actually did things. In the first two weeks I scrubbed in on more than twenty cases, drained a giant abscess, tied off an appendix, and flew to the Central Valley to harvest a liver. I loved it.

And then in the third week, just minutes after giving what my team told me was a great presentation at the predawn morbidity-and-mortality conference, I was standing outside operating room 14 reviewing the day's cases with my resident when a group of gray-haired surgeons passed behind us. At first, post-call and coming down off the adrenaline of my talk, I thought I'd been stung on the butt by a bee. By the time I realized that my ass had been pinched by one of the august, scalpel-wielding, nationally renowned, and locally revered leaders of my future specialty, it was impossible to know which one had done it.

I told my resident.

“Assholes,” he said with a smile.

I told my attending.

He leaned back against the hallway wall and asked me to present our new admissions.

I told Hank, who said, “C'mon, you knew stuff like that would happen.”

I didn't call my father or brother, and at the time, I couldn't have explained why not.

Dr. Michelle Hitchens, (former) locked inpatient psychiatry ward attending, taught me a lot about mental illness, and I think the least I can do in her memory is to make sure others realize that depression is a common and crippling disease too often suffered in silence and shame even by those of us in the medical profession. Dr. Hitchens, for example, had all the symptoms listed in my
Diagnostic and Statistical Manual of Mental Disorders
under the diagnosis “major depression,” but she seemed either to have no insight into her situation or to be in complete denial.

Every day, we rounded on people who, just like Dr. Hitchens, felt hopeless, slept poorly, ate little, and enjoyed nothing. She worked slowly, cried often, and at the strangest moments would reveal some detail of personal life that was clearly none of my business. One day she mentioned that her husband hadn't worked since about six months after their marriage. Another day she said that he claimed to be writing a play, but really he just went out for coffee and read magazines. She did the grocery shopping, the cooking, and most of the cleaning. On weekends he stayed in bed while she got up to deal with the kids and the dog. He called weekends his days off.

“So,” she would say, standing outside a patient's room, gazing at me through eyes bloodshot from fatigue and framed by dark circles, pale cheeks, and sunken temples, “Can we do anything for this sad soul?”