The Real Doctor Will See You Shortly

by Matt McCarthy

  He shook his head. “I know you’re a busy guy.”

  “You obviously don’t have to tell me, but—”

  “Next time I’ll tell you.”

  Once again I felt like I was awkwardly straddling the line between physician and friend. “Let’s make a deal,” I said, “either one of us gets admitted to the hospital, we’ll tell the other one.”

  “Ha. Deal.”

  We shook hands just as my pager went off, and I again resisted the urge to throw it against a wall. It seemed like the thing had a sensor, an organ capable of identifying important moments and interrupting them. “I really hate this thing.”

  “You look different,” Benny said. Again our conversation was clumsy, bouncing from one unfinished thought to the next. I considered how significantly Benny’s appearance had changed from when I’d met him on my first day as a doctor, but I said nothing. He was gaunt and his limbs were thin; he was a far cry from the vibrant man I’d first seen on the stationary bicycle.

  “I put on some weight,” I said, tugging at some loose flesh. “Somehow it all went to my neck.”

  “Hmm…That’s not it.”

  “Bags under my eyes?”

  “Nope.”

  “Bereft of—”

  “You look older. That’s what it is.”

  “I feel older.” A week earlier I’d squealed in horror in my bathroom after acknowledging a tiny patch of gray hair. “I’ve accepted my fate,” I said lightly. “I’ll be bald by spring.”

  “I’m just messing with you,” Benny said. He pressed a button on the side of his bed and asked for assistance. A moment later, a respiratory therapist appeared with an oxygen tank and a long, thin plastic tube that she placed under his nostrils.

  “You’re gonna get that fuckin’ heart,” I said. It was the only thing I could think of when I was in his presence. I didn’t believe it, but I said it.

  “Probably need a liver, too.”

  “And liver. You’re getting the liver.”

  “Also need a noodle,” he said, pointing at his head. “If you got one to spare.”

  He flashed a grin and shifted his eyes toward a picture of his wife and daughter on his nightstand. Why had I never seen them during visiting hours? Would one of them serve as his healthcare proxy? There were many probing questions that I had asked Benny, but I’d avoided this topic. Why? I suppose because I wanted to stay positive. I didn’t want to venture into what would likely be an uncomfortable conversation about his absentee family. Maybe they were still in Miami.

  But it wasn’t just family that was absent. Throughout all these months I’d never once seen Benny with a visitor. How could someone so personable be without anyone from the outside for support? Maybe he did have visitors and I’d missed them, but that seemed unlikely. I peeked in on him at all sorts of hours, and he was always alone. Perhaps his network of friends and family simply got tired of visiting. Or tired of hearing that there was no news to report.

  Did he have a dark past like Sam, my primary care patient with the criminal record? Impossible. “I’ll be on the lookout for a noodle,” I said as I stood up to leave. “Gotta get back to the ICU.”

  “Say a prayer for me,” he said as oxygen began to flow from the tank into his nose. I paused, perhaps a moment too long. “Just say a prayer for me.”

  —

  As I left Benny’s room and hopped down a flight of stairs to the medical ICU, I ran through the questions I wanted to ask Darryl Jenkins, who, hours earlier, had been weaned from a ventilator. I wanted to see if I could connect with him—to find out if I could figure out why he had gotten so sick—while remaining emotionally detached from him. It was a fine balance, and I wasn’t sure I could pull it off, but I figured it wouldn’t be nearly as nerve-racking as breaking the news to Ingrid Hansen. Picking my spots with patients like this seemed both smart and a bit cowardly; how could I hedge with some and not others? The important thing, I told myself, was pushing forward, even with an imperfect plan. It would be the only way to move beyond the hesitation Dre had instilled in me, to let my guard down in a tactful yet meaningful way to get patients to trust me the way they trusted Jim O’Connell.

  Darryl was one of the few patients in the unit capable of speaking, and I wasn’t sure when I’d get another chance to work on my bedside manner in the ICU. Questions bounced around my head as I approached the double doors of the unit:

  Could Darryl reveal some trigger or some aura that had preceded his respiratory collapse?

  Why was he so profoundly and disturbingly obese?

  Did he get a flu shot?

  The tube had just been dislodged from Darryl’s trachea, so speaking was going to be uncomfortable. I had to prioritize my questions and tried to determine if it was better to ask one or two open-ended questions or a number of yes/no questions. I wasn’t sure.

  “Big day,” Don said, as he did every morning when I entered the ICU. His predawn arrival served as a reminder that my second year of residency would be no picnic. The hours would be just as long, and I’d have the added pressure of supervising an intern.

  “Let’s do it,” I said, before giving him a rather inept high five and heading toward Darryl’s room. It always took me a moment to adjust to the relentless braying of alarms in the ICU. On a good day, it was like dance music and I bopped from one room to the next as I made my morning rounds. On a bad day, it reminded me of honking car horns in rush-hour traffic. Today the bleating was faintly reminiscent of German prog rock, and I couldn’t tell which way the day was headed.

  “I’m hoping you could give me a moment of your time,” I said, as I took a seat in a small chair by Darryl’s bed. “I have a bunch of questions and I know you just got the tube out.”

  He nodded and gave a soft grunt.

  “I think we can help prevent a future attack if we know more about you,” I said.

  He pulled a blanket up to his nose and closed his eyes. My eyes drifted to his hands and the curvature of his fingernails.

  “Could you walk me through what happened the night you got sick?”

  I already knew a fair amount about Darryl from the medical records that had been generated by the team of emergency room physicians who’d stabilized him before he arrived in the ICU. But there were still some holes in the story.

  I knew that obesity did not run in the Jenkins family. I knew that when he was an adolescent, Darryl’s mother had taken him to a specialist and the diagnosis of Prader-Willi syndrome—a condition in which genes from chromosome 15 are not expressed properly, causing a chronic feeling of hunger that often leads to life-threatening obesity—had been entertained. When it was determined that there was no genetic mutation to account for his unfortunate physique, Darryl sank into depression. And that depression, more than any other issue, dominated his life.

  I had learned from his medical records that before he came to our unit, Darryl had noticed a twinge in his throat. A few hours later, he developed the telltale wheeze of an acute asthma exacerbation. But this time, his inhaler provided minimal relief. In the early evening, when his eyes began to feel like sandpaper and his breathing became labored, he called his mother from his dorm room. But there was no answer. So he called a taxi and was driven to the nearest hospital.

  In the Columbia emergency room a short while later, a yellow sticker was slapped on the top of his chart and he was given an oxygen tank. Darryl was too large for a wheelchair, so he was placed on a stretcher and wheeled across the ER to have a chest X-ray. As soon as the image was uploaded, it was reviewed by Baio, who noted several profound abnormalities of the lung tissue. Not long after that, Darryl’s breathing worsened and he was shipped to our ICU. And then he got the breathing tube and the ventilator.

  I could see that Darryl’s lip had been split open when the breathing tube was tunneled down his throat, and it reminded me of the lady from Mass General ER with the pet toucan. If it didn’t heal properly, his scar might resemble Don’s surgically repaired cleft palate. “I
can also come back,” I offered. “You must be exhausted.”

  An anesthesiologist once told our Harvard Medical School class that the ease of intubation was inversely related to neck flab; in the professor’s opinion the most challenging patient in Boston would be the mayor, Thomas Menino. Based on his body type Darryl was undoubtedly difficult to intubate, and that’s presumably why his lip had been split open. I glanced around his room, waiting for him to speak. There were no flowers, no get well cards; just a pile of XXXL clothes in a clear plastic bag. Where was his family? Was he someone, like Benny, who would pass the hospital days in solitude?

  “Yeah,” Darryl said softly, staring down at his abdomen. “I don’t really want to talk. Don’t want to talk to anyone.”

  “I understand.”

  “Just want to get out of here.”

  “Of course. We’re gonna get you out of here as soon as it’s safe.”

  “Cool. Hope it’s soon.”

  “It will be.” I decided to make one last go of it. I moved my head so that it more fully entered his field of vision. “I’ve been sick and alone before,” I said. “And it sucked.” I drew on my time taking the HIV medications. “I felt like I was gonna die and nobody cared.” Darryl exhaled deeply; it was the largest breath I’d seen him take on his own. “But people do care. Everyone here cares about you.” He remained silent, but I thought I saw a nod. I wanted to ask about his family, but I didn’t want to risk opening a wound. “If you just let me ask you a few questions, I’ll leave you alone. For the rest of the day. Just a few quick—”

  “Fine.”

  “Okay,” I said, turning to the questions I’d scribbled on my scut list. “Did you, out of curiosity, did you get the flu shot this year?”

  “Nope.”

  “Why not?”

  “Didn’t think to.”

  “I’m sure you saw a doctor before you started college. Didn’t he or she offer it to you?”

  “Yeah, probably.”

  “Why didn’t you get it?”

  “I don’t know, man.”

  I noted a small patch of hypopigmented skin at the angle of his jaw and jotted down vitiligo? on my scut list. “Do you know how important it is for someone like you to get a flu shot?”

  He raised an eyebrow. “Someone like me?”

  “Someone with asthma.” I rolled my scut list up like an old newspaper. “Were you depressed?”

  He shook his head. “No.”

  “I get depressed as shit in the winter.”

  His eyes shifted to the window. “Who doesn’t?”

  “Sucks.”

  We sat in silence for more than a minute. “I also feel like shit,” he said, “in the summer. Feel like shit all the time.” It was a difficult thing to hear, but I was encouraged that he was talking.

  “You ever…I’m not saying you should or shouldn’t, but…you ever talk to anyone about it?”

  His jaw clenched. “Like a sociologist?”

  “I don’t know, anyone. A psychiatrist.”

  “No.”

  “When I get depressed,” I said, “I don’t want to talk to anyone. I want the world to leave me alone. I just want to turn it all off.” I thought about the times I’d been depressed. I recalled how, in a fit of despair, I’d screamed at my HIV pill bottles after I’d vomited up what little dinner I could swallow. I thought about how much more difficult it all would’ve been if I had also been dealing with a chronic, debilitating illness. And if I’d been left to handle things on my own.

  I tried to imagine Darryl’s inner world, but I couldn’t. His life was different from mine and he hadn’t given me much to help me understand what he was going through or how I could help him. And I wasn’t a mental health professional, so perhaps it wasn’t my place to fully investigate these issues. I had learned this detail about the flu shot, and that was significant. Darryl rolled over in bed and yawned. “I’m good, man. Really. Kinda beat, actually. Just want to be left alone, honestly.”

  “Right,” I said, looking at my pager. “Glad we got that tube out.”

  “Same.”

  “So…to be continued?”

  “Sure.”

  I closed the tan curtain and headed back to the lounge.

  —

  “I think we have our answer,” I said to Don a minute later. “He didn’t get the flu shot.” Don held a New England Journal of Medicine in his left hand and was typing with his right. Like many of my colleagues, Don set his password so that it could be typed with one hand, allowing orders to be entered at breakneck speed. “And he’s depressed,” I added, while taking a seat on the black leather couch.

  “I’d be depressed, too,” Don said.

  “Really depressed.”

  “Any plan to act on it?”

  “No interest in talking to a psychiatrist.”

  “That’s not the question.” He typed a final order and spun toward me. “There’s an algorithm,” he said. “If someone is depressed, the follow-up question is: Do you have homicidal or suicidal thoughts? If yes, do you have a plan to act on those thoughts?”

  “Got it.”

  “There’s a big difference between ‘My roommate bums me out’ and ‘My roommate bums me out and I’m going to murder him next Tuesday with my new AK-47.’ ”

  “Obviously.”

  Don tapped his index finger on the keyboard. “Suppose he does tell you that he has a plan. Plans to do something bad. Then what?”

  “Call the cops, certainly.” I hadn’t yet met a patient who was actively planning to harm himself or someone else. I mostly thought of my patients as kind, temporarily debilitated beings in need of help, not deranged monsters capable of harming others.

  “What about patient-doctor confidentiality, Matt? If a patient tells you about something devious in confidence—a plan to hurt someone or whatever—can you tell the cops?”

  “I suppose I’d consult the hospital ethicist.”

  “That’s passing the buck, Dr. McCarthy.”

  “I’d try to talk him out of it. That goes without saying.”

  “You haven’t done your outpatient elective yet, have you?” Don asked.

  “No.”

  “I take it you’re not familiar with Tarasoff?” I shook my head. “One minute.” He printed out a document and handed it to me. “Read this.”

  It was a summary of Tarasoff v. Regents of the University of California, a court case that all Columbia residents were eventually exposed to. In the summer of 1969, I read, as Don returned to his New England Journal of Medicine, a graduate student at Cal Berkeley told his psychologist that he was going to kill a woman, Tatiana Tarasoff, who had rejected his advances. The graduate student was briefly committed but ultimately set free. Several months later, he murdered Tarasoff by stabbing her to death. Neither Tarasoff nor her parents were ever given any warning about the threat and sued. The case went before the California Supreme Court, where it was ruled that a physician or mental health professional has a duty not only to a patient but also to individuals who are specifically being threatened by a patient. “The protective privilege ends,” the majority opinion reads, “where the public peril begins.”

  “Well?” Don asked after I had put the paper down.

  “I’m gonna talk to Darryl later today. See where his head is at. I don’t think it’s anything like that.” I remembered that I’d promised him no more questions today.

  Once again I marveled at all I was expected to master. Beyond the medical knowledge and procedures, beyond writing clear, informative notes and interacting with a wildly diverse hospital staff, I had to understand bioethics. I had to be familiar with court cases and legal precedents. I needed to know what to do in situations I’d never considered. The professional expectations were breathtaking.

  “Told me his roommate calls him fat as fuck,” Don said, still staring at the journal.

  The words startled me. Don had already gotten Darryl to talk more than I had. How? My residents were always one st
ep ahead of me. Or several. “I’ll talk to him.”

  “Fine,” Don said, “but don’t do it now. We’ve got a lumbar puncture, two central lines, and a paracentesis that need to get done.”

  “Got it. I’ll grab the stuff.”

  —

  Three hours later, as I was finishing up the lumbar puncture, I caught Darryl Jenkins out of the corner of my eye. He was on a stretcher, wrapped in several blankets, with that plastic bag of clothes on his lap. His asthma had been stabilized and he no longer needed to be in the ICU. He was being transferred to a general medicine floor and would probably be home in a matter of days.

  But I hadn’t gone back to talk to him. I had been too busy sticking needles in other patients. I needed to ask him if he’d ever thought of harming himself or another person, like his roommate. It felt like a small betrayal, like I was suggesting that I thought he was capable of something heinous. It just didn’t seem right to ask Darryl—a kid who’d almost died because of an asthma exacerbation—if he thought about committing unspeakable acts because he was unhappy.

  I dropped my pen and scut list and rushed over to his stretcher. “Hey,” I said. “Congrats on getting out of here.”

  Darryl was staring into a cell phone and didn’t look up. “Thanks, man.”

  This wasn’t the moment to ask him about homicidal or suicidal thoughts, but someone needed to. Someone who was better trained than I was. I motioned to the patient escort to give us a minute. “Darryl,” I said, leaning in close to his face, “can I ask something of you? It’s nothing major.”

  He was texting and didn’t look up. “Me do you a favor?”

  “Yeah. But I want to run it by you first.” I paused to consider my words. This was my final shot with him. “If we send in a mental health, um, if we send in a psychiatrist or whatever, will you speak with that person?”

  He put down the phone and looked up at me. “Why?”

  “Because I think it’s important.” As he stared me up and down, my pager went off. I quickly silenced it. “I can give you a longer explanation if you’d like, but the short answer is that I think you’d benefit from talking with someone about depression.” He continued to stare, not saying a word. “So would I,” I added. “I’d benefit from talking to someone, too.”