A Life in Medicine

by Robert Coles

  He was immediately sedated with a bolus of morphine injected into one of his lines. He was paralyzed with a curare-like agent, a cousin of the paste used on arrow tips by indigenous tribes in the Amazon. As the drug shot through his circulation and reached the billions of junctions where nerve met and directed muscle, it blocked all signals, and he lay utterly still and flaccid.

  The respirator sent breaths into him with rhythmic precision at the rate dialed in by Ray, even throwing in a mechanical sigh—a breath larger than usual—to recruit and keep patent the air sacs in the base of the lung.

  The young man’s parents now arrived at the hospital and were escorted up to their son’s bedside. They had been waiting for him at home. Now they stood, I was told, in utter disbelief, trying to see their son through the forest of intravenous poles and the thicket of tubing and wires that covered him, asking again and again what had happened. And why?

  By the next day the pneumonia had progressed. His lungs were even stiffer, making the respirator work overtime to drive oxygen into him. Ray performed a bronchoscopy, sliding a fiber-optic device into the endotracheal tube. Through the bronchoscope he could see the glossy red lining of the trachea and the bronchi. All looked normal. He directed the bronchoscope as far out as it would go, then passed a biopsy forceps through it and took a blind bite of the air sacs of the lung.

  Under the microscope, the honeycomb-like air spaces of the lung were congealed with a syrupy outpouring of inflammatory fluid and cells. Embedded in this matrix were thousands upon thousands of tiny, darkly staining, flying-saucer-like discs that the pathologist identified as Pneumocystis carinii.

  The young man had no predisposing illness like leukemia or cancer that would explain this fulminant pneumonia caused by an innocuous organism.

  His immune system had to be abnormal.

  It was clear, though no one had yet seen a case, that he was Johnson City’s first case of the acquired immune deficiency syndrome—AIDS.

  Word spread like wildfire through the hospital. All those involved in his care in the ER and ICU agonized over their exposure.

  The intern remembered his palms pressed against the clammy breast as he performed closed-chest massage.

  Claire remembered starting the intravenous line and having blood trickle out and touch her ungloved skin.

  The respiratory therapist recalled the fine spray that landed on his face as he suctioned the tracheal tube.

  The emergency room physician recalled the sweat and the wet underwear his fingers encountered as he sought out the femoral artery.

  Even those who had not touched the young man—the pharmacist, the orderlies, the transport personnel—were alarmed.

  Ray worried too; he had been exposed as much as anyone. In the days to follow, he was stopped again and again in the corridor by people quizzing him about the danger, about their exposure. Ray even felt some anger directed at him. As if he, who had done everything right and diagnosed the case in short order, could have prevented this or warned them.

  An ICU nurse told me that the young man’s room took on a special aura. In the way a grisly murder or the viewing of an apparition can transform an otherwise ordinary abode, so cubicle 7C was forever transformed. Doctors and others in the ICU peeked through the glass, watching the inert body of the young man. His father was seated beside him. The hometown boy was now regarded as an alien, the father an object of pity.

  Ray told me how the parents took the news. The mother froze, staring at Ray’s lips as if he was speaking a foreign language. The father turned away, only the sound of his footsteps breaking the silence as he walked out into the corridor and on out into the parking lot, unable to stay in the building where that word had been uttered.

  Much later, the father asked, “But how did he get it? How could he have gotten this?”

  Ray pointed out that he had had no time to get a history: perhaps they could give him some information. Had their son been healthy in the past year and in the days preceding the trip? Lord, yes! (The father did all the answering.) Did he ever use intravenous drugs? Lord, no! And to their knowledge had he ever had a blood transfusion?

  No.

  Was he married?

  No.

  Did he live alone? No, he had a friend in New York.

  A male friend? Yes . . . they had never met him.

  “Oh Lord! Is that what you’re saying? Is that how he got it? Is my son a queer?”

  Ray just stood there, unable to respond to the father’s words.

  The father turned to his wife and said, “Mother, do you hear this? Do you hear this?”

  She gazed at the floor, nodding slowly, confirming finally what she had always known.

  The mother never left the ICU or her son’s side. And in a day or so, the father also rallied around his son, spending long hours with him, holding his hand, talking to him. Behind the glass one could watch as the father bent over his son, his lips moving soundlessly.

  He balked when his son’s buddies flew down from New York. He was angry, on the verge of a violent outburst. This was all too much. This nightmare, these city boys, this new world that had suddenly engulfed his family.

  Ray tried to mediate. But only when it seemed his boy’s death was inevitable did the father relent and allow the New Yorkers near him. He guarded the space around his son, marshaling his protection.

  The two visitors were men with closely cut hair. One had a pierced ear, purple suede boots, tight jeans, and what the ICU ward clerk, Jennie, described to me as a “New York attitude—know what I mean?”

  Jennie said the other friend, clearly the patient’s lover, was dressed more conservatively and was in his early forties. She thought he was “a computer person.” She remembers the tears that trickled continuously down his cheeks and the handkerchief squeezed in his hand. Jennie thought the mother wanted to talk to her son’s lover. He, in turn, needed badly to talk to anyone. But in the presence of the father there was no chance for them to speak.

  Three weeks after his arrival, the young man died.

  The New Yorkers left before the funeral.

  The respirator was unhooked and rolled back to the respiratory therapy department. A heated debate ensued as to what to do with it. There were, of course, published and simple recommendations for disinfecting it. But that was not the point. The machine that had sustained the young man had come to symbolize AIDS in Johnson City.

  Some favored burying the respirator, deep-sixing it in the swampy land at the back of the hospital. Others were for incinerating it. As a compromise, the machine was opened up, its innards gutted and most replaceable parts changed. It was then gas disinfected several times. Even so, it was a long time before it was put back into circulation.

  About two months after the young man died, I returned to Johnson City. I had previously worked there as an intern and resident in internal medicine, and I was now coming back after completing my training in infectious diseases in Boston. People who knew me from my residency days stopped me and told me the sad story of this young man’s homecoming.

  But it was not always recounted as a sad story. “Did you hear what happened to Ray?” a doctor asked me. He proceeded to tell me how a young man had dropped into the emergency room looking like he had pneumonia but turning out to be “a homo from New York with AIDS.” The humor resided in what had happened to the unsuspecting Ray, the pie-in-your-face nature of the patient’s diagnosis.

  Some of the veteran ICU nurses, perhaps because this case broke through their I’ve-seen-it-all-and-more-honey attitudes, astonished me with their indignation. In their opinion, this “homo-sex-shual” with AIDS clearly had no right to expect to be taken care of in our state-of-the-art, computerized ICU.

  When I heard the story, the shock waves in the hospital had already subsided. Everyone thought it had been a freak accident, a one-time thing in Johnson City. This was a small town in the country, a town of clean living, good country people. AIDS was clearly a big-city problem. It was somethi
ng that happened in other kinds of lives.

  Raymond Carver

  WHAT THE DOCTOR SAID

  What is the nature of the doctor’s skillfulness when there are no real therapeutic options available to a patient? What does it mean for one human being to tell another that he or she is going to die? When does a discussion in “an honest and objective fashion” suddenly turn into a moment of grace?

  This poem by Raymond Carver, perhaps his best known, begins with a physician discussing sobering test results with his patient. It presents the limits of one type of skill and the beginnings of another sort altogether, the art of simply being with someone in a difficult moment.

  RAYMOND CARVER is one of this country’s most famous short-story writers and poets. Carver died of lung cancer in 1988. His short story “A Small, Good Thing” also appears in this anthology.

  He said it doesn’t look good

  he said it looks bad in fact real bad

  he said I counted thirty-two of them on one lung before

  I quit counting them

  I said I’m glad I wouldn’t want to know

  about any more being there than that

  he said are you a religious man do you kneel down

  in forest groves and let yourself ask for help

  when you come to a waterfall

  mist blowing against your face and arms

  do you stop and ask for understanding at those moments

  I said not yet but I intend to start today

  he said I’m real sorry he said

  I wish I had some other kind of news to give you

  I said Amen and he said something else

  I didn’t catch and not knowing what else to do

  and not wanting him to have to repeat it

  and me to have to fully digest it

  I just looked at him

  for a minute and he looked back it was then

  I jumped up and shook hands with this man who’d just given me

  something no one else on earth had ever given me

  I may even have thanked him habit being so strong

  Jeanne Bryner

  THIS RED OOZING

  This poem reflects the challenge of gathering an “accurate history.” Does the single sentence “I was raped” reflect the impact of such an experience or provide enough information to proceed in making clinical judgments? How does the patient convey to the physician the depth of her struggles and the lifelong impact of that simple statement? Jeanne Bryner’s poem is powerfully descriptive; it provides imagery that will not be put aside once such a history is taken, recorded, and filed away.

  JEANNE BRYNER is an emergency room nurse. She received a Pushcart Prize nomination in 1994. Her poems have appeared in several literary magazines, among them Hiram Poetry Review, Poetry East, Prairie Schooner, and an anthology titled Gathering of Poets. Her own collection of poetry is titled Breathless, from which this poem is taken.

  I’m a nurse in emergency.

  You’re a hostess at Benny’s Lounge,

  thirty-five, divorced. After three beers,

  you can never let the friend of a friend

  drop you off at your apartment,

  then ask him in for coffee.

  Never pee with an accountant in the house,

  especially one dragging his briefcase.

  See how the balding sheriff shakes

  his I-told-you-so-eyes

  while you tell how the man shoved

  your bathroom door open,

  pulled out his revolver, grinned.

  We know what he said next; we hear it

  nearly every week: I’m gonna fuck you;

  you scream, I’ll kill you.

  We believe you cried, begged on knees,

  told him your kids might be home soon.

  You kneeling on the fuzzy pink rug—

  he likes that—you genuflecting.

  The safety clicks on his forty-five.

  You know guns; your father hunted—

  black roundness against your right temple,

  your hoop earrings clang, train whistles

  in your ears and his words squeeze:

  suck hard bitch.

  We’re sorry, but now the doctor

  makes you say all of it again,

  how a single lamp burns on the nightstand

  and your kids smile in their school pictures.

  How tight he holds the cold muzzle to your neck,

  jerks your dark hair like a mane and rips

  you until you bleed, your breath becomes

  grunts, your face in a pillow.

  Doctors in ER speak like priests,

  and they try to explain it, clean it up

  when they swab, hunting for sperm, trying

  to mount rage on slides—dead or alive.

  This red oozing,

  this trail from your buttocks to your thighs

  will not fill him, and it doesn’t matter

  how many times you throw up green

  or call on God or bruises rise

  like small iris on your cheekbones,

  the razor moves on.

  The friend of your friend

  with the pinstriped suit will probably walk.

  I think you know that.

  What you don’t know is how he rapes you

  endlessly: how he crawls out of your lipstick

  tube in the morning, slithers out of the soapy

  washcloth in the shower, snickers every Friday

  when you dust those photos on your stand.

  How his boots climb the back stairs

  of your mind year after year

  as he comes and comes and comes.

  John Stone

  FROM THE LISTENING END OF THE STETHOSCOPE

  “What kinds of music, or noise, arrive at the listening end of the stethoscope?” John Stone asks at the outset of this exploration. Stone demonstrates his own thorough skillfulness in presenting the history of listening to the heart, what health care professionals listen for and why, and, above all, what it means to obtain and interpret the language of the heart.

  JOHN STONE is a cardiologist and a poet. He is the author of three collections of poetry—The Smell of Matches, In All the Rain, and Renaming the Streets—and a co-author of On Doctoring. This essay is taken from his collection of essays titled In the Country of Hearts: Journeys in the Art of Medicine.

  He calls my office late Friday afternoon to say that his heart has been running away with him all day. He’s thirty-five and has had an artificial aortic valve in place for twelve years. Out of curiosity, I ask him to place the mouthpiece of his phone firmly against his chest wall. I listen closely: the clicks of his artificial valve are easy to hear. His heart rate is very rapid, about 180 beats a minute, and grossly irregular. The diagnosis is clear: He has a rhythm disturbance called “atrial fibrillation.” I tell him that I’ll phone in a prescription for him. He’s to pick it up on his way home, take three of the tablets, and call me back in an hour or so. It’s dark outside when the phone rings, but the news is good—a few minutes ago, abruptly, his heart slowed and the sense of “fluttering” in his chest vanished. Over the phone, the clicks of his valve are slow and regular. I’ve never used the telephone as a kind of long-distance stethoscope before, but the technique worked beautifully. Over the miles between us, he and I are smiling as we say good night.

  My stethoscope, by now, is an old friend. It is, after all, the one I bought in medical school, twenty-eight years ago, though it’s been replaced several times over, part by worn-out part, like atoms of the body. The earpieces slip into my ears tightly, the sounds of the world diminish. I enter the cave-dark, tonedense hollow of the chest and tune in to the mother heart. My patient is a mother and she’s better this morning, but still very sick. I bend and listen. As I do, I am aware of the film of sweat over the bridge of her nose and a flaring of her nostrils related to the work of her breathing. Her heart tones remind me of a racehorse laboring for the finish
line: “lup-dup-pah, lup-dup-pah,” and so forth. This triple cadence, understandably, is called a “gallop rhythm,” after the canter of a horse. It connotes heart failure: her heart is unable to pump all the blood that it receives and her lungs are congested. Her heart muscle, the pump itself, is sick and unlikely to get better. As I slip the stethoscope back into my pocket, there is no way for me to know that within two years, she will be dead, suddenly, at the age of forty-one.

  But most songs heard by the stethoscope are not as sad. Some are quite happy.

  The idea for the stethoscope came to a young man in France as he watched two children at play with a wooden baton; one child scratched his end of the stick while the other, holding the opposite end to his ear, listened expectantly for the scratching to be “telegraphed” to him. The young man’s mellifluous name was René Théophile Hyacinthe Laënnec (lan-eck). During his short life (1781–1826), he made many contributions to medicine, but he is best known as the father of the stethoscope.

  The Ur-stethoscope, in fact, was a rolled-up cylinder of paper improvised by Laënnec in 1816 to better examine an obese young woman with heart disease. Laënnec was impressed with his cornet de papier: “I was not a little surprised and pleased to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of the ear.” Later, the instrument was crafted out of wood, a hole was bored through the baton to facilitate the passage of sound; and it was divided, for portability, into halves that could be screwed together.