Internal Medicine: A Doctor's Stories

by Terrence Holt

  I stared at her.

  “That’s why she’s not eating.”

  I didn’t know what to say.

  “Say something,” she hissed, nudging me with one elbow. She gestured with her head toward the face on the pillow.

  “Mrs. Turner?” I said as I edged toward it. “I’m Dr. Harper.” I stopped at the head of the bed. The mask fluttered, but no sound came out.

  I reached out and took her hand. She let me, let it rise off the bedspread as I went through the motions of taking her pulse. This is something they teach you in medical school: when you don’t know what else to do, check the pulse. It breaks the ice.

  Her pulse was on the rapid side, and not very vigorous. Looking at her eyes, I suspected she was dehydrated.

  “Are you in a lot of pain?”

  The eyes closed. Then opened again, as she nodded. Without the lower half of her face, it was hard to read her expression.

  “How much pain?”

  She stared at me for a long moment before she shrugged.

  The combination of her mask and her silence, the economy of her gestures, the dullness of her skin in the gray light, all made her seem more like something carved in marble than human.

  “Do you think you’re swallowing the morphine?”

  Another nod.

  This time, I nodded back. “You’ll need a higher dose,” I said.

  The eyes above the mask were looking at me. I had a brief, vivid impression that what she was really doing was measuring me for a canvas, a parrot on my shoulder.

  I shook the thought away, disturbed by it more than I wanted to be, chased it away with an overly detailed explanation of how we were going to treat her pain. I moved on from there to her difficulty swallowing. I had figured out by now, looking at the profile revealed each time she inhaled (the mask fluttering in to cling against the face), that there could be no nose left under there. There seemed, in fact, to be a cavity. And then I realized where I had heard that strange pattern of lost consonants before: in children with a congenitally absent palate.

  I kept trying to imagine, to construct a clear picture of what her oral cavity must be like, but I could not come up with an image, just shards of what I might glimpse if I pulled away her mask. I tried to puzzle out how the cancer could have spread from the roof of her mouth to erode the root of her tongue when a voice behind me made me start.

  “She’s not eating,”

  I had forgotten the husband. Charles Turner loomed out of the shadows, his voice a rumble in the dark.

  “I can’t get her to take anything.” The rumble twisted slightly at the end, caught on the last syllable.

  The figure on the bed lifted a hand. It hovered, palm outward, brushing gently at the air.

  “Sylvie—” The voice was half a plea.

  The eyes closed and then the hand made one last sweep, waving us away.

  IN THE DINING ROOM, the parrots gazed down on us as we sat at the table.

  Linda laid her hand on Turner’s hairy paw.

  He turned toward her, reluctantly met her gaze.

  “What do you think she wants now?” Linda asked.

  “I think she wants—a nap.” He shook his head and blinked repeatedly.

  Linda looked at him for a moment, then nodded.

  “That’s right,” she said. “I think she’s tired. And when she rests, maybe you can rest, too.” With a glance at me she reached to the floor and pulled her backpack into her lap. I leaned back and let the conversation go on without me as Linda counted out on the tabletop a boxful of syringes filled with pink syrup. The parrots watched silently.

  A booted foot caught my right shin. “Isn’t that right?” Linda was saying brightly, looking at me with an expression that didn’t match her voice.

  “Yes,” I said automatically.

  She rolled her eyes and turned back to Turner. He hunched in his seat, his large hands holding a handful of syringes like a lover’s posy.

  Linda kept talking to him gently. “So we think it makes sense to treat it,” she was saying.

  Turner looked up, smiled at her faintly. “Thank you,” he husked. The parrots hunched motionlessly, as if waiting for something.

  Outside, the rain was coming down harder, spattering the windshield as Linda pulled the wheel around. She was looking at me instead of the road.

  “What the hell got into you?”

  “What are you talking about?”

  “You just checked out in there.” She pulled out onto the pavement. I watched wet woods slide by and let the silence grow. I had nothing to say.

  “Sometimes,” Linda said finally, “something about a case can be too much for you. It happens to everyone. It helps if you do your job anyway.”

  “What are you talking about?” I said again.

  “You didn’t even examine her.”

  That stopped me.

  She was right. I’d stood there by the bedside, taken her irrelevant pulse, and talked about drug absorption and swallowing, her fluid status, and at this point I couldn’t remember what else, but hadn’t done the simplest thing to assess the situation.

  Which would have been lifting up that mask and seeing what lay beneath.

  “You’re right,” I said.

  Sometimes I find myself in a situation so confusing that the only thing to do is tell the truth, I think.

  ONE OF THE ESSENTIAL skills in residency is a capacity to forget. There are some things you just don’t want to take home. I had no special facility at this skill, but I was usually able to set aside whatever needed setting and pick it up again the next day. The hospice rotation had been no different in this regard: whatever tragic or pathetic or sordid or horrific scenes I passed through each day faded like dreams before I reached home.

  Which is why I was disturbed, that night as sleep evaded me, to find Sylvia Turner’s face looking out at me from the darkness, the eyes above the blank white mask. I had learned not to remember faces. I had learned not to be disturbed. I wasn’t bothered (I thought) that her face—the absence of it, whatever it was that white mask implied—was disturbing; I was bothered that it was still visible to me at all.

  If I was frightened by its persistence, by the possibility that it was asking a question of me, I mistook my fear for annoyance. But even if I had recognized what I felt, I could not have told you what it was I feared. There was just the blank square covering—what?—and that was more than enough.

  THIS VAGUE SENSE OF annoyance was gone by Monday. I dozed through morning staff meeting, through updates on who had died over the weekend, who had been doing badly, who needed to be seen today.

  Linda nudged me with her elbow. Arthur, who had been on call over the weekend, was looking at us.

  “What happened?” Linda had just asked, a little too brightly, overdoing it in a way that I felt dimly as a reflection on me.

  Arthur’s expression went cloudy. “I’m still not exactly sure.” He riffled his notes. “The husband called, about twelve-thirty Sunday. P.m.,” he added fussily, looking over his glasses. “About some ‘church ladies’ he wanted off the premises.”

  “And what did you do, Artie?” Linda asked innocently.

  “About church ladies?”

  Dry laughter rustled in the corner.

  “I mean, were they . . .” Linda paused as if searching for a word. “Causing a disturbance?” She was clearly enjoying herself. Everyone else was laughing.

  Arthur was reddening. “As a matter of fact, they were,” he replied. He read without expression, “Patient’s husband reports ‘Church ladies are back again,’ and upsetting patient with unwanted religious advice. Husband wants church ladies removed and sedation for patient.”

  He looked up again over a hedge of paper. In the overhead fluorescents, his glasses had taken on an opaque glare. “I offered to call the sheriff, and reminded him about the Ativan in the comfort pack. I think what he really wanted was the Ativan.”

  “Don’t we all,” somebody muttered, st
irring laughter again.

  “THOSE CHURCH LADIES ARE going to ruin our day,” Linda growled, spinning the Honda’s front tires in the hospice lot. She pulled out onto the highway thirty yards in front of an oncoming gravel truck. I closed my eyes. “Ordinarily,” she explained, “the Turners wouldn’t be on the list again until Wednesday.” She straightened out the wheel and gunned the engine. I settled back to ignore the ride.

  The day was bright, the air cool, still drenched with last week’s rain. Puddles stood in the gravel arc before the house, reflecting patches of pale sky. The reflections shivered in the breeze.

  The house itself might have been deserted. From somewhere out back rose a strangled cry—for a brief moment it seemed the sound of someone calling for help, and then I realized it was a parrot. It called again.

  “Bah!” it seemed to say. Then, more clearly, “Bad!”

  Linda looked at me. “Do you think that’s one of the church ladies?”

  “Bad!” the bird called again. “Bad! Bad!” Linda’s joke, and the repeated screeching, combined to set my skin crawling: I thought of a small, angry old woman crammed into a wooden hutch, screaming.

  “Listen,” she said, cocking her head.

  “Bad bird!” the parrot called. Then, after a pause that stretched out as if in contemplation, “Go to hell!”

  Linda burst out laughing. “Who trains a bird to talk like that?”

  Charles Turner was waiting in the doorway, looking slightly embarrassed. “You heard that,” he said.

  “What, the bird?” Linda laughed again. “Hard to miss it.”

  He smiled weakly. “Sometimes we get calls from the neighbors.” He glanced back over his shoulder.

  “Just let the bird tell them to go to Hell,” Linda suggested brightly.

  “He’s not the one the neighbors complain about.” Shaking his head, he led us down the hall.

  “What do you suppose the other birds say?” Linda whispered to me. By the time we had made our way through the darkened dining room, I realized I was hunching my shoulders, prepared to fend off a verbal assault. But no more sound came from the back of the house.

  In the bedroom, Sylvia Turner sat propped up on pillows. The mask fluttered, puffing out a series of nonsense sounds.

  I had a chilly moment wrestling with the possibility that the words really were nonsense, Mrs. Turner driven mad by whatever the church ladies had said. Then Linda started to laugh.

  “You didn’t teach him that?”

  Mrs. Turner rolled her eyes heavenward.

  Her husband, still standing at our backs, said quickly, “Lord, no. They’re rescued birds. They came that way.”

  Another burst of sound from Mrs. Turner—a string of vowels, low and flat.

  Linda laughed again, but though I listened closely to the mangled words I couldn’t put them together.

  Shaking off a sadness that irritated me for being ungrounded in anything I could name, I moved to the bedside opposite Linda.

  “Mrs. Turner?”

  The mask turned toward me. The eyes were unreadable. Had I interrupted? Off in the distance, a bird was croaking something about a pretty girl.

  “We heard you had some trouble yesterday.” I said this as gently as I could, but still it felt like I was pushing something faster than it wanted to go. I was anxious, I realized, to get out of there.

  And while I was trying to penetrate the jungle that had grown up in my own motivations, the woman on the bed started to cry.

  It took me a while to recognize this. What I saw, from my perspective, was initially obscure. The face above the mask simply crumpled, withdrew, eyes squeezed tight. Then, after a sharp intake of breath, the mask plastered itself against the lower half of her face: as it clung there, it showed for a distinct instant the outline of a crater far too large to belong in any human face. It reminded me of the plaster casts archaeologists make of the voids left where something has crumbled into rust. Then the mask bulged out again on a gust of inarticulate woe. The face turned away from me, burying itself in the pillow, where, twice muffled in cancer and down, it sobbed. I watched her shoulders heave, how clearly the bones slid beneath skin. This woman is starving, I thought.

  Linda’s hand appeared, stroking the lank hair. A movement at my elbow caught my eye, and I gave way to Turner as he bent over the bed. He was muttering something I could not catch beyond a tone of barely contained rage. At me? I wondered momentarily. In the distance, a parrot uttered an obscenity. Turner glanced up in that direction, straightened, and in a very low voice repeated it. The room fell still, the word rolling through the stillness like thunder far away. From the pillow, muffled but clear, the voice spoke what it could of the man’s first name, a short a cut off at either end, but the tenderness and the mild reproof were clear enough.

  The big man glanced around sheepishly. “I’m sorry, Sylvie,” he said.

  She straightened, but kept her gaze to herself as she tugged at her hair; some wisps had stuck to the fabric of the mask, held there by the tears that had soaked into it. She pulled the hairs away, composed herself, smoothing the spread. “A,” she said again calmly, and then something more. Turner’s face clouded again.

  “They can too help themselves, Sylvie. They just don’t want to. They—” He broke off. “They’re just vultures,” he growled, and fell silent again.

  Sylvia rolled her eyes. The gesture looked very odd from where I stood: without a face to support it, the expression lost its moorings, as if her eyes had gotten free from their sockets and in the next moment might fall onto the pillow. She closed them briefly, as if drawing them back in. When she spoke again the tone was a determined contradiction.

  Turner snorted. “ ‘Christian,’ my eye.”

  Sylvia nodded emphatically.

  “What has ‘Christian’ done for us lately?” Turner snarled, turning away.

  For a long moment, Sylvia’s gaze lay inscrutably on her husband’s back, and then the head turned back to the pillow, and from its depths came again the sound of muffled sobs.

  This time they did not subside. As none of us said a word they began to rise in pitch and volume. From the distance a bird took up the cry, inarticulate screeching now. Another joined in. The birds sounded distressed—or was the tone, too, only mockery? The crying on the bed grew louder, one clawed hand reached out, clenched the pillow, withdrew, formed a fist, and began pounding on the bed. With each blow the cries grew louder, higher, and from the end of the house the screeches of agitated birds came back—echoes, I kept imagining, of Hell. Harpies, I was thinking. Or was it Furies? I couldn’t remember which was which, I realized, as the shadows of Linda and Mr. Turner moved in, hovering over the bed.

  SOME TIME LATER, after the Ativan had done its work and Sylvia had subsided into sleep, the three of us sat around the dining table. Linda had been trying to think of some means of fending off the church ladies. The hospice chaplain, she thought, could call them. Turner had refused, shaking the suggestion off as a horse shies flies. In the awkward pause that followed, Linda pointed at the wall.

  “Is that you?” she asked. It was clear she was trying to change the subject, giving Turner a ladder out of the dark hole he had dug himself into.

  Turner looked up, laughed bashfully. “Yeah.”

  Linda let out a bright peal. “Did you pose for that?”

  Turner shook his head emphatically. He was coloring up to his receding hairline. I turned and craned my neck. It was clear which of the canvases she meant: a large oil of a muscular male nude standing in a hubcap emerging from the sea. Hovering at the figure’s shoulders, a pair of scarlet macaws clutched in their beaks the ends of a long leather tool belt, which looped between them in front of the figure, obscuring its genitals but little else. The figure gazed modestly toward the shallows; in the air above it, flights of cockatoos flushed pink in the sunrise.

  We all gazed at it for a while.

  “She loved to paint,” Turner said quietly.

  “Yes,
” Linda said. “I can see that.”

  Turner brightened. “It shows, doesn’t it? How she just loved it? And the birds—” He twisted away. “She loved everything.” There was a long silence. I could hear a faint metallic twanging from the back of the house. When he spoke again his voice was barely audible. “She used to love everything,” he said.

  Linda reached across the table. “She still does.”

  He did not look up. “I don’t know,” he said quietly. When he looked up again, it was to study the wall. “I don’t know what I’m going to do with these.”

  “YOU DID GOOD IN there,” Linda said as the farmhouse receded behind us.

  I stared at her. Was she joking?

  When I did not respond, she gave me a sidelong glance. “Bringing up those church ladies,” she explained.

  Had I done that? How that had helped anything I could not begin to fathom.

  “All I did was make her cry,” I said.

  “Exactly.”

  I puzzled over this until she added impatiently, “We’re hospice.”

  “Oh.”

  “She’s dying: she needs to cry.” The tires thumped and she pulled the car abruptly onto the shoulder. “He needs to cry.” She stared meditatively out the windshield. “I’m not sure I want to be around when he does.”

  “Ah,” I said.

  Another sidelong glance. “ ‘Ah?’ Are you getting this?”

  “Oh, yeah,” I said. “I get it.”

  She stared at me flatly for a long moment, until I grew embarrassed and turned to look out the window.

  WHEN MY SON WAS not quite four, he had drawn a picture that was supposed to represent a spleen, a swarm of red and purple dots he had copied laboriously from a textbook on histology. His teacher had been so charmed by the description (“spleen, mag 240x”) that she had taken it off that afternoon to an art show put on by the hospital, children’s drawings meant to brighten the lobby. From which it had never, tragically, returned. The disbelief, then anger, and finally inconsolable sorrow, had lasted the better part of a week. They still resurfaced months later, a muted echo wistfully raised at odd moments, from the back seat of the car, or twenty minutes after bedtime, to which my own and my wife’s helpless response had become almost automatic. But we also felt a trace of that same sorrow, not so much from the loss as our helplessness in the face of it.