Just Like Someone Without Mental Illness Only More So

by Mark Vonnegut, M. D.

  I had about fifteen minutes before the Smiths could get over to MGH and register, so I headed down to the basement for my last ten o’clock meal. Whatever hadn’t been eaten that day and the day before at the ten o’clock meal was dolled up a little and put back out there one more time. Amazing numbers of calories were consumed by deranged absentminded overstressed hospital personnel. It was free. Whenever anyone said that there was no free lunch, I always thought, “No, but there is the ten o’clock meal.”

  Malvesti Hedley Smith was about five feet nine, 190 solid pounds; he looked like he was carved out of ironwood. He had jet-black African skin, wore designer jeans and a free-flowing bright African-print shirt, and walked slowly on the balls of his feet like he wouldn’t make a sound walking through tin cans in clogs on a tin roof. It was hard to look at Malvesti and not feel inferior. He checked out the waiting room briefly and ushered in his wife, their one-week-old son, and three colleagues in battle fatigues and combat boots. They took stiff seats in hard plastic chairs.

  “Prince of the River Nile Smith,” called out Helen, the triage nurse, just as she would call out any other name.

  Mother with babe in arms, Malvesti, and three friends rose in unison and allowed themselves to be led into one of our small exam rooms.

  “Undress the baby down to his diaper so we can take his temperature and the doctor can examine him,” said Helen.

  “My baby’s only problem is with his eyes. He has been examined many times. We prefer that you not take his temperature. I would like to talk to the doctor in charge.” Each word was clipped, enunciated perfectly and with a slight British-colonial accent that suggested English wasn’t his first language.

  His wife, Asanti, was a very pretty, soft-featured, medium-complected young woman of about twenty, one or two inches taller than her husband. The three friends were all about six feet tall, clean-shaven, athletic, in their mid-twenties, distinguished only by their military attire, ramrod-stiff posture, and deference to Malvesti.

  Malvesti had a spooky left eye that would break into herky-jerky circles while the right stared fixedly ahead. Then the left would be drawn back into line as if by gravitational force. I tried to map out what pathways must be broken to make his eye act like that but couldn’t help finding it just plainly unsettling. He also had ceremonial scars on his face.

  “Every patient has to have vital signs taken before being seen by the doctor,” explained Helen, who stood a good four inches taller than Malvesti.

  “I will see the doctor now. I do not want you touching my child.”

  “What’s going on here?” I interrupted cheerfully. I had been watching and listening through the two-inch round hole in the door. “I’m Dr. Vonnegut, the doctor in charge tonight.” Any senior resident in his right mind would have sat back and let the intern handle the case. The truth is that I got bored when I wasn’t taking care of patients, and this case seemed way more interesting than most.

  “He doesn’t want to undress the baby or have us take his signs,” said Helen, rolling her eyes behind and over Malvesti.

  “It can’t hurt to talk a little before taking vital signs.” Sometimes I make myself gag.

  Helen rolled her eyes again and left.

  I reached out my hand to Malvesti, who ignored it. I did my best to ignore that he ignored it. If I was armed with a stun gun and a baseball bat and Malvesti was blindfolded with both hands tied behind his back, he could have destroyed me in a minute or less. I knew from his patient-registration data that he was thirty-four years old, almost exactly my age.

  “I am expecting that you will tell me what is necessary to make sure my son does not go blind from the infection in his eyes.”

  “I promise you that we will not let this infection harm your son’s eyes,” I said, standing slightly stiffly and speaking with a clipped, vaguely British-colonial accent that made it sound like English was maybe not my first language.

  The baby was resting quietly in his mother’s arms. His eyes were not even a little bit red or swollen. There was a very small amount of crust where the upper and lower lids came together at the nasal bridge.

  “I understand from the last place we took our son that the germ that might blind him is one that is passed by sexual activity. I do not have any symptoms of disease, and my wife has never been with another man. How is it possible for our baby to have this germ?”

  At Children’s Hospital Malvesti and his wife had balked at allowing the doctors to swab their son’s eyes or apply antibiotic ointment, insisting they be allowed to treat him at home.

  There were now nine sidekicks in battle fatigues left in the waiting room. And more and more of our beefy security guys milling around.

  “The doctor there filled a care and protection order,” I said. “If a doctor thinks that parents are not acting in the best interest of their child and that their child might be at risk of serious harm, he can ask a judge to temporarily give custody of the child to the hospital,” I explained.

  “We will do the ointment and go home now,” said Malvesti.

  I later learned that there were twenty-four state troopers backing up hospital security out front.

  “We believe in preparedness and self-defense but not hurting people. It’s very good for the morale and discipline of my men to be taken so seriously,” said Malvesti.

  Everyone else was blending into the woodwork. “I’m afraid I’m going to have to make some calls,” I said.

  The judge was not in a good mood. No compromises, no deals: Prince of the River Nile Smith would be admitted for observation and treatment of conjunctivitis that wasn’t really there.

  “There will be no blood tests or injections, right?” Malvesti asked, realizing that the trap was swinging shut.

  “I’m just the doctor in charge down here.” My heart was in my throat, and racing. My goal right then was to not throw up. “You will stay with him of course. And when the culture comes back negative, you can go home and forget about this place. I’m sorry.”

  Malvesti looked like he had a bad taste in his mouth and nowhere to spit it out.

  Half an hour after the family went up to the floor, Louis, the weasel of a junior resident who would be Prince of the River Nile Smith’s admitting doctor, called me. “Do you have any idea what was in the herbal compress they were using? There was a case once where a baby almost died from herbal tea.”

  “The eyes don’t look all that bad, do they?”

  “No, they don’t now, but I’m not comfortable admitting this baby without doing some sort of a work-up.”

  “We already have done a work-up, Louis. MEEI has the cultures cooking. And we’re observing the baby.”

  “It’s my case, and I can’t see the harm in doing a septic work-up.”

  A septic work-up means obtaining blood for culture and complete blood count, urine for culture and analysis, and spinal fluid for cell count and culture. Most unnecessary tests have the good manners to come back normal. But if they come back abnormal, you become obliged to do more tests to confirm or refute the abnormal test. You can end up miles from where you started chasing your tail.

  Lynn, a cheerleader-type bubble-brain fourth-year medical student, did the procedures. She got blood on the first stick, the lumbar puncture on the second pass, and the bladder tap. She stopped by to talk with me in the emergency ward.

  “What’s wrong with the dad’s eye? It almost seems like he can control it and uses it to spook people.”

  “It’s central,” I said.

  “Oh. Thanks,” said Lynn. “Louis has agreed to no more tests unless the baby acts sick or has new symptoms. The dad must have taken off while we were doing the tests. At least his mother’s still with him. Is it true that black people are better at breast-feeding?”

  I tried to sleep on the sticky black vinyl couch in the chief resident’s office. In a fitful half-sleep dream I watched myself bent backward across Malvesti’s knee, him pulling my head back by the hair with his left hand as he
transected my heart with the knife in his right, entering my chest at the anterior axillary line between ribs nine and ten and pulling it to the midline.

  A few hours later I got up, had some coffee, and went to senior rounds, where we discussed Prince of the River Nile Smith and all the other admissions from the previous twenty-four hours.

  “There was absolutely nothing wrong with that baby,” I was compelled to throw in.

  “There might have been,” countered Louis, “Besides, there was a court order. We had to admit and treat that baby. It was the people at Children’s who gave us no choice.”

  On to the next case. As I got on my bike and pedaled home, I half hoped that Malvesti or one of his lieutenants might run me over before I could cross over to the Charles River.

  I had a job lined up with a small respected pediatric practice. In a month I would be calling the shots, doing my best to keep kids out of emergency rooms and getting tests they didn’t need. There were pediatricians practicing in their eighties who still seemed to be having a good time with it.

  The last thing I did as a senior resident was to transport a critically ill newborn girl who was thought to have an overwhelming infection from an outlying hospital to Mass General. I made the guess, which turned out to be correct, that she had congenital heart disease even though she didn’t have a murmur or blueness or any other sign of heart disease. I treated her for heart failure instead of infection and she responded well and survived the trip back to MGH. Her heart was 100 percent fixable. Instead of being dead or crippled, she would grow up with as good a chance as the rest of us.

  When the cardiologist praised me to the parents and said that their little girl hadn’t been hurt by her rough start and was going to grow up 100 percent normal I felt sick and couldn’t get out of that room fast enough.

  I was just doing my job. It had been a lucky guess. I hadn’t actually diagnosed the specific cardiac defect their daughter had.

  The day after I finished my residency, my mother had an operation that was supposed to be for a uterine fibroid that turned out to be stage-four ovarian cancer. I hadn’t admitted to myself the possibility of something being seriously wrong till I got the phone call.

  Enthusiasm

  (Vonnegut family photo)

  chapter 9

  Crack-up Number Four

  It’s important to me that I owned the house they took me out of in a straightjacket.

  I loved the rhythm and rank of being a primary-care pediatrician. I started paying down the money I had had to borrow to get through medical school and residency. I’d tried to cut down a few times but still smoked two packs of cigarettes a day. I’d take care of a couple of patients, go out to my car to have a cigarette, and come back and see a few more patients.

  I was dealing mostly with self-limited viral illnesses in otherwise well babies and children, but life and death wasn’t the point. I didn’t feel less than neurosurgeons, oncologists, or cardiologists. Someone had to be looking through the haystack to find treatable diseases in salvageable patients. Leukemia or brain tumors would always be trying to sneak through, and I was ready to catch them. Maybe I was the catcher in the rye.

  I didn’t want to be rich or famous. I didn’t want to write again. I wanted nothing more than to keep doing pediatrics forever.

  ——

  For a year or so before I went crazy for the last time, an odd feeling of panic would take hold of me almost every night driving home from work. I’d feel sick to my stomach, my heart would race, and I’d have chest pain. I’d imagine getting into accidents or getting dragged out of my car and beaten. I went to a cardiologist, got on a treadmill, and passed my stress test. He reassured me that my heart was fine and joked that it was nice seeing me but that he had to go take care of sick people.

  He asked me about alcohol and drugs, and I told him I drank a few beers after work, had half a bottle or less of wine with dinner, maybe a shot of bourbon after dinner, and Xanax as prescribed for insomnia. He said nothing, so it must have been okay. Apparently what I had used to be called “soldier’s heart” because so many soldiers complained of the same thing during World War I. I was a good soldier. Crushing chest pain and nausea were just part of being me.

  My wife and I were two cordial, barely connected children of divorce who mostly wanted no drama. The harder I tried to be a good husband, the worse it seemed to get. She was married to a doctor—what more could she want?

  My sisters and I were on good terms. I was glad they were married to decent men and having children. We all knew Jane had cancer that wasn’t going to go away, but she was doing remarkably well.

  Man Recovers from Mental Illness, Goes to Medical School, and Becomes a Doctor. It was a perfectly good story with a perfectly good ending.

  For about ten years running, Kurt had hosted a family fishing trip out of Montauk, near his place on Long Island. It was usually the weekend after Labor Day. It was usually an all-guy thing, though sometimes my father enjoyed inviting Betty Friedan along. We were all fighting our own battles, looking for some time off, and willing to show up for Kurt and see what happened. Bluefish are, pound for pound, the most vicious of God’s creatures, and we caught a lot of them.

  Bernie, Kurt’s older and only brother, usually came with two or three of his five sons and sometimes a grandchild. Sometimes my sons came with me, but not on the 1985 trip. Kurt and Bernie would tell the same stories and jokes. I knew most of the punch lines, as did Bernie’s sons.

  Bernie was Kurt’s only real peer at that point in his life. Eight years Kurt’s senior, he was a scientist who did things that hadn’t been done before, like seeding clouds to make it rain. My favorite experiment of his was the release of several tons of chicken feathers into thunderclouds to see where the air currents were going. Kurt and Bernie’s sister, Allie, the mother of the four cousins who came to live with us, had been a gifted painter and sculptor who said, “Just because you’re talented doesn’t mean you have to do something about it.”

  One of my favorite stories about Bernie and Kurt involved a trip they took to see their father, Kurt senior, when he was dying. On the way to Indianapolis, the car they were driving ran out of gas, so they were going to hitchhike to a gas station. Kurt propped the hood up to let people know there was mechanical trouble and asked Bernie if there was anything else they should do.

  “We could let the air out of the tires,” suggested Bernie.

  ——

  On the 1985 fishing trip, Bernie brought twenty glass-and-gel plates he had used to record the path electricity took through gel under different conditions. The branching patterns were intricate and beautiful. Bernie’s provocative question to Kurt was whether or not they were art. Kurt thought they weren’t art, because the objects weren’t made by an artist who could have a conversation with himself or anyone else about what he had done. For it to be art there had to be an artist who could learn from it and do something different or the same the next time.

  Maybe Bernie, by noticing these things and dragging them to Long Island for us to see, was the artist? You can’t create or destroy matter or energy, but you can take blank paper and write a novel or canvas and make a painting or wood and make furniture. An artist is someone who isn’t put off by how terrible his first tries are, who finds himself talking back and notices that he changes and grows when he makes art.

  That trip was the beginning of the end of what I had assumed was a lifetime no-cut contract with alcohol. I can’t remember why, but I drank much more than I usually did, and nothing happened. I drank beer steadily through the morning and then had two glasses of bourbon. No click, no feeling a little looser, nothing.

  We caught a bunch of bluefish. The mate filleted them and I grilled them over charcoal with garlic salt and everyone said they tasted great just like always, but I couldn’t get away from the feeling that another shoe was going to drop.

  What if you pick up the early signs too late?

  Back home, I was playing the pian
o better than ever. I’d be playing the piano and singing and start crying after a beer or two. Unless we had a business lunch on Friday, I never drank at work or before getting home, somewhere around 6 P.M. I sometimes kept beer in the office refrigerator on Fridays if I was going to be going to the Cape, but that was okay because of the traffic. If I had had a drinking problem, I would have hidden it, but I didn’t so I didn’t.

  The thing that keeps the gambler gambling is the illusion that he has control, special knowledge that will make him come out on top. If the gambler comes to believe that he is up against a random number generator and that what he once thought of as special knowledge is worthless, he stops gambling. What keeps the drinker drinking is the certainty that she can stop whenever she wants. It never would have occurred to me that stopping the pathetic little bit of drinking I did would have mattered.

  I kept in touch with MGH by serving as the ward attending once a year and teaching in the ER one night a week along with admitting my patients there. It was a way of giving back. They paid me about sixteen dollars an hour.

  Four years after I’d finished my residency at MGH, right after Thanksgiving, a twelve-year-old girl came in having had a seizure that had stopped by the time she arrived. We examined her, drew labs, reassured her parents, called her pediatrician, and had the resident doing pediatric neurology come down to see her. He started her on medication, decided she didn’t have to be admitted, and set up a time to see her in the pedi-neuro clinic two days later.

  Off the top of my head I gave the medical students a ten-minute lecture on the differential diagnosis, work-up, and treatment of pediatric seizures. I was a hardworking, integral part of a wonderful hospital and a wonderful medical school and a wonderful city, full of people all doing the best they could. I was headed off into the sunset with two hours of movie left.