Our next patient was a tiny man who had lost both his legs in a car accident several years earlier. Despite his devastating disability, he was fairly spry. Above his bed, which had a special mattress to prevent bedsores, was a pulley contraption, which he immediately grabbed with his unusually muscular arms to help himself up. As he leaned forward, holding on to the metal handlebars, Rohit pointed out a pressure ulcer on his upper buttocks, which looked infected. On his abdomen was a stapled wound from a recent gallbladder operation. Again with his bare hands, Rohit pressed on it, trying to see if it was tender, which it wasn’t. The patient pointed to a tiny bulge under the skin of his abdomen. “What is this?” he asked.
Rohit rubbed over it with his fingers. “Maybe a gallstone.”
“But they took my gallbladder out.”
Rohit shrugged. “Call Surgery and have them take a look at it,” he told Alphonse. Then he tapped on the man’s stumps and walked out, Alphonse and I following in step.
In the hallway, I looked over at Alphonse and made a face. The thought of all the resistant microbes in the room—perhaps even on my skin—was making me queasy, and I was disgusted by the fact that Rohit hadn’t washed his hands. “Wash your hands, dude,” I said before we moved on. Rohit gave me a withering look. “Oh, I guess I forgot,” he said.
My team had several Russian-speaking patients. They always insisted on talking through interpreters, but there was never anyone around who spoke Russian. On rounds, we managed to get by with a few miscellaneous words, like balit, rubbing our chests or abdomens or pointing to our temples to inquire about pain. We often promised to come back to talk to these patients, but we rarely did. By the time an interpreter showed up, you were done with your notes and had already written orders and made a plan for the day, without any verbal input from the patient.
We went to see my night-float admission. Agnes Lahey was an obese woman of about seventy with a large broad face and a mouth that was missing several teeth. She was wearing dark, horn-rimmed glasses, a steel bracelet, and several rings, even though jewelry was supposed to be put away by the nurses for safekeeping. She had the overweight, sweaty look of a trailer-park queen.
Rohit had described her as a “social admit,” a “frequent flyer,” and, in fact, this was her eleventh hospital visit, including visits to the ER, in the past six months. Social admissions were a significant percentage on 10-North. The hospital, we were told, nearly always lost money on these patients. “Utilization reviewers”—hospital spies, basically—would continually check with us to make sure we were getting these patients out in a timely manner.
Lahey met all the demographic criteria for the type of patient who is often a social admit. She was elderly, a widow, with a long list of chronic medical problems, including diabetes, hypertension, arthritis, perhaps even a touch of dementia. She was a retired hospital cook whose husband had died in a “personal fight” about ten years ago. Now she was living with her daughter and granddaughter in a small apartment on Seventy-seventh Street. A social worker had written that in the summertime, Lahey frequently came to the hospital complaining of heatstroke. The hospital had even bought her an air conditioner to prevent repeated visits to the ER.
When I asked her why she was in the hospital, she said that she slipped while walking with a cane in her house and fell into her cat’s litter box. “I went to three hospitals before I came here,” she said. I asked which ones. “One was St. Charles . . . or St. George . . . or some such saint. Another was—” She stopped.
“St. Luke’s?” I said.
“No, it was a funny name.”
“Presbyterian, Bellevue . . .?”
“No, those are natural names. I think it started with an S.”
“Southside?” I said.
“Yes, Southside,” she replied hesitantly. “Yeah, I think that was the name.”
I took my stethoscope out of my coat pocket. “Everyone here keeps saying I want to be here,” she said. “But I don’t want to be here. I hurt my hip falling down and now I can’t walk. I hear what people say. They say, ‘I wish she wouldn’t come around so much.’ It makes me feel really rotten, real bad. I’m here because I need to be here. I don’t get a thrill from it.”
I lifted the edge of her diaper to inspect her hip. A rancid, fishy smell wafted into my nostrils. “Years ago, the hospital was very good,” she said as I took a step back. “You could call a nurse and ask for this, that, and the other, and you got it. Don’t get me wrong, I like it here. People are more friendly in the hospital than on the outside. I’m just saying that the old hospital was much better. People had more time for you. The food was pretty good, too.
“Look here.” She pointed to her IV, which had a half-filled syringe attached to it. “The nurse came in to give me an injection and she just left it here. She said she’d come back but she didn’t. She was flushing the IV and then she went off, said she had something else to do. I just noticed it. It’s hard to get something, sometimes. They’re always doing something, the nurses.”
I bent over to listen to her chest. She leaned forward to meet me. “Don’t tell the nurse I said anything,” she said. “Or else she’ll take it out on me.”
I nodded, putting the stethoscope back in my ears.
“I don’t want to go to a nursing home or a retirement center,” she whispered. “If I can’t come into the hospital every once in a while, I don’t know what I’m going to do.”
MORNINGS ON 10-NORTH were a collective phenomenon. It was like the bhajans Sonia and I once attended in the West Village, where a few people would start chanting—“Om namo shivaya, om namo shivaya”—and then people would start clapping, and the clapping would synchronize, the energy grow, and then you were one, a collective being. Life on the wards was like the plasmons I had studied in condensed matter physics, where individual electrons, moving randomly, coalesced into something greater than the sum of their parts. There was a sort of synchronized buzz. You could almost hear it, the hum. You could see it, the mass of doctors and nurses and social workers and case managers and utilization reviewers becoming one organism, running around doing seemingly random things that were so amazingly coordinated. In the midst of this collective excitation, I kept thinking, Why am I so lonely?
Ward life as an intern was a constant juggle of competing tasks. You could be speaking to an attending when a nurse would interrupt and tell you that the blood test you had ordered for that morning somehow got overlooked, and now you had to draw it yourself, and oh, by the way, the patient has kidney failure and the last serum potassium was at a life-threatening level, so you’d better hurry up before the patient has a cardiac arrest. It was hard to develop perspective because everything seemed equally necessary. Ensuring that the radiology department received the requisition slip seemed as important as the scan itself—perhaps even more important because it was your job to ensure that the slip was faxed and received, not sitting in a corner somewhere. Tasks got reduced to their most elemental quality: done/not done. The rhythm of the day was digitized into tiny boxes, to be filled in at every hour.
Having so much to do was bad enough, but not knowing why you were doing what you were doing was terrifying. Why was I ordering a tagged red-blood-cell scan? That CAT scan: Should it be done with or without dye, and with high-resolution cuts or not? Why exactly was I calling the Infectious Diseases service (whose famously distempered fellow seemed to relish tearing into diffident interns). I was constantly afraid. When you didn’t know what you were doing from moment to moment, it seemed like anything could happen.
Patients were needy, their demands overwhelming. Sometimes they’d want you to linger so they could talk, especially the VIPs, who’d tell you about all the hospital fund-raisers they’d chaired or the money they had donated or the philanthropy they had performed, but none of that really mattered, not because I was egalitarian or inured to wealth or power, but because for an intern nothing is more important than finishing up and getting the hell out of the hospital.
Sometimes, after a long day, I’d simply walk up to the bedside and place my stethoscope on a patient’s chest without any pleasantries or preliminaries. One time I did it when a patient was sitting on a bedside commode, straining to have a bowel movement. “I’ve been sitting here so long,” she said mournfully. “Least the nurse could do is give me toilet paper to wipe.” I told the woman that I’d find a nurse for her. “But first—first, could I just listen to your lungs?” I loathed myself for even asking, but it was the end of the day and I didn’t want to have to come back to conduct my exam. I had her lean forward on the commode, all the while thinking: Has it come to this? Have you lost all shame?
Everyone seemed to know how the place worked except me. “Don’t you see I’m waiting for the chart,” a transporter would shout while I was on hold with the lab. “I’m sorry,” I’d say. “I didn’t realize you were waiting.” And then she’d turn to a colleague as though I had said the most incredible thing in the world. “He said he didn’t see me standing here. Ha!” The colleague would murmur her support. If I asked where my patient was going, it would lead to further rebuke. “Taking him where?! To X-ray!” Not only had I been inconsiderate, I didn’t even know which test my patient was having!
People always acted like you were doing something wrong but they wouldn’t tell you what it was. Sometimes I’d be sitting by myself in a corner and someone would come up and say, “Pack it in, honey, you can’t always be getting in people’s way.” My brother had warned me to keep the nurses happy. If they liked you, they’d look out for you, keep you from going astray. Without doubt they were powerful, but their power was only in the inverse: they couldn’t really make things better for you, but they could certainly make things worse. The ward clerks were generally rude and abrupt. Leafing through their tabloids with their long false fingernails, they would barely look up when you asked them a question, and then only impatiently. The ecology on the wards was hostile; interactions were hard-bitten, fast-paced; conversations were brief, clipped, urgent, spoken at a volume and frequency I wasn’t used to or comfortable with. I kept waiting for a sense of hardiness, a sort of occupational pugilism, to develop, but it never did.
It seemed like the only people I wasn’t scared of were my patients. They were as much at a loss in this place as I was.
AT SIX-THIRTY ONE EVENING on 10-North, I had finished my notes, checked labs, ordered medications and morning blood draws, updated the medication sheets, and held several conferences with anxious families. I had tickets to the U.S. Open that night and was hoping to get out to Flushing Meadow in time to catch one of the stadium court matches. The ward was quiet; most of the other residents had already left. I was getting ready to page Alphonse to sign out when a patient walked up to the workstation pushing an IV pole. Stocky, middle-aged, Mr. Diaz wore a drab, light blue hospital gown that looked like it was about two sizes too small. The intense scowl on his face might have alerted me as to what was going to happen next, even before he started shouting.
“Where is my fucking pain medicine?” he blared.
The ward clerk swiveled around in his chair. He was a big, burly man with a shiny globe of a head, who was nicknamed Mr. T. “Who is this man’s nurse?” he boomed.
She emerged from the medication room: thin, grim-faced, with short brown hair tied in an imperious bun. She asked Mr. Diaz what the problem was.
His eyes darted furiously. “Where is my Percocet?!”
The nurse replied that it wasn’t due for another hour.
“My legs are burning. I got AIDS neuropathy! I was supposed to get my Percocet at four o’clock!”
“That’s not what the doctor wrote,” the nurse shot back. She turned to me, as if trying to enlist support. “I’ve been trying to explain to him: the order is for every six hours with no rescues. I can’t give him anything until someone changes the order.”
I was happy to do it, but before I could say anything, Mr. Diaz’s face turned an unhealthy maroon.
“That is not my fucking problem,” he roared. “Give me my pills!”
“Get them yourself,” the nurse retorted, walking away. That seemed like the wrong thing to say at that moment.
Mr. Diaz bent over and hoisted the IV pole over his head. Fluid was still running into his arm as he charged at the nurse.
“Watch your back!” Mr. T shouted. The nurse sprinted around to where I was sitting.
“Give me my pills!” Mr. Diaz said, still holding the pole over his head, pointing it at us like a javelin. We remained frozen in place. One of the nurses continued her charting.
I had always sympathized with people who lost control. It used to happen to me all the time when I was a kid, getting into fisticuffs with other children on the playground or with my brother, who with his shrinking disposition would always run away when I became enraged. One time, I boxed his ears so hard the ear canal bled. I remembered how compassion from my parents had always defused my anger. And now, as I gingerly walked over to Mr. Diaz, I believed the same approach would work on him.
I stopped about ten feet away from him. Mr. T shot out of his chair. “Get back now,” he commanded.
“Sir, please put the pole down,” I said gently. “We’ll give you your pills.” I was ready to fly if he charged at me, but something told me that wouldn’t happen.
“I know you’re in pain.” I inched a little closer, emboldened by his quiet attention. “Just try to relax. I’ll change the order.”
Still brandishing the pole above his head, Mr. Diaz looked me up and down curiously. His face seemed to smooth out a bit, even as his gown still clung wetly to his chest. Then he turned back to the nurse. The sight of her appeared to enrage him again. “You think you can treat people like dogs,” he snarled. “I ask you for pills, you don’t come. I ask you for water, you say I’m asking too much.” He turned back to me. “When you want something, they don’t come. When you don’t want them, they’re on top of you.”
I nodded sympathetically. From what I had seen of 10-North, his comment didn’t seem that far off the mark. The nurses were taking care of too many patients per shift to pay sufficient attention to any one person.
“What are you smiling at?” Mr. Diaz blared at the nurse. “You think this is funny? I got the virus! I’ve been in pain all afternoon!” He was gesticulating violently again, spittle spraying from his lips. “I’m a veteran. I served my country!” He took a half step and flung the pole at the workstation. He did it almost halfheartedly, as if it was an inevitable consequence of the stakes he had set. The pole wobbled and dove into the tile floor, clattering loudly, yanking out his IV. Blood started trickling down his arm and dripping onto the tile floor. He leaned against a wall and let himself down. No one moved.
“Anyone come near me, they’re going to get AIDS,” he said, choking back sobs. We watched him quietly. A sort of calm descended on the ward, like after a suicide bombing.
Security officers soon arrived. Their mere presence, with their quiet authority, seemed to relax him. “All I wanted was my medicine,” he said, watching the officers put on gowns, gloves, and plastic face shields. “She could have just gave me my medicine.”
The officers roughly stood him up and frog-marched him back to bed. A nurse followed with a syringe filled with sedative. Once they disappeared, a quiet buzz returned to the ward. Mr. T went back to answering the phone. Nurses arrived for the change of shift. “Never a dull moment,” someone said.
A little while later, I went to see him. A nurse was tending to him as a security guard kept watch. He was sprawled on his bed, out cold. His arms and legs were tied to the bed rails and over his midsection was a restraint that looked like a cloth corset. Beads of perspiration glistened on his balding head, like dew on morning grass. His pupils responded sluggishly to my penlight, a consequence, I assumed, of the massive dosage of sedative he had just received. Punching buttons on his IV monitor, the nurse said: “This is the sort of crap we have to deal with every day.”
I nodded
. Though I was sympathetic to Mr. Diaz’s suffering, I was annoyed that the episode had disrupted my plans for the evening. “He was out of hand,” I told the nurse.
The next day, I heard Mr. Diaz was sorry, but when his doctors found out about his outburst, they dismissed him from their clinic. He apparently had a history of threatening behavior and was already “on probation.”
Over the next few days, intrigued by what had happened, I asked my colleagues about their own brushes with menacing patients. At least half claimed to have been verbally or physically abused by a patient within the past year. Many were innocuous encounters of the sort I would have been inclined to ignore: ranting by a paranoid schizophrenic, a wild punch from a withdrawing alcoholic. But a few were of a more serious nature. A nurse told me that a patient had tried to break a window in his room with an IV pole. When asked why, the patient said he needed to go to the bathroom, but that the nurse had waited too long to help him. A doctor in the emergency room, a short, balding man with a gruff, thuggish demeanor, recalled the time a CEO with chest pain had shouted maniacally at him, then swung at him and threatened to have him fired. “I call it the McDonald’s mentality,” he said. “At McDonald’s, it’s first come, first served, but it can’t be that way in the ER. I’ve heard people say, ‘That guy’s only had chest pain for two hours. I’ve had back pain for six months.’ ”
And this was just in my hospital, a relatively staid institution on the Upper East Side. When I looked in the medical literature, I was shocked by what I read. An ear, nose, and throat specialist in Michigan had been shot and killed by a patient who faulted the doctor for making him dizzy. A plastic surgeon in Washington was killed after performing a face-lift. A psychiatrist in Miami was shot and killed on a hospital psychiatric ward. On average, I learned, one American physician is killed by a patient every year. And many more are victims of assaults.
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