Hospital (44 page)

Sominsky’s words sounded more cynical than her tone. “So everyone can come here and have children born here and apply for services?”

Razaq returned to medical issues. “She became tachycardic,” he said. “Afterward I spoke to the sister. The patient knows she hasn’t got a good prognosis. I haven’t spoken to her about time.”

Astrow asked, “How do you plan to talk to her about her children?”

Razaq looked pained. “The children. The oldest is five years old,” he said. “Can you tell them?”

No one answered.

“The children are now staying with whom?” Astrow asked.

Keen replied. “Mom and her boyfriend,” she said. “The patient’s boyfriend of three months.”

“There’s a whole literature on how to talk to children about their parents’ illnesses,” Astrow said. “It would be good for us to review this whole topic.”

“This meeting is to look at what the family dynamics are and how they can support her,” said Keen.

“I’m going to tell the family they need to take responsibility immediately,” said Razaq. “Even if she survives a few months, she won’t be in shape to take care of children.”

“How will she get to Coney Island?” asked Keen. If Ms. Hernandez got well enough to be discharged from Maimonides, her treatment would continue at the public hospital. Then the social worker moved from practical matters to spiritual. “She’s an ecumenical Christian and looking for spiritual support. We called around and found a priest who came over Saturday to pray with her.”

Astrow asked, “Who do we have in this hospital for patients who aren’t Jewish?”

“Deacon Tom,” said Keen.

“Episcopalian?” asked Astrow.

“Catholic,” said Keen. “We have all kinds of churches on call, and there’s a priest regularly on Wednesday and Friday. Jewish support is hard to get unless a patient is dead.”

“It’s surprising in this hospital there’s very little religious support,” said Warshawsky.

Astrow laughed. “I see all these rabbis floating around here,” he said. “What do they do?”

Robert Rosenblum, another social worker, middle-aged with a beard and yarmulke, smiled slightly. “They float,” he said.

Astrow was about to change the subject. He looked at Keen. “It’s very important for the mom to think about her children and how she wants them to remember her,” he said. “A fairly tough discussion.”

At 3:00 P.M., the time scheduled for the meeting, Regina Tarkovsky was waiting outside Hernandez’s room. Tarkovsky, a Russian with pensive eyes and short blond hair, was a firm director like Gregory Todd, a full-time staff physician who had her own patients and, along with a nurse manager, supervised clinical care of all the patients on her floor.

While we waited, Tarkovsky brought us up to date. “It’s a very interesting case,” she said. “She’s so young, and it is not likely for a young person to present this way, stage-four lung cancer. Plus, she has no insurance, and we’re all thinking, ‘What is going to happen? How will she get treatment?’ She looks better, she just got chemo. But the five-year survival rate is almost nonexistent.”

God help the interesting patient. “We have teaching rounds at one-thirty; ten A.M. morning report on interesting cases,” she said. The floor was full of them.

She told us about another patient she had, metastasis to the brain, no hope. Her group collected money to send him home to Ukraine.

Tarkovsky sighed. “Sometimes I think there is too much teaching.” I noticed she wore frisky boots with skinny high heels and pointed toes, and I wondered how she managed to get around; the doctors never stayed in one place very long.

“This patient can’t get treatment in our cancer center if she leaves the hospital,” said Tarkovsky. “She can go to Coney Island. The resident already talked to her about advanced directives, Do Not Resuscitate. But she’s in denial.”

Tarkovsky explained that she was in charge of Hernandez but felt that the oncologist should talk to the family. Suddenly a dizzying smell oozed into the hallway from the room on the other side. Tarkovsky and Keen seemed oblivious to the stench and its source, an elderly man walking in small circles, and periodically lifting his gown, exposing his naked rump. He grabbed some plastic gloves from a container and leaned over to swipe at something on the floor but missed the fresh turd he had just deposited there.

Tarkovsky finally noticed and called out to the nurse’s aide—the “patient-care technician”—a slender black woman walking down the hall. Smoothly the PCT shifted course and quickly cleaned the mess, while gently talking to the man.

The Spanish-speaking student social worker couldn’t come to the family meeting Lisa Keen had scheduled because of the snow. Keen decided to proceed with another interpreter, a resident who spoke Spanish.

The family arrived shortly after the hour. It was a modern family, nonnuclear, ordained by neither religion nor state, held together by blood, passion, children, culture, and now necessity: the patient’s sister and brother-in-law, the father of the children, and the new boyfriend of three months. They were young people, in their twenties, outfitted in jeans, a baseball cap, stylish boots, but apparently ready to assume this grievous responsibility.

The resident who had offered to interpret appeared. It was David Kho, the Chinese resident born in Singapore, married to the half-Jewish Puerto Rican. Last time I’d seen him, he was interpreting for a Chinese patient. Now he was needed for the Spanish he’d perfected working with Dominican patients while a resident at Columbia’s medical school.

While the group waited for the oncologist, Phil Rubin, Keen explained the purpose of the meeting. “Dr. Rubin is coming to talk about chemotherapy,” she said. “But the reality is, you have a limited time to be on this earth, and we want to help the family use this time in the best way.”

Kho interpreted carefully. The sister began to cry, as did the children’s father. The boyfriend looked dazed. Only Hernandez herself, ethereal in her hospital gown, thinner and paler than when I last saw her, was composed, despite the breathing tube in her nose. She handed tissues to her sister and to the father of her children.

Rubin arrived. He was a bulky, awkward Orthodox man whose yarmulke always looked ready to slide off his head. Bangs added to the impression of a big, gawky boy, even though his hair was graying. He was known for his thoroughness, an unwillingness to rush that contradicted every impulse of hospital momentum, and for a desire to cure so fervent that it compelled him to put a positive spin on the direst situations.

He looked like he wanted to hide behind his bangs as he explained that the cancer in the patient’s lungs had spread throughout her body by the time she entered the hospital. Fluid around her heart had been drained so she could have chemotherapy, which had begun the previous Friday. “If no treatment was given, she would not be alive today talking to us now,” he said, looking at Kho, with an occasional sympathetic nod in Hernandez’s direction.“We hope the chemotherapy will fight the tumor around her lung and allow her to breathe by herself.”

Rubin paused periodically, giving Kho time to interpret, in careful textbook Spanish. Rubin explained that the chemotherapy, which would be given intravenously once a month, was a poison, so it would affect healthy cells, too. It would take one or two weeks to recover her blood counts and at least two cycles of chemotherapy to test the overall effect.

Rubin tried to use language that was hopeful. “If over the next week or so she has improvement in her breathing, that is a good sign and an encouraging sign,” he said. “She is not ready to leave the hospital until she recovers from the effect of the chemotherapy.”

His young audience listened with petrified faces.

Keen whispered something to Rubin.

Dutifully he said, “The chemotherapy will not be able to get rid of all the cancer, but it can help her feel better and live longer. If it works, she can do as much as six cycles.”

Keen interjected, “There is also the possibility she may not respond.”

Kho interpreted. Rubin looked miserable. “Yes, as she says, you can only know if the patient will respond to chemotherapy by giving it,” he said. “It is possible she may not respond. If she responds, this may . . . it could give her many months, even years. The only thing to do is support her and see if she responds.”

Once again Keen prodded. “We should mention the same people who follow her here will follow her at Coney Island.”

Rubin nodded. “When she leaves here, that will be a good sign. Some of our doctors will follow her at our affiliate, Coney Island Hospital,” he said. “With God’s help we’ll pull her through this.”

As Kho interpreted this, Hernandez smiled. Her sister continued to weep.

Keen talked about the children and the need to make some formal arrangement for their care, even temporarily.

Then, for the first time, the family spoke. The children’s father said, in English, “I can take care,” he said. “They ask mother if that’s what she wants. She says yes.”

Keen asked Hernandez, “You don’t want them to come see you?”

She nodded.

The brother-in-law, leaning on the windowsill, volunteered to take her to and from chemotherapy at Coney Island Hospital, before and after work.

Rubin said, “I hope it will only be a few times a month,” he said. “Two or three times a month. She has to be there five hours.”

Keen asked about telling Hernandez’s own mother, but the brother-in-law said she suffered from high blood pressure. The news could be dangerous.

Keen asked Tarkovsky, who had been standing by silently, to discuss the health-care proxy. They gave the sister brochures in Spanish from an agency that helps children.

Keen said, “You can call on any of us for help. Me, Dr. Rubin, Dr. Tarkovsky.”

Kho said, “And me,” reminding them he was a doctor as well as an interpreter. He then repeated in Spanish Keen’s offer to find someone to pray with them and stumbled on the word “
religioso.
” For the first time, Hernandez’s sister laughed, as she corrected his pronunciation.

Keen looked at Hernandez. “We appreciate how brave and strong you are, but there will be a time you want to cry and carry on, and that’s okay,” she said. “At some point you’ll want to tell the kids, and if you need our help with that, we can do that.”

Nothing—not even bad behavior or dirty floors—preoccupied Pam Brier Nas much as the area of patient care referred to as “pain management.” At Maimonides the pain program was combined with palliative care and directed by Beth Popp, who had trained in oncology at Sloan-Kettering. Helping patients deal with pain strained the budget. Anesthesiologists in private practice, with a different reimbursement structure, could make money at it, but hospitals dedicated to pain management were forced to treat it as a luxury.

Alan Astrow often returned to the theme of the dictates of the payment system. “All the things that are really good—diabetes care, asthma care, taking good care of cancer patients—you don’t get paid for that, no way,” he often repeated in one form or another. “You get paid for radiating people, doing complicated surgery, giving them chemotherapy. That’s what you get paid for. You don’t get paid for taking care of people.” What set him off that time was an article in the
New York Times,
about how diabetes centers were all going bankrupt. “Well, I could have told you that,” he muttered. “People think doing good will lead you to doing well. Absolutely not!”

Brier and I had a long conversation about pain one day. It was a typical Brier tour de force, which began with a story about constipation. Specifically, she told me about a telephone call she’d made to Vincent Calamia, the endocrinologist who had taken on the thankless job of running Victory Memorial Hospital while the Berger Commission decided whether to close it. Calamia and Brier had a cordial relationship, quite different from the one she’d had with Victory’s previous chief executive.