Internal Medicine: A Doctor's Stories (20 page)

“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.

W
HEN 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.

My sleep that night was broken repeatedly by that helplessness—dreams, fragments of nightmares in which lost things cried plaintively out of the dark. But when I went to find them there were only drawings of whatever it was I so urgently sought: crude, parodic cartoons, mocking my deep need. And even as I held each crumpled bit of drawing paper, the voice kept crying, somewhere else.

L
EAVING
U.S.
I, WE
descended into a wilderness of wooded hollows, surfacing into small clearings of abandoned tobacco holdings, then woods again, until we stopped in a crunch of gravel. A small cabin perched at the edge of a four- or five-acre clearing, much of it fallow and ragged with early weeds, but around the house a neat plot of fescue lay smooth and emerald green. The cabin looked vaguely like a chalet, the clapboard siding pine under varnish. Inside, the walls and kitchen cupboards were all the same yellow pine, shining dully in the morning light. The front room was dominated by a large picture window, and directly beneath it a low single bed, on which lay a man who might have been sleeping, but his eyes were open, fixed on the view outside. He gave no sign that he heard us enter, ushered in by a small woman in a brilliant purple dress. She brought us back into the kitchen, where she steered us to the long pine table.

On the wall by the sink a framed rotogravure showed Jesus on his knees, praying beneath a lowering purple sky. Facing Jesus from the other side of the sink was a yellow sunflower woven from colored straw. It bore the rubric,
Every day is a sunny day somewhere
. The image of Jesus did not bear this out.

“Doctor?”

The woman was looking at me, evidently waiting for a response. Off to one side I saw Linda looking amused.

“I’m sorry,” I said. “I didn’t catch that.”

“That’s all right, Doctor,” the old woman said. “You’ve always got a lot on your mind, I know.” She settled herself in the other chair. “I was just saying it was so good of you to come.”

There was something here, as well, that seemed to be saying more than I could grasp. She sounded almost as if I had been here before and she had been expecting me to return. I looked around the room, half hoping to find some clue, but the more I looked about the kitchen, the more firmly it refused recognition.

Until my gaze fell on the refrigerator, where, among snapshots of a diverse assortment of young people, half of whom had been caught in the process of graduating from middle school, I saw a sheet of bright yellow paper (the same shade as the sunflower still trying to cheer up Jesus by the sink) headed with a red stop sign: a standard out-of-hospital DNR form. There, at the bottom of the form, was printed my own name, and below it my illegible, unmistakable signature. I had met this woman before. And the passive figure lying out in the front room: I knew him now. Terminal heart failure, discharged to home with hospice. I had taken care of him in the hospital two or three months before. Alston: the name came back to me at last.

I cleared my throat. “How is he?” I said.

The woman looked into the front room, intent for a long moment on the figure on the bed. Then she looked back at me.

“He’s not good, Doctor.” Her voice was flat, her expression unreadable.

Finding myself here, so unexpectedly, in a home I had never thought to enter (one of the inescapable facts of hospital medicine is that, upon discharge, a patient vanishes from sight), I felt as if my presence here was a falsehood. This woman thought I had come to see how her husband was. She thought I had remembered him.

How many patients had I discharged this way, I wondered, patients I knew were going home to die, and never had a moment to think of again? I couldn’t begin to guess, no more than I could count all the others who had died in-house: for a long moment I saw a flickering of images like a primitive newsreel: not their faces, not their names, just shapes in beds. I could remember much better the rooms in which they had spent their final hours, sometimes multiple ghosts inhabiting the same room: their rooms, their diagnoses, and sometimes (these were the worst), when I could remember faces, it was only how they had looked when I had come into the room to pronounce them dead: the blank mask where before had been a personality.

I looked around at the bright, spotless kitchen, the woman’s face across the table still expressionless, and my presence in this house seemed the inevitable outcome of all those unthinking discharges: I was here to expiate some sin of omission.

I had just begun to contemplate how little I knew about the expiation of sin when Mrs. Alston shook her head.

“He’s not good, Doctor,” she said again. Then, dropping her voice, in a tone that combined urgency and grief: “Why didn’t anyone tell us what it would be like?”

I felt a stab of guilt.

Linda was at her shoulder, murmuring something I couldn’t catch. Looking over the woman’s head at me, she gestured toward the front room: “Go see Mr. Alston,” she said. I rose and left the kitchen, relieved to be anywhere else.

The figure on the bed shifted as I came in. Mr. Alston’s face seemed inscrutable at a distance, but as I approached and the eyes followed me, I recognized what it held: the utter weariness of a man whose heart had failed. When we had discharged him, he had been too weak to lift himself from his bed; if I had thought about it I would have given him only a week or two. But he was still here, his heart still feebly beating, the chest still rising and falling, the minutes continuing to pass and each day following the last into the night. He watched as I approached, as impassively as I imagined he watched for Death itself, because his life had narrowed down to this: watching or not. The eyes followed my approach, but beyond registering my existence they gave away nothing.

“Mr. Alston?”

The eyelids closed.

“Are you all right?”

The absurdity of the question felt like a slap in the face, but he gave no sign, and for a moment I felt a surge of anger: What else was I supposed to say?

“Is there anything . . .”

I wasn’t sure what I wanted to know.

“Is there anything you want?” I finished lamely.

The eyes opened. A hand appeared from beneath the quilt and grabbed my arm. It pulled me down, the strength in it shocking, until I was close enough to smell the decay in his mouth. For a long moment he held me there, the eyes searching my face. Then he gave the slightest shake of his head and turned away. I wasn’t sure if he was answering my question or dismissing me, pronouncing judgment.

The two women both looked up as I reentered the room.

“How is he?” Linda asked, her studied cheeriness deflecting any questions. As I muttered something bland and noncommittal, I realized suddenly that Linda, for all the time I had spent in her company, was almost as much a blank to me as Mr. Alston. If I had noticed this before, I would have said this was her nursing training, the professional polish that kept her work from consuming her, but now I was unsure. Perhaps she seemed that way only to me. Perhaps I really understood nothing, nothing at all. I looked around the kitchen, and the room, for all its sunny cleanliness, seemed as inscrutable as if it were the work of an ancient civilization. In the portrait of Jesus, the bruise-colored sky looked sinister, Gethsemane just one more episode in an endless history of suffering. A history from which I wanted only to be excused.

“Thank you, Doctor,” Mrs. Alston said.

I could only stare at her.

“For coming,” she explained. She rose from the table, levering herself up to her full five-foot-one, and made her way over to me in a series of short, rolling steps. She slipped her warm, dry hand into mine and gave it a tremulous squeeze.

“Doctor,” she said quietly, and her voice had a note in it beyond sadness, an unmistakable tone of the reproach I always worry I will hear. “Doctor,” she said again, and squeezed my hand one more time, using it to turn me back toward the front room. We stood and looked together at Mr. Alston gazing out the window. She whispered, “Why didn’t you tell me that it would take so long?”

W
EDNESDAY MORNING, AS I
followed Linda to her car, she asked, “Ready for a trip to the bird museum?”

After a few moments, she asked again.

“You up for it this morning?”

“What?”

“The Turners,” she said, sounding a little exasperated. “Are you going to show up this time?”

The car swooned around a turn that tightened as it curved, and for a dizzying moment I thought we might skid, but Linda’s grip on the wheel didn’t shift; we hit the straight. In that moment I had experienced an inner equivalent of a near-skid: I saw the past week and a half of this rotation as they must have looked from some other perspective. I had been a shadow, a cardboard cutout, the mere image of a man, through the whole thing.

Linda was still looking at me.

“I don’t know,” I said.

T
HE GRAVEL PATCH IN
front of the Turner house was occupied. Two cars—large, middle-aged sedans, one a tan Buick, the other a dark blue Olds—were parked nose-to-nose beside the old fruit tree, which in the past several days had pushed out plump buds frilled with pink. The sun was working on the last of the morning haze, heating everything to a silver shimmer. As we pulled onto the gravel and Linda killed the engine, I thought I heard the parrots screaming.

“Uh-oh,” Linda said quietly.

Above the voices of the birds a dark rumble rose, breaking into deep, staccato barks. For another moment I allowed myself to believe a dog had gotten in among the birds—a vivid flash of red, green, yellow swirling feathers flying, shrieks of outrage, inhuman voices shrieking “Bad dog! Bad dog!” The image was frightening enough: my heart hammering high in my chest, I stared at Linda for a cue.

Linda stood half out of the car, looking not toward the back of the house but over the tops of the parked cars toward the porch. The Buick blocked my view, but, even so, as I tried to follow Linda’s gaze I realized the sounds weren’t coming from the back of the house. And then what I thought was barking resolved into a man’s voice, shouting a single obscenity over and over, overwhelming a chorus of high-pitched protests that sounded now less like “Bad dog,” and more like “Praise God.” Or perhaps I was only forcing sense into what was actually inarticulate shrieking.

Certainly by the time Linda and I rounded the rear bumper of the Olds and stopped, separated by five or six yards from the knot of figures on Turner’s front porch, the sounds coming from the group had broken down entirely into shrieks and wails, broken repeatedly by Turner, who stood filling his doorway, red-faced, the muscles and veins of his neck standing out like the anatomy of Hell. Which was what he was saying now to the group of women surrounding him:
You go to Hell! You go to Hell!
He said this more times than I wanted to count, the words taking on an incantatory force, as if he expected his rage to blow an opening in the air.

He advanced, one straight-legged stagger, then another, the porch shuddering at each
Hell!
as his feet came down. The women were wearing, I realized, Sunday churchgoing dresses. Several of them clutched small Bibles at their chests, like shields against the assault; others held their hands to their ears and turned their faces sidelong away and down, their own mouths open in Os of dismay. The whole scene had a weirdly static quality, like a medieval landscape with figures, a saint or a prophet, a hostile mob. I waited for someone to pick up a stone.

Linda struck out for the porch, her backpack over one shoulder, passing through the knot of church ladies as though oblivious to them. She took the two steps in one stride to Turner’s side, her hand out to rest on his forearm.

He shied it off, staring pop-eyed at her as if unable to make sense of what he saw: a slight, pale figure in black leather amid the dark purple proprieties assaulting him. He blinked and turned back to the crowd, seeming to mouth one last invocation of
Hell!
but his voice made no sound. His mouth opening and closing would have been comical if the whole scene hadn’t been so entirely terrifying.