Internal Medicine: A Doctor's Stories (23 page)

She sniffed again, then carefully extended her left arm in my direction, and rotated it slowly to bring the bandage at her wrist into view.

I looked, but did not move closer to inspect. “Does it hurt?”

She looked at it curiously. “No.” The arm hovered in the space between us, quivering slightly before—slowly—it withdrew.

When Carrie B was done with this languid demonstration of her capacity to hurt herself, there seemed little more to say. I recalled—with an effort—that it wasn’t her wrist I was worried about. I’d never entertained the possibility that her presentation had anything to do with the superficial lacerations on her wrist. Like any good stage magician, she had waved her hand in front of me knowing that it would distract me—knowing as well that it would hold my attention on her.

But tonight the show was plumbing some new depth of drama. What was going on in Carrie B that held her so uncomfortably on the edge of the examining table?

“Would you mind lying down?” I held up the bell of my stethoscope. “I’d like to listen to your heart.”

She made a face, a brief curl of her lips as if she had tasted something unpleasant, and then began to lower her upper body to the surface of the table.

It was an extraordinary performance. Her hands, which had been braced on either side of her, walked haltingly back toward the head of the table, while, inch by inch, she levered her body down. Her face took on a series of different expressions as she moved: eyes opening wide, as though astonished by something, then wincing, then widening again, her pupils very large in a way that suggested some huge autonomic discharge to which I was only a peripheral witness. She caught her breath repeatedly, in a series of gasps, each cut short. As she settled the last six inches I found my own breath catching in my throat.

As her back touched the table, the three of us—the nurse had been holding her breath too—let out a long sigh. I glanced over my shoulder at the nurse, who was looking back at me, her RN’s deadpan broken to the extent of an elevated eyebrow. Shaking my head, I leaned over Carrie B and placed my stethoscope on her chest.

A healthy young heart thudded under my hand. Air moved freely as she breathed. Her respirations were rapid and shallow, and her pulse was rapid as well. Moving down to her belly, I let my stethoscope lie there for half a minute, listening to the ordinary gurgling of an untroubled digestion. Then I started bearing down on the bell. This is an old trick: if you suspect someone is overreacting (as many do) to overt pressure, but fails to respond to the more subtle pressure from the stethoscope, you can be fairly certain that their reaction has more to do with mental processes than abdominal ones. But I hadn’t gotten more than an inch or two down before I heard a sudden sharp intake of breath, followed by a spasmodic clenching of the obliques.

I looked at the patient’s face: it was pinched, pale, except for two distinct red spots over her cheeks. Her eyes were closed, and her breathing fast and shallow. I listened again, and heard only the subterranean gurglings of an ordinary belly.

Tentatively, I placed a hand on the right upper quadrant, fingertips two inches below the margin of her ribs. “Take a deep breath,” I said, and prepared to dig in to find the edge of her liver. As she started to comply, her breath caught: her eyes flew open again with the same odd expression of surprise, and wild, dilated pupils. And something else: behind the surprise something kept close.

I lifted my hand from her belly.

“Does that hurt?”

The gaze she turned on me was theatrically blank.

“What?”

“When you take a deep breath. It seems to hurt you.”

“Oh. Yeah.” Pause. A tentative trial of deep breathing, staged carefully up to the point of pain. “It does. A little.” She smiled at me then, and there was nothing stagy about the smile, and there seemed nothing duplicitous about it, either: it was actually a very nice smile, winning, even, and I thought for a moment that Carrie B might under other circumstances have had a pleasant life. Instead of being not much short of terrifying. I looked back at her, trying to get her to come into focus: a small woman with finely chiseled features, pale blond hair with a slightly reddish cast to it, and it struck me that she was unusually well groomed. Her hair was clean, her skin clear, although I knew the color on her cheeks was more hectic than health. All of which was only a setting for the disturbing thing that glimmered in the depths.

“Do you think it’s anything serious?” she asked.

“What?” I said, a little abruptly. I muttered something noncommittal, as I always do, and started to scribble orders in the chart. There was a staginess in the question I found irritating. I hadn’t time for it. My pager was going off again, cutting like an alarm clock through the fog that had filled the room. The nurse picked up her clipboard in a gesture so matter-of-fact it seemed staged as well. Was everything staged? I wondered briefly, one of those odd thoughts that surface all the time but took on too much meaning in a place like this. “Frequent vitals,” I muttered, and left the two of them to manage as best they could. I finished up my orders—X-rays of the chest, expedited—and left the chart on the unit clerk’s desk.

T
HE PAGE THAT HAD
broken the spell in the examining room had been the intern, who was waiting for me outside the second set of locked doors. He had a somewhat hectic expression himself, a shock of thick black hair standing straight up from above his forehead. As he read off from his clipboard summaries of the three cases he had already seen and the seven more that were waiting, he repeatedly brought his hand up to his forehead and drew it back across the top of his skull. He seemed to be trying to press it—the top of his skull, not the crest of hair—into place, but the only effect was to make the crest stand even higher. That, and the way his eyes kept opening very wide, made him look a little mad himself.

I couldn’t blame him; as he dutifully read off the minutiae marshaled on his list, I had the impression the nurses had been leading him on a merry chase around the building. Half of what he had been called about was, as usual, junk. In a medical hospital they wouldn’t have merited a note in the chart, much less a page to the on-call MD. But here the staff didn’t have the luxury of deciding what to ignore: they were required to call for anything out of the ordinary, and did. And the intern was required to see everything he was called about, no matter how unlikely. And now that I was done reviewing admissions, it was my job to supervise him as he made his rounds.

The intern—his name was Joe Bellagio—was one I had worked with several times before, and every time it had been like this: so busy we barely had time to talk about anything beyond the exigencies of the case at hand. I hardly knew him, beyond an impression of a tall, skinny fellow who usually seemed more rattled than he actually was, who took his responsibilities seriously, and generally knew what he was doing. He seemed sensible, thoughtful, and kind. All of which inclined me to like him.

He reached the end of his list of pending calls. “Who needs to be seen most?” I asked.

He studied the list again. “I think the guy in F-Max.”

“The chest pain?”

“Forty-eight, diabetes, smoker, eight out of ten for the last”—he checked his watch—“thirty minutes.” He checked his list. “And a prior MI.”

My own heart bounced slightly on a passing wave. “F-Max, huh?”

“Yeah.”

I sighed. “It’s chest pain.” And stopped. “Can’t they send him over?”

Joe was walking at my side, head down, hands thrust in the pockets of his lab coat so his elbows stuck out behind him. He shook his head without looking up. The gesture made him look like a discouraged stork.

“Can’t do that anymore. Not from F-Max.” He glanced at me. “There was an incident.”

We had reached the front lobby. My dinner, the white cardboard box going a translucent brown along the edges, was sitting on the counter at reception. I scooped it up as we passed. The guard looked up from his screen, said, “It’s cold by now,” and pressed the button that let us out.

The night outside was loud with crickets and katydids, the humidity thick enough to scatter the glare of the sodium vapor lamps over everything. Objects stood out with a weird vividness, wearing halos in the streetlight. As we crossed the parking lot, a raft of palmetto bugs froze at our feet, then scattered madly in all directions. We watched them vanish. The slice of pizza I had been stuffing in my mouth had lost some of its savor. I gulped it down anyway.

“There’s a metaphor,” Joe said quietly.

This was not the kind of thing I usually hear from interns, even in psychiatry. I offered Joe the open pizza box. “A metaphor? For what?”

He shook his head. “Not sure.” We started walking again. As we turned out of the parking lot into the darker street, he said, “I think it’s for our relationship with this place.”

He gave me a sidelong, self-conscious glance. I had the sudden impression that Joe was shy.

“I think I need that one spelled out,” I said, I hoped kindly. The second slice of pizza was no improvement on the first. The guard had been right. And I kept thinking about the bugs as I chewed.

He hunched his stork shoulders and sighed. “You come onto a ward—like Acute Women’s—and there’s all this stuff going on.” He laughed. “Haven’t a clue what, but there’s a lot of it. And the minute we arrive, they all freeze, and whatever it was—the pattern of it?—breaks up. Just because we’re there.” He strode along a moment in silence. “We think we’re straightening these people out. But the moment we leave the ward, it all starts up again. Whatever it was. And we haven’t got a clue.” He sighed again. “You know?”

I had been so busy marveling at this moody, humane discourse that I almost missed the request for reassurance. “Yeah,” I said. “I think I know.” In the dark of the oak tree overhead, a bird awoke and screeched loudly, once. I looked up and shivered theatrically. “Now you’ve got me thinking it’s all a metaphor.”

He ignored the gesture, caught up in his idea. “Well, it is, isn’t it? Not the way the paranoids think: it’s not all about us. That’s the point. We’re nowhere near as central as we think. But all the same, there is this huge invisible order: but we have access to it only through the grace of God.”

Now it was my turn for a sidelong glance. He was gazing, his face rapt, into the lurid haze overhead. “We can’t see Him.” He said. “All our works just cloud the view.”

We walked the rest of the way to F-Max in silence. I found myself thinking irrelevantly about Carrie B. She seemed to have something to say about Joe’s view of the world, but just what exactly I couldn’t catch. The connection hovered just beyond my reach.

F-Max is the one part of the complex where our master keys do not work. We waited at the door several minutes under the gaze of a video camera until a guard appeared behind the thick glass and turned a key. We followed him meekly into the guard station, where under a bank of several dozen black-and-white monitors we emptied our pockets of keys, cell phones, wallets, spare change, pens—anything that met the definition of
Contraband
spelled out on a handwritten notice taped below one of the monitors. Pizza seemed to be contraband. I left the remainder for the guards.

Past four iron gates, at the top of the stairs our escort hung back and locked us in as we walked out onto the central corridor. The doors that lined both sides had little portholes of wire-reinforced glass, and no doorknobs. At the far end of the hall, half a dozen figures were standing about. None of them was with any of the others. They watched us as we approached. Another guard ushered us into the nursing station, where the door locked behind us.

“Doc!” the nurse cried. “How have you been? Haven’t seen you in weeks! You well?”

I smiled weakly. “Well enough, Lucy. You?”

“Oh, you know me, Doc.” Lucy levered her two hundred pounds out of her chair and lumbered across the cramped floor to the chart rack. “Not complaining.” She laughed abruptly, a harsh bray. “Not complaining.” She settled into another chair beside the rack. “Unlike some people I could mention,” she added. The chair creaked as she sat down, bent forward, and pulled a thick, battered binder from the rack. She pushed the chart in our direction and sniffed derisively.

“So? What’s the story?”

“It’s the same old bullshit.”

“I thought somebody said chest pain.” I opened the chart, flipped past the face sheet to the problem list.

She made a rude noise with her lips.

“Diabetes,” I read, pretending to ignore her. Joe stood nodding at my elbow as I ran down the list. “Smoker.” I had to squint at the next entry. “Hy Per Lip Id Emia.”

Lucy laughed. “Does it mention he’s a stone bastard?”

I pretended to scan the list.

“No. No, it doesn’t.”

“Here.” Lucy swiveled to another rack. “That’s ’cause you’ve got the wrong chart.”

The chart Lucy was pulling was his psych chart. She flipped it open, thumbed through a few pages, adjusted her glasses on the end of her nose.

“Ah. Here it is. Hmm-hmmhmm. Yeah. ‘Patient states that when he locked his children in the closet, he was unable to say what exactly was concerning him.’”

She looked up over the rims of her glasses to see if we were paying attention.

“ ‘He adds that the fire was necessary to prevent the spread of something he again is unable to identify, calling it at various times an infection, at other times a magnetic field. Even so, he states that he was aware while he was setting the fire that it would result in the death of his children. All three children died of smoke inhalation. The subject himself suffered third-degree burns to fifteen percent of his body surface area, mostly over the right side of his head and neck, apparently as he stayed within the building with his head against a wall until the wall collapsed.’”