Making Rounds and Oscar (2010) (6 page)

Mary shook her head.

"I'll call the GI doctor tomorrow and make an appointment," she said. She knew what Frank was after and had been hoping that I could dissuade him. She walked into her office to write herself a reminder.

"It's not going to make a difference, is it?" I could hear her just fine through the open door.

"No, Mary, it isn't, but he's not ready to hear that."

"Give him time," she said.

"We've got plenty of that."

CHAPTER SEVEN

"I have studied many philosophers and many cats.
The wisdom of cats is infinitely superior."

HIPPOLYTE TAINE

IT WAS JUST AN ORDINARY WEDNESDAY. OR SO I
thought until I encountered a new face working behind the third floor nurse's desk. Actually, it was an old face and it belonged to a woman whom I guessed to be in her early eighties. She was tastefully dressed in a light blue cashmere sweater with carefully applied makeup and meticulously painted nails. Her graying golden hair was pulled back behind her ears and arranged with an expensive-looking antique clasp.

Mary spoke before I could say anything. "Dr. Dosa, I'd like to introduce you to Louise Chambers. She's our new receptionist."

"Our what?" The third floor didn't have a receptionist; it wasn't in the budget. Mary laughed at my confusion. "Just one of the patients, David."

I noticed that Louise was picking up the phone when it hadn't rung and saying something into the mouthpiece. I recalled another patient Mary had told me about, a former insurance salesman who sat in his room with his feet on a desk, selling insurance into a disconnected phone.

"Is she new?" I asked.

"Oh, no, not at all. Louise has been here for about three months. Lately, though, she's started to wander down to the front desk and sit here with us. Sometimes, if we're not around, she'll answer the phone."

I looked at Louise, who was repeatedly lifting up the phone and putting it back down again, and wondered how many family members had tried to get through while she had been manning the front desk.

"Look, I know finances are tight and you could use the help," I began.

"C'mon, David," Mary laughed, "lighten up. The families just love her. I think she was a secretary for some big executive years ago. Answering phones is probably just in her blood." She glanced over at Louise, who seemed to be watching us out of the corner of her eye. "And you know, David, she just
loves
tall men."

At this Louise muttered something, which prompted a childish laugh from Mary.

"What did she say?" I asked, moving toward the desk.

"I told you she would like you," Mary replied.

"But what did she say?"

"She says you're cute."

I shook my head incredulously.

"How did you get that?"

"Years of working here, I guess."

I had noted this Dr. Dolittle-like ability of Mary's before. She could understand patients no one else could--just one of her many talents.

Mary got up from her desk and grabbed a chart from the rack behind her.

"Take a look at this," Mary said. "It's Saul Strahan's labs."

The antibiotics I had prescribed for his leg didn't seem to be helping, and there were other complications. His white count appeared to bear the signs of worsening infection and he was likely dehydrated based on his recent labs.

"I'll go see him," I said.

Mary nodded, but not in a manner that conveyed much hope.

"I think we both know which way this is going," she said. "Now if only we could bring his daughter inside the tent."

That was a big tent she was talking about but in my experience, you couldn't get people inside until they were good and ready. Saul's daughter was a long way from ready.

"Well, let me go take a look at him," I said, and headed off for his room. As I passed Louise she got up quickly from her chair and stepped in front of me. Her hands opened wide, as if expecting a hug.

"You see," said Mary, "she really
does
like you."

I gave Louise a hug, which prompted a huge smile on her face.

Suddenly I understood.

"She thinks I'm somebody else!" I backed off a bit, feeling slightly offended. I headed for Saul's room with Mary laughing behind me.

"You know, David, whoever you're substituting for, you're not half bad."

I FOUND SAUL
in his recliner again. The TV was on but he made no pretense of watching it. He was still wearing his Red Sox cap. Like so many others in this part of New England, Saul was a devoted sports fan. His room was festooned with baseball paraphernalia and mementoes. On his nightstand there was a picture of him standing proudly in front of Fenway Park with his arm around the neck of a young boy, likely his grandson.

"Spring training starts soon, Saul!" I said and pulled up a chair beside him. I wondered if he even knew his team had finally won the World Series. Even Sox fans that hadn't suffered strokes couldn't quite believe that the eighty-six-year-old Curse of the Bambino had finally ended.

I listened to Saul's heart and lungs and then finished my assessment by looking at his leg. Mary was right: It was inflamed again, despite the earlier antibiotic treatment. This time, though, the redness appeared to be spreading up his leg toward his knee. I took a moment to draw a line around the redness with a ballpoint pen--a line of demarcation to tell whether the infection would respond to our treatments. Then I sat down next to Saul and surveyed his other labs, quickly noticing a recent test that showed he was colonized with an increasingly common, highly resistant bacterium. This particularly nasty strain of staphylococcus has become the bane of every physician's existence in recent years. These resistant strains of bacteria have become almost ubiquitous in health care institutions around the world.

As I pondered my limited treatment options, I felt another presence in the room. I looked down to see Oscar sitting on the floor, watching me intently.

"Hey, you. Are you making rounds with me now?"

I reached over and offered my hand. Oscar sniffed it intently, then stood up to move toward me, allowing me to gently scratch him behind the ears. Then with a single leap, he jumped on my lap and sat down, eyeing me. He purred.

"So, what do you think?" I asked Oscar, nodding my head toward the patient.

For a second, he looked over at Saul as if he were actually assessing the situation. Then he jumped off my lap and approached the chair. He leaped up on the arm of the recliner and sniffed the air. Then he jumped down and scampered out of the room. It occurred to me that I had just received a second opinion from a cat.

I finished my exam and said good-bye to Saul. Returning to the front desk, I found Mary busy writing in a chart.

"So, I've just been on rounds with Oscar," I announced, smiling.

"Are you a believer now?" she asked.

"I wouldn't go that far but I've been wondering. Let's say, for the sake of argument, that he has this ability to sense when death is coming. Do you think he just smells a hormone or something you or I can't perceive?"

"I don't know, David. I'd like to think it's a little more than that, but I've read about stories from health care workers who say they can smell when death is near."

I considered what Mary was saying and realized that there was at least one possible scientific explanation.

"When cells stop working, you get a state of starvation and you can smell ketones," I said, referring to the sweet-smelling chemical by-product that can also be sensed in out-of-control diabetics.

Mary shrugged. "Personally, I'd like to believe that there's more here than just a smell. Maybe Oscar's patterning the behavior of the staff on the floor. After all, you were in the room just now showing interest in Saul. Perhaps he just wanted to be part of the team? A cat's got to earn his keep, you know."

I looked down the hallway, lost in thought. "In a way that makes sense," I said, "but it doesn't explain why he's sometimes the first to enter a room when a patient is dying."

I must have been frowning because Mary punched me in the arm in a playful fashion. "Careful!" she said. "You look like you might hurt yourself!"

"It's funny," I said. "I've had all of this medical education and experience and I still often walk into a room and have no idea what is going to happen. I mean, how often do family members ask you how long their loved one has?"

"All the time."

"What do you tell them?"

"I tell them that only God really knows and I don't have his telephone number."

"Like a cat," I said, unconsciously.

"
What?
" Now Mary was the one who looked incredulous.

"You know: 'A dog comes when you call and a cat takes a message and gets back to you.'" I looked under the desk where the cats' food was kept: no Oscar. "The thing is, Oscar walked into the room just now, took a deep whiff, and walked out of there as if there was nothing to worry about."

"I guess he knows that you're going to fix Mr. Strahan."

"Maybe. But it does bring you down a peg, knowing that in the great medical org chart, you're in a box below a cat."

Mary chuckled at my response. As I looked at her, I suddenly became curious about her own thoughts related to our cat.

"Mary, when did you first think about what Oscar was doing?"

She put her pen down and sat back in her chair.

"I guess, at first, I didn't really think about it. Some of the aides started to talk about the cat always being there when patients died. As I remember it, I suspect Oscar's first patient was Marion McCullough. Her son Jack used to bring Oscar into the room with him because her mother really loved cats. Oscar would never really stay with her for long, but as she got sicker, he would stay longer. On the day Marion died, Oscar actually jumped into her bed of his own accord and sat down beside her. Jack telephoned me a few days later and told me how fortunate it had been that Oscar jumped on the bed."

"Why?"

"I guess he thought it was a signal that she was going to die soon."

Mary looked over at me.

"At the time, I thought it was a cute story, but I didn't give it much thought. You should talk to him, though."

"So, that was your first inkling," I said. "But what did it for you?"

"I suppose the thing that made me a believer was a death that occurred several months later. By then, a number of people were talking about Oscar, including several of the hospice nurses. Your patient Ralph Reynolds was dying and we were trying to do everything to make him more comfortable. One of your colleagues was up here and went in to take a look at him. She came out suggesting that he was close to death and gave some hospice recommendations. One of the aides overheard her and went off to find Oscar."

Mary paused for a second, savoring the telling. "The aide returned a few minutes later, carrying one unhappy kitty into the room. She put Oscar on the bed and announced to us that if the patient were dying, Oscar should be present. Oscar looked at all of us like we were all stark mad and ran out of the room quicker than she could finish her sentence. Hours later, we found him hiding under the nurse's desk."

"So, what happened?"

"Ralph actually hung on for another thirty-six hours. But sure enough, four hours before he died, we found Oscar pacing in front of the patient's closed door. Oscar looked profoundly unhappy. When we opened the door, he dashed straight for the bed and leaped up next to Ralph. He curled up there and refused to budge. A few hours later, Ralph was gone. Oscar didn't leave his side until the funeral director came and even then, we needed to bribe him with cat treats to get him away from Ralph."

I shook my head, but I don't know if it was in wonder or disbelief. Mary gauged my reaction and offered me a hint of a smile.

"Dr. Dosa, it looks like you're starting to take our cat here more seriously."

I threw up my hands. "Who knows, Mary? I'm still a scientist at heart." I knew Mary hated my
I'm a scientist
talk, but I continued. "I've always been taught to look dispassionately at the facts--to analyze them, form theories, and then poke holes in them until other theories develop that are closer to the truth. You know that. When you consider it from a scientific point of view it's easy to shrug off suggestions that a cat can predict death. It's so much easier to say that he's just sitting with those patients because of the activity--the gathering of family, the holding of hands, the saying of good-byes. It just makes more sense. Or maybe he just likes to hang out with dying people because they don't bother him. Most cats sleep two thirds of the day anyway, so chances are a cat is going to be found on a warm bed somewhere, right?"

Mary smiled widely. She seemed to sense that I had reached some sort of tipping point and that I was prepared to believe in this gift of Oscar's. She didn't want to push it, but she couldn't seem to help herself either. "But you've got to admit that there's something unusual about our cat, right?"

"When you consider all the circumstantial evidence, it certainly looks that way."

"So, do some more investigating," she said reasonably. "You're a researcher. I think you should talk to some of the family members of the patients who died on Oscar's watch, see what they have to say."

"I guess it couldn't hurt," I said. I was thinking about the part of my job that required me to be a detective. Science is, among other things, an art of detection. I felt that I had to get closer to the heart of this mystery.

"So, where should I begin?" I asked.

"I'd start with someone you trust," Mary prompted.

"Donna Richards?" I asked.

"I can't think of anyone better!" she said, perhaps a little more self-satisfied than was necessary.

I hate it when she's right.

CHAPTER EIGHT

"Cats always know whether people like or dislike them.
They do not always care enough to do anything about it."

WINIFRED CARRIERE

TO SAY THAT I TRUSTED DONNA RICHARDS WAS SOMETHING
of an understatement. It was like saying that Sherlock Holmes trusted Dr. Watson, or that Captain Kirk trusted Scotty to run the engine room.

As any doctor will tell you, good office managers are worth their weight in gold. They manage large staffs, stay one step ahead of government regulations, and make sure that important phone calls get returned. They see that the billing is current and that everyone gets paid, and make sure we don't run out of supplies--everything from tongue depressors to copier paper. Office manager is one of those thankless jobs that only gets noticed when something goes wrong. That may be why it can be such a difficult position to fill. I know that's why we snapped up Donna Richards when she, quite literally, landed on our doorstep.

Donna had brought her mother into our office one morning for an appointment and happened to ask one of my colleagues if we needed an office manager. She had recently returned to Rhode Island after fifteen years in California to take care of her parents and needed a job. Talk about synchronicity.

During the three years we worked together, Donna and I would often chat long after my patients and the rest of the staff had gone home. We would sit together in my office as we finished up paperwork. She'd ask me about my newborn son, offering the kind of parenting advice you couldn't find in any medical manual. In turn, I'd ask her about the balancing act she performed every day as a single working mother with the added responsibilities of caring for a parent with dementia. It was during those evening talks that I first saw the complexities of dementia care through the eyes of a friend. Donna opened up to me about the compromises she made in leaving her career to return home to take care of her mother. She spoke of the difficulties of navigating the health care system--one that she knew well from her days as a senior health care executive--to ensure that her mother had high-quality care. It was Donna who introduced me to the term "sandwich generation," and it was from her that I began to really understand what it's like for the millions of Americans caught between raising kids and caring for elderly family.

Now I hoped she could help me once more by giving me some much-needed perspective on Oscar. But first we had to catch up. It had been two years since Donna left our office for another job and over a year since her mother had passed away with Oscar by her side. We had a lot of ground to cover.

"
IN THE WEEKS AFTER
my mother died I would wake up in a cold sweat." I was sitting with Donna in her suburban home outside of Providence. "My mother would come to me in my dreams," she continued. "She was younger, the way I remember her from my childhood, and she would look up at and accuse me: 'I wanted to go to the hospital but you didn't let me...If you had just sent me to the hospital.'"

Donna looked up at a far-off corner of the ceiling, as if the movement itself would keep her from crying. She took a drag off her cigarette and let the smoke waft up through the air.

"David, I know how much you hate my smoking," she said with a smile.

I rolled my eyes but said nothing. It's not my place to come into someone's home and tell them to stop smoking. I do that enough in the office.

Donna considered the cigarette again and then stamped it out in the ashtray. "After one of those dreams I would sit in bed for hours, trying to talk myself out of what she had said. I knew she didn't like the nursing home, or at least she didn't like it when she could still process things. You have to realize, putting her in the home was the hardest decision of my life, but I really had no other choice. I was a single mom trying to provide for my son as best I could. I just couldn't take care of her at home anymore. She had that dementia with Lewy bodies and her decline was just so quick."

Aside from neurologists, geriatricians, and psychiatrists, few people are familiar with Lewy body dementia (LBD). Though it's likely the second most common cause of dementia, LBD is frequently underdiagnosed because of its similarities to Parkinson's and Alzheimer's diseases. As with Parkinson's, LBD involves a movement disorder: Those afflicted become rigid and unsteady on their feet. They frequently suffer from psychotic symptoms such as hallucinations, sleep disturbances, and significant behavioral changes--as well as an extreme sensitivity and intolerance to the antipsychotic medications that are often mistakenly prescribed for the hallucinations. This behavioral component of the disease makes caring for patients with LBD especially difficult.

"It was like one minute, my mother was fine, and the next month she was lost. She just wasn't herself anymore. We took her to the best doctors, the best specialists, and they would give her pill after pill. She must have tried them all at one point. The doctors thought she was depressed, so they gave her antidepressants. She couldn't sleep, so they gave her sleeping pills. Her memory failed, so they gave her a memory pill. The more medications they gave her, the worse she got. Eventually, things got so out of hand that your colleague finally admitted her to a psychiatric hospital just to wean her off the medications. Turns out, they probably were just making it worse."

She shook her head at the irony of it all. "Kind of strange that we had to admit her to a hospital to get her
off
medications."

It's actually not so strange. Over one-quarter of hospitalizations today result from the collective effects of overmedication. The fact is that all medications, even herbal and over-the-counter drugs, are potentially dangerous in certain clinical situations. Elderly patients today are exposed to more and more medications all the time.

"When she got out of the hospital," Donna continued, "it was obvious that she couldn't come home. From that point on she went from one nursing home to another. What an eyeopener that was!

"When my mother was in the first nursing home, I got a phone call from the nurse at the facility telling me they were sending her to the emergency room for evaluation. I asked them why and she told me that, at eighty-four years of age, my mother had hit an aide while they were trying to change her. Now, my mom was feisty, but she never would have done this if it wasn't for her disease. I rushed off to the ER and they did the workup. The doctors ended up finding nothing, but when they tried to get her back to the facility, the nursing home refused to take her. In the end, my mother stayed in the emergency room for three days while we tried to find a place for her to go."

Donna got up from her chair and walked nervously around her kitchen.

"You know, David, this is what really gets me. It was like no one in the hospital really cared where my mother ended up. They just wanted to get her out of the ER as soon as possible. I had to fight tooth and nail; finally, I was able to pull strings and get my mother into a nursing home like Steere House. To this day, I know that the only reason they took my mother was because I knew all of the doctors who worked there. Imagine if I hadn't had those connections or hadn't known how to find information about those different nursing homes? The whole system is just plain bad."

Donna became quiet. The memories washed over her and again tears came to her eyes. This time she let them flow.

"Sometimes, when I think about those days, I don't know how I did it. I had a plan every day that was minute-to-minute; I had to have a strategy just to be able to work, care for my son, and be there for my mother."

"That must have been hard on you."

Donna looked at me as if I'd just said something like "It must snow a lot in New England in the winter."

"David, unless you go through it, you truly have no idea. I had no life for myself."

In anyone else this might have seemed like self-pity. With Donna it was just the facts.

"I had no life, but that wasn't so bad. I could deal with that. I understood that this was my cross to bear. The worst part was the guilt about not being there for someone else. When I would miss my son's swimming meet because something was going on with my mom, I would feel terrible. When I would go to the swimming meet, I would feel guilty that I was not visiting my mother. Sometimes when I left Steere House, I would feel so guilty about putting my mother in the nursing home that I would drive home crying the whole way. 'Good Italians' are not supposed to put their parents into nursing homes."

Donna managed a halfhearted smile and shrugged her shoulders.

"In the end, I guess I didn't have a choice. I just did the best I could."

She looked at me and I could tell that we had gone as far as she intended to go.

"Doesn't stop the guilt, though?" I asked.

"It never really goes away. And those dreams..."

WE TALKED
for another two hours, about everything from her job to her social life as a single parent, and then I told her about the recent birth of my daughter. Eventually I glanced at my watch and realized how late it had become. I got up off the kitchen stool and began to gather my things.

"Wait!" Donna said. She looked at me with the hint of a smile. "You came here wanting to find out about Oscar and you almost left without asking me."

"I guess our conversation seemed to go in a different direction," I said. "Or maybe I'm not as open to the idea of Oscar as I thought I was."

She laughed and gestured for me to sit down again.

"So, Ms. Richards," I said, putting on my best reporter's voice, "what do you think about our four-legged friend, Oscar?"

Donna laughed and gave me her
Oh brother!
look, an expression I hadn't seen since we worked together.

"First off, my mother hated cats! Earlier in her life, I would have half expected her to poison Oscar had he jumped on her bed. It wasn't just cats. My mother really didn't like animals, period. Didn't see the point of them. Yet, as she got worse and worse with the dementia, she seemed to take more comfort from the animals on the unit. I don't know what it was about them, or about the changes in my mother, but something really had changed. It was like she was more receptive on some deeper level. Does that sound strange?"

"Not at all. In fact, lately I've been wondering a lot about the true nature of our connection with animals, especially when we're very young and very old. My son has always been drawn to animals, even before he could talk. I've seen that same intense curiosity with some of my patients, too. It's as if the relationship somehow transcends language. I'm just now learning how smart animals are."

"Well, Oscar was smart. That much I'll say. He generally kept a safe distance and left my mother alone, but when he'd wander by and she would stop to talk to him, well, he stopped too. He never stayed long and he never cuddled up to her--Oscar was more like a visiting dignitary than a house cat--but he always stopped as if to hear her out."

Visiting dignitary indeed.

"What did you think of the animals at Steere House?"

"Well, in a way, it was strangely comforting. A distraction of sorts. I mean, it didn't change the fact that my mother was in the nursing home, but it did make her surroundings a little more bearable. More like
home
than
a home,
you know? In a way, I think the presence of the animals also helped my son."

"What do you mean?"

"Well, nursing homes are not easy places for kids. Sometimes he'd come up to the floor and go off in search of the cats. It was better for him, playing with Billy or Munchie on the first floor rather than sitting in a straight-backed chair swinging his legs. And it would give me a little more time to spend with my mother."

"Was Oscar there at the end?"

"Absolutely. When my mother got sick for the last time, Oscar spent more and more time in the room with me. It was as if he knew I needed the support. It was truly bizarre. He seemed to warm toward me. More than that...he seemed to understand."

Donna gauged the look on my face and continued.

"Well, I was at the bedside for pretty much the last seventy-two hours of my mother's life. I even slept in the recliner next to her during that time. When I would try to rest, Oscar would wander into the room and snuggle up next to me. Then he would jump over from my chair to my mother's bed and sit down beside her. He did that for pretty much the entire time that my mother was dying.

"The thing I can't get over is that Oscar always seemed to know when he was needed, and he never seemed to want anything in return. Oh, he'd let me stroke under his chin and rub his little ears, but even that--well, it was as if he knew that it was helping me. Which it did. There's something really calming about petting a cat..."

"Was he there when she died?"

"A few hours before my mother died, one of the nurses came to talk with me and convinced me to go home for a little bit. I wasn't sure if it was a good idea, but the nurse persuaded me to go. Sure enough, my mother died shortly after I left. Oscar never left, though. He was there when she drew her last breath."

"Were you upset that you left before she died?"

"No. Quite honestly, my mother probably waited for me to leave before she let go. That was just her style."

Donna smiled.

"Besides," she said, "she wasn't alone. My mother had Oscar."