Chapter 2: April 2010

Solomon turned his alarm off at its first ring and slowly sat up. He turned on his bedside lamp, then tossed a medical journal onto the nightstand from where it had lay splayed across his chest all night. He gingerly moved out of bed and yawned as he reached for a neatly folded pair of sweatpants from the topmost dresser drawer and slipped them on over his black silk boxers and a plain white t-shirt, then moved to his kitchen where he opened a granola bar and ate it as he walked towards the door. He slipped his feet into a pair of clean black running shoes that stood near the door and walked out the door to the elevator, which was just across the hall from his apartment. While in the elevator, he pulled his iPod out of his sweatpants pocket and started the New England Journal podcast, carefully placing the bright white earbuds in his ears.

The elevator came to a stop, wherein the doors opened and a young woman dressed similarly to him– sweatpants, a t-shirt, sneakers, and earbuds– walked in. Her shiny black hair was tied into a clumsy-looking ponytail and her olive skin was dotted with tiny red studs of acne, which Solomon always noticed in their building but never at work. She grinned at Solomon, who nodded hello. They both removed their earbuds.

“A little late this morning?” she said playfully, her voice going up at the last part of her sentence. “You’re always down there already when I arrive.”

“I was the attending on service last week,” he explained..

“Saturday and Sunday too?” she asked.

He nodded.

“No wonder you didn’t respond to my text yesterday. Still coming down for your workout?”

“Not a full one,” he said. “I’ve gotta cut myself a break every now and then.”

“I see. That’s why I’m running into you at seven and not six. When I cover the weekend I always take Monday off,” she admitted.

“I know. “ He smiled. “I could never do that. Too much to do.”

She chuckled. “Speaking of which… you’re taking Adam’s sample today?”

“I am.”

“Good,” she said. “I saw him yesterday. Not doing so hot. I hope this works.”

“It will.” He did not hesitate, nor did his words carry any irony.

“Well, then, in that case let me help you out some more,” she said.

“You have another patient to send me?” he asked cheerfully.

“I do! Perfect for your protocol. 45 years old, longtime alcoholic. Bad cirrhosis. He’s got varices but nothing else.”

“One of your outpatients?”

“Picked him up after he got admitted two weeks ago. A resident is following him in the family medicine clinic. She precepted with me and when I went in to see him with her, I suggested your research.”

“Does he have a liver MRI?” asked Solomon.

“Uh… no.”

He smiled. “Dr. Chambliss, if you had paid attention to my lecture, you would know that no one qualifies for my protocol without a liver MRI.”

She put her hands on her hips smartly. “Okay. Because you surgeons wouldn’t cut open an abscess without imaging it first.” She grinned.

“Some of the residents might,” he admitted.

“I heard that happened last week,” said Rita.

“You’re damn right it did. One of your family medicine residents called one of my surgical residents to open a damn abscess on someone’s head.” The elevator stopped and the doors opened. “…and my resident graciously asked for an ultrasound. And your resident gave him a piece of her mind about wasting valuable resources on an unnecessary scan. Why couldn’t she just open it herself? She’s a doctor, too, I’m sure. A second year, if I recall correctly.”

They began walking towards the gym, a long room encased in glass on either side with mirrors running along either wall. There were a few people scattered throughout running on treadmills but it was mostly quiet.

“Liability,” explained Rita. “Dr. Oneida doesn’t do any procedures in the hospital. Always calls a consult. If there’s an abscess, the team is calling surgery. The resident didn’t really want to do it, but she was kind of forced to. And your resident was just absolutely enthusiastic to be doing a simple abscess drainage.”

“He also foolishly asked for an ultrasound sight unseen. Dr. Patel told me about it briefly the other day.”

“Well, there you go.”

“There we go indeed. These residents, I tell you what.”

“We were all there ourselves, Solomon,” she said with a smile. “I remember a few turf wars with you back in the day.”

He chuckled. “You were ruthless. You could talk my interns into admitting or transferring any patient you didn’t like. I still don’t understand how you did it.”

“Oh, you know. I just know how to talk.”

“You certainly do,” he affirmed.

By this time they had both climbed onto treadmills next to one another and started running. Solomon put his earbuds in first and turned on his podcast, and after a moment Rita did the same, although she did so with more hesitation. He ran for exactly thirty minutes, varying his speed a small amount but mostly maintaining an eight-minute mile. He heard two endocrinologists talking about a gene receptor that was upregulated in hypothyroidism, a thickly accented African doctor describe the first issue of the Ghanaian Journal of Medicine & Surgery, and a dry academic talking about a new movement in Maryland to pass some sort of health care reform. He slowed the treadmill down and quickly dismounted just as the podcast ended. He wondered if he should say something else to Rita on his way out the door, as she had been especially friendly with him lately in a way that he found himself enjoying, even if he was a little overwhelmed by it and didn’t want something encroaching on his work.  He decided to simply nod to her as he walked past her towards the door, able to hear the thumping beat from her earbuds as he passed.

“Will you come get a drink with me sometime this week?” she responded as soon as he made eye contact, taking out one earbud quickly. “There’s a great place in Harbor East that serves the best Diet Coke you’ll ever try.”

Solomon smiled nice and big, the way that he often did with his patients. “Of course, Rita.”

She smiled back, which he tried to savor as he went back up the elevator, walked back into his room, and took a shower. Within moments of the elevator door closing, his mind again began whirring with all of the tasks he had to do today, and by the time that he had showered and eaten some oatmeal Rita was as far from his mind as the Ghanaian Journal of Medicine & Surgery. He dressed himself in a neat, two-button black suit with a forest green tie and checked his small leather bag to ensure that his wallet and keys were still inside of it before leaving his apartment again.

He rode the elevator back down to the first floor and walked out to Washington Boulevard, where a long line to get into Camden Yards was already forming. There was a preseason game between the Orioles and the Yankees, and while the Orioles had only a few diehard fans in Baltimore that would be interested in a preseason game, the Yankees had innumerable enemies in this city. He noted several Red Sox jerseys in the crowd and chuckled to himself as he walked past the hot dog vendors and gaudy orange t-shirt stands. His building, on this side of the street, was simply an enormous wall of glass curving with the street and facing the stadium. His neighbors across the hall could easily see the games from their window, while he could only see the sprawling University of Maryland Medical Center campus from his.

He walked confidently and quickly to the main hospital and passed through the main atrium, a ten-story brick facade with hallways enclosed in glass on the opposite side. When the hospital had been renovated and a whole new building added, the old building’s brick wall had simply been left up and those patient rooms turned into offices; the new atrium and patient rooms were added on to create an enormous open space where every faction of humanity in and around Baltimore was represented: lost-looking suburbanites coming for specialty care, doctors and nurses all varieties walking to and fro, large black families from West Baltimore traveling as a group to a single appointment, and various hospital support staff trying to appear cheerful and direct people to whatever they were looking for.

Solomon strode up three flights of stairs effortlessly and turned down a few hallways to his office. He unlocked a plain pine door and turned on the lights. His office was small and neat, located within a small suite on the third floor of the hospital that was helpfully marked, “Division of Transplant and Vascular Surgery.” There was a small wooden desk that had an ordered stack of journals on one side of the computer and a few papers laid out in a square on the other. A single black lamp and a worn black swivel chair– which he had used since his days in fellowship– stood next to each other. Solomon rested in it for a moment before shaking his mouse briefly to awaken the computer from its weekend slumber.

Solomon rubbed his eyes and looked back at his computer. His inbox occupied his entire screen and, as often was the case after a week of being the attending on the transplant service, every subject line was bolded. There were numerous red exclamation points and he noticed the phrase “Did you get…” pop up a couple of times.

He looked at his watch. 8:25AM.

“I need some work hour restrictions,” he muttered to himself. He quickly opened three or four of the most urgent appearing e-mails and dashed off several one-line responses, though being careful to properly capitalize his words and be as clear as possible. Most of the time, this was, “Sorry I didn’t get back to you right away. I was on service this week. Will respond tonight.”

Once he had completed his five minutes of electronic triage, he pushed himself away from his desk and got up. He picked his clean white coat off a hook on the door and threw it on as he walked quickly down the hall. He turned a corner into and went down a flight of stairs, then down a long hallway with glass along the right wall exposing the atrium. He entered the radiology suite and passed by several dark rooms filled with enormous machines that hummed as various body parts were exposed and then bombarded with radiation to reveal their secrets. He entered the ultrasound suite, where a young man was lying on a table in the center of the room with his belly exposed and a white sheet tucked into his pants.

“Adam!” exclaimed Solomon. “It’s good to see you!”

“Dr. Bode,” said Adam with a smile. He had well-maintained dreadlocks falling to his shoulders and big, bright eyes that had only a mild hint of yellow discoloration. His face transitioned from mild worry to enthusiasm when he saw Solomon, which was something that Solomon had proudly become accustomed to. He walked over and shook Adam’s hand.

“How are you feeling?” he asked.

“Okay,” answered Adam, his face turning somewhat dour again. “Lots of nausea. My gums were bleeding this morning, too, when I brushed my teeth.”

“Can’t have that,” said Solomon. “What was your INR yesterday?”

“Dr. Chambliss said it was 1.7.”

“Hmmm.” Solomon crossed his arms briefly in thought.

A tall, lanky man arose from the corner where he had been sitting and extending his hand to Solomon, who shook it firmly.

“Kofi. It’s good to see you.”

“It’s good to see you, too, Dr. Bode,” he replied in a thick West African accent, letting each of his o’s sink down low and long. “Tell me, will you still do the biopsy with his INR this high?”

“I’d prefer it to be 1.5 or below so he doesn’t bleed. Obviously, sticking a needle into his liver is a little riskier when he’s coagulopathic like this.”

“But we must get the sample!” exclaimed Kofi.

“Don’t worry,” replied Solomon quickly. “We’ll still get the sample. We’ll just be very careful.” He allowed his hand to rest confidently on Adam’s shoulder.

“I trust you,” responded Adam.

“Then it’s settled!” said Solomon. “Let’s get started. I have to do this for six other patients this morning, so we’d better get going.”

He greeted the radiologist and the radiology tech who were going to be helping him, then removed his white coat and jacket before drawing wide circles on Adam’s abdomen with iodine. He laid a small drape with an opening in the center over the area that he had cleaned after putting on sterile gloves. The tech, who was also in sterile gloves, gently placed an ultrasound probe over Adam’s right side, just below his ribcage. A black and white image appeared on the ultrasound screen that was almost entirely incomprehensible to Adam and his father but instantly recognizable by Solomon. Sound waves that were fired from the probe bounced off Adam’s organs and reflected back to be interpreted and displayed on the screen, with denser portions turning lighter and darker spaces representing the less dense parts. He turned to a table next to the bed and started drawing a clear liquid from a small vial into a syringe.

“How’s school been?” asked Solomon as he placed his hand over the tech’s to find the angle he wanted.

“Oh, not too bad. I’m up to full-time this semester– 12 credits.” Adam’s accent was nearly indistinguishable compared to his father’s; he spoke emphatically and quietly but without the strong vowels. Solomon tried to remember what Adam was studying because he had asked him several times before, but couldn’t bring it back.

“Great!” he said. “Do you still expect to graduate on time? I know that you had to drop out of two classes last semester when you got sick.”

“Yeah, we’ll see how it goes. Fix my liver and I can take more credits next semester.”.

“You got it.” Solomon answered without hesitation. ”This is Adam Freeman, and we are performing a liver biopsy on his right upper quadrant. May I see your wristband?”

Adam held out his wrist for the sake of the perfunctory time out required before every invasive procedure and blood draw. Solomon still found it absolutely incomprehensible that anyone would ever replace the wrong knee or take out the wrong person’s gallbladder, but he didn’t mind a double-check for safety. After he examined Adam’s name and date of birth and found them to be accurate, he then gently inserted the needle in the center of his iodine bullseye over Adam’s liver. “This will just sting a little. Just some anesthetic.”

Adam grimaced slightly but then breathed deeply and relaxed as he demonstrated the nonchalance that most of Solomon’s patients acquired towards the pain and discomfort that attended a chronic medical condition requiring frequent testing and treatment. Each incident was no less unpleasant, but when there were regular injections, foul-tasting medicines, and innumerable blood draws, the bodies under his care had no recourse but to simply let it happen when their normal protective instincts were routinely violated. The ultrasound machine was by Adam’s head, but he could easily turn just a little to see the long white needle piercing his skin on the image and then slowly withdraw.

“What classes are you taking this semester?” asked Solomon.

“English Lit. Statistics.. Biology 301. And a business class.”

His father jumped in almost as soon as Adam had spoken. “He is still doing very well in his pre-med classes. He will be a doctor like you.”

Solomon smiled. “Well, if you decide to become a doctor like me, let me know. I could use someone to split the work with.”

They all laughed, and Adam for a moment forgot entirely about the much larger needle that Dr. Bode had in his hand.

“This one’s for the actual biopsy,” he explained.

“I don’t remember the last one being so big,” said Adam, trying to make a joke but not getting any laughs in response mostly because of the sympathy that his comment elicited. Solomon took a look at the needle himself as if to check, then shook his head.

“About the same. I’m sorry,” he offered. He was quite used to apologizing for things that he was about to do or had done that he had absolutely no regrets about, and this time was no different. He only meant to convey sympathy for the pain that he had necessarily inflicted to help his patients get better, and this time he was yet again successful. He took the syringe in one hand and steadied the needle with his other hand against Adam’s skin.

“Here goes.”

Adam did not react as the needle entered this time, watching with curiosity as it traveled deeper and deeper towards his liver. Solomon watched the image on the screen twitch as he moved his instrument beyond the reach of his anesthetic, eliciting visceral pain. This was not Adam’s first biopsy, but it was still clearly an unpleasant experience. Solomon worked with absolute confidence, his left hand drawing back on the syringe as his right hand guided the needle. Adam’s discomfort never left his mind, but he did not allow it to slow him down by a second.

The syringe quickly filled with thick, dark material and Adam winced. He closed his eyes and then relaxed as he felt the needle come out

“Done.” Solomon sighed and quickly placed a large piece of gauze where his needle had been, holding it tightly against the skin to stop the bleeding.

“Ow.”

“I’m sorry. It’ll be a little more involved putting it back inside of you.”

“What are you going to do then?” asked Adam.

“Well, like we explained when you signed the research consent, we’ll cut into your abdomen and seed the treated cells inside your liver in a few crucial places. Then we’ll wait and see if they regrow.”

“Okay.”

Solomon removed the needle and carefully placed a cap on the syringe full of Adam’s liver cells with one hand, holding the gauze tight the whole time. Blood was already starting to soak through.

“It’s just…”

Solomon looked up from his syringe to Adam’s face. He was clearly more worried now than he had been before the procedure, for the pain of the biopsy had been brief and would pass, but now there were weeks of waiting until the new liver cells were introduced and then weeks of waiting after that to see if they’d work.

“I just… have been through so much already. Steroids, chemotherapy, herbal medicines. My dad took me to Saint Louis, back home to Africa, you name it. I’ve done three experimental treatments already.”

“Hold this for me, Adam,” said Solomon, gesturing to the gauze. Adam moved his hand to his wound. “Hold it firm.”

Solomon removed his gloves and took a chair from the corner, arranging it to face Adam and his father.

“Kofi, how long have you been working for Verilife?” he asked.

“Ten years,” replied Kofi.

“And tell me, Kofi, you’re the CFO. What was your gross profit last year?”

Kofi did not seem surprised by the rather blunt question, although Adam and the radiology tech, still gathered round, were. He responded quickly. “53.2 million dollars.” He stretched out the word “million.”

Solomon nodded. “And how much funding has been put into Hepatolife over the last five years, including the human trials in Ghana?”

“10 million dollars,” answered Kofi. “Give or take a little.”

“And that doesn’t count the 30 million in NIH and state grants that I’ve gotten for the initial work, before you guys picked it up.”

“Yes,” said Kofi.

“Would you have invested 10 million dollars in something if you didn’t think it would work?”

Kofi shook his head. “Never.”

Solomon turned to Adam. “Your father’s company is cunning. They know how to pick winners. That’s part of how they found me. That’s why they’re funding me. They bet 10 million that it’ll work. It worked in 90% of the mice in the lab we tested it on.”

“But I’m no mouse,” protested Adam.

“No, you’re not,” said Solomon. “Because you won’t just be alive a little longer with a new liver. You will thrive.”

With that, he lifted the gauze a little, and, seeing that there was no more bleeding, placed a clean gauze pad over the same area and taped it securely.

“It may ooze a little bit for a day,” he warned. “Call me if it doesn’t stop bleeding, your pain doesn’t go away, or you have a fever.”

“Of course,” said Kofi.

“Thank you,” said Adam.

“Thank you.” Solomon turned towards the door. “I couldn’t do this without you.”

With that, he put his jacket and white coat back on and strode out of the room.

 

***

 

Jessi took a cigarette from her pack and placed it between her lips. She took a seat on her front stoop as she fished for her lighter in her back pocket and laid the packet on the dirty marble. The familiar smell of dry tobacco gave her relief, even though it had not yet started to burn. She raised her lighter to just below the cigarette’s tip and struck once unsuccessfully.

The cigarette disappeared from her mouth.

“Grandma! No smoking!”

She reached out a hand instinctively to swat at Jamie, who was already outside of her reach and running down the street with the lighter in his hand. She rose and opened her mouth to cuss him, but hesitated as soon as she stood up. As she sat back down. Jaquan pulled up in front of her on his tricycle and pointed a chubby finger up at her face.

“No smoke, Gamma.”

Jessie couldn’t help but giggle and shake her head at the two-year-old’s authoritative tone that mimicked the one she’d already used on him several times today.

“Oh, honey, don’t you start on me, too. Bad enough your brother’s busting my a– bottom. Bustin’ my bottom. Help me, Lord.”

She instinctively reached for her pack of cigarettes again, but let them fall to the marble as she walked down the stairs. Jaquan had already made it halfway down the block where a few other kids were gathered, tossing around a half-deflated football in the open field where several vacant houses had been cleared years ago. A clump of dirt pushed into a pile as tall as her that was now sprouting weeds and shrubs was the only physical evidence remaining of a promise she had once heard from someone at the Parks and Rec department to build a playground there. She heard the children giggle as her cigarette was ceremonially destroyed, torn by at least twenty-five little kindergarten-size fingers.

“Mommy coming?” asked Jaquan.

“I don’t know where your mother at,” said Jessi. “She ain’t called me. Maybe she outta minutes. But she knows I ain’t been to the supermarket and I’m not about to haul you all the way down to Pennsylvania Avenue to buy some chicken nuggets.”

She looked up the street to the decrepit parking lot and the shuttered Stop Shop N Save at the corner of Monroe and Presstman. She shook her head again and reached down for her pack of cigarettes. Fingering each one individually, she let herself smell the tobacco again before resolving that she would not smoke another one until the boys were gone.

Jaquan continued to pedal on his tricycle towards the older boys, who were all wrestling over the ball. Jamie’s lanky frame stood out as his legs kicked in the air out from the pile-up. Jessi smiled as she thought about his pluck and heart in snatching her cigarette away. He rolled away from the other boys, football clutched tightly in his arms, and squealed as he hopped to his feet and began running in the other direction from them.

A horn beeped from behind her. Jessi turned and saw a dull red Acura pull up next to the house. Her daughter Tanisha sat inside, looking at her phone as she put the car in park. Jaquan circled his trike on the sidewalk to turn around. “Mommy!”

Tanisha emerged from the car and put her phone in her pocket as she walked to the curb. Her long braids tied falling evenly on her starched white uniform and a small gold badge dangled precariously from the left side of her enormous bosom. Jessi noticed that her usually striking features– large, full lips and round, soft brown eyes were more accentuated than usual with lipstick and mascara.

“Sorry I’m late, Ma. They kept me after for a meetin’.”

Jessi gave her a hug. “It’s okay, they was just gettin’ hungry. How you doin’? Your day alright?”

“Yeah, it was fine. They been changin’ my shifts all around. I don’t know if they tryin’ to get me to quit or what, but it’s crazy.”

“I’m sorry, honey. At least you got a job. Gotta be thankful for that.”

“You know I am, Just give thanks every day for every breath, like you always used to say. Ma. Anyway, the boys behave for you?”

Jessi chuckled and shook her head. “Jamie done stole my cigarette outta my hand as I was gonna light it.”

Tanisha’s mouth dropped open. “Get out! Someone at his school said something about smoking the other day and he been goin’ on and on about how bad cigarettes is ever since. That is– it’s just so disrespectful. I’m gonna have to whoop his–”

“No, no, no, don’t do that! I needed the reminder. I’m gonna quit.”

“You know you got to.”

“One of these days when I ain’t so stressed all the time.”

Tanisha snorted. “When’s that gonna be?”

“I dunno. When the Lord takes me home.”

“Don’t talk like that, Ma! I need you to be strong for me. We need you.” Tanisha gestured towards Jamie and Jaquan, who were making their way up the sidewalk. Jessi fingered her pack of cigarettes again and sighed. Jaquan’s chubby torso wobbled as he loped towards them, while Jamie strode up with eager confidence.

“I know, I know. Didn’t mean it like that. Just don’t see anything changing any time soon.”

“What about Uncle G? He gonna get a job one of these days, or just watch TV on your couch forever?”

“He made me his payee for his SSI check, so he doin’ his part for the family. He ain’t had a sip o’ alcohol since they started testin’ his urine. Plus he gets his surgery next week to try to fix his liver, and they tell me he gets reimbursed whether he live or die. So you know that’s how I’m fixing the toilet that leaks into the kitchen.”

Tanisha raised her eyebrows. “Well, then. I guess he can lay on your couch as long as he damn well pleases.”

“Shhh!” Jessi raised her finger to her mouth. “Not around the boys. Tryin’ to get them out of our bad habits.”

“Sorry,” murmured Tanisha as she scooped Jaquan into her arms and hugged him tightly. Jamie embraced one of her thighs with the same enthusiasm.

“You wanna come in?” asked Jessi.

“Nah, I should get some dinner and take the kids home.” Tanisha pulled her phone out of her pocket and started furiously typing her with free hand as she shifted Jaquan to her other arm.

“Let’s stop at McDonalds!” ejaculated Jamie.

“Okay, sure,” replied Tanisha absentmindedly.

“Who you talkin’ to?”

“Oh, nobody.”

“Nobody ain’t gonna write you back that fast.” Jessi’s eyes narrowed.

“Just some guy at work.”

“Oh?”

“Ma, we just talking. Ain’t nothin’ else at the moment.” Tanisha looked up briefly from her phone, then back down.

“Were you gonna mention him to me at some point?”

“Yeah.”

“How long you two been  just talking?”

“Just a week or two, Ma! Give me a break, please. I’m a grown woman.”

“You may be a grown woman, but up until a year ago you was still foolin’ around with that crackhead Marcus.”

Tanisha rolled her eyes and set Jaquan down. “I don’t appreciate you talkin’ about the boys’ father like that while they around. We wasn’t even doin’ anything a year ago. He was just tryin’ to see them and spend some time before he got sent away.”

Jessi stared more intently at her daughter, cocking her head downward with suspicion.

“Aw, Ma, it was just that one time. And that’s the troof.”

“If you say so.” Jessi reached down to give Jamie a hug.

“Thanks, Grandma,” he said. “I love you. I’m sorry I took your cigarette.”

“Love you too, boy. It ain’t no problem. I’m gonna quit soon, don’t you worry.”

She pushed up on her thighs, feeling a twinge of pain in her back as she came up. Tanisha had finally put her phone anyway.

“Anyway, this new guy ain’t never touched drugs in his life. He’s in school, too. He says he wanna take me back to church.”

“Well then.” Jessi reared her head up in mock pride. “I’ll have to meet Mr. Straight-and-Narrow when I get the chance.”

“He’s already asked about meeting you,” said Tenisha, her tone matching Jessi’s in terseness. She raised her eyebrows.

Jessi smiled and extended her arms to hug. “Alright, you just be careful. Hear?”

Tanisha leaned into her mother, clutching her shoulder. “You know I will be. We been workin’ too hard to be careless.”

She kept her hands on Jessi’s shoulder as their torsos parted. “You want me to give you a ride to work? I know Saturday night into Sunday ain’t easy.”

“Naw, I’ll take the bus. You know you gotta get these two to bed and I gotta make sure Gainers take his evening meds.”

Tanisha held Jaquan up for a good-bye kiss before buckling him into his car seat, whilst shouting at Jamie to do the same. Jessi climbed back up her front stair and watched the Acura pull away down the street, past the neighbor children from around the block. They were clearly making the most of the vacant lot despite any failed promises from the Parks and Rec department.

She reached into her pocket and took out another cigarette. She lit it before she could realize what she was doing and took one long draw, letting the nicotine fill her lungs. She needed something to help her stay awake for her 12-hour shift tonight. She took the cigarette out of her mouth and stared at it, watching the gray-white smoke rise into the air. The sun was just about to disappear behind the Stop Shop and Save, casting an orange glow across the weed-strewn parking lot. She exhaled westward.

“Jessi! Dinner ready?” called Gainers from inside.

“I dunno, did you cook it yet?” replied Jessi with a snort.

She held the cigarette to her lips again, then paused. The smoke floated into her eyes.

“Huh?”

Jessi laughed under her breath and threw the cigarette into the street.

 

***

 

Hannah dramatically dropped her folder onto the table in front of her, making a satisfying sound as it hit the thick wood. Thwap! She let out an exhausted sigh as she visually examined the stack of papers and noted that it was easily three inches high.

“All of this. By Monday,” she said. “We have to somehow be familiar with all of these notes.”

“Yup. All of this,” said her classmate Pooja. “But just think! Only two more tests in second year. And then Step 1! And then we’re third years!”

“Have you seen any third years lately?” asked Hannah. “They don’t seem to spend much time outside of the hospital.”

“Oh yeah,” said Pooja. “One of my roommates is a fourth year, so she’s seen it all. There are some ups and downs, but she says it’s way better than studying all the time. Some rotations you’re there from 5:30 in the morning ‘til 7 at night, but others you show up at 9 and leave at 4. It really all depends.”

“What did she say about Step 1?” asked Hannah, referring to the nationally standardized test that all of her classmates were dreading at the end of their preclinical years this spring.

“Well, she said you just kinda have to get through it. She said no one really asked her much about it on her interviews for residency. Just study every day for six weeks and you’ll be fine.”

“I guess that six weeks of studying all day every day isn’t too bad when you realize that we’ve been studying all day every day for nearly 2 years,” observed Hannah. “I just feel like there’s a lot of pressure to do really well on Step 1.”

“Like she said, it’s not that big of a deal. You just have to get a decent score. And if you’ve done well on tests in school, then usually Step 1 isn’t too hard.”

Hannah sighed. “You’re right, you’re right. At least… that’s what they say. Let’s get started. Tell me about brain tumors.”

“Uh…” Pooja’s face demonstrated some uncomfortability. “Why don’t you tell me first what you remember?”

“I don’t remember anything from class,” said Hannah. “I was up late last night working on something for Dr. Bode and kinda fell asleep in class.”

“Oh. I was up late last night watching TV and kinda fell asleep in class too.”

They both laughed. “I guess we could call this study group ‘swimmers drowning together.’ Seriously, though, I must be getting old. I used to be able to do this all the time in undergrad.”

“Do what?” asked Pooja. “Stay up late, go to class the next morning, and get straight A’s?”

“Yeah,” nodded Hannah. “That.”

“Well, it’s just a lot more material to learn,” said Pooja. “Plus, that research thing seems to suck up a lot of your time. Did you decide about taking a year off?”

“Yeah, I did. I am going to take a year off to keep up with the research. I’ve been doing it since I was a sophomore at UMBC and this is the year that really makes or breaks the project. The phase II clinical trial. It’ll be halfway over when the year starts, but exciting things are happening.”

“Remind me again what phase II clinical trial means. That was at least three tests ago.” Pooja, like most of Hannah’s classmates, found it hard to think outside of the test cycle during the school year,

Hannah giggled. “Um, it just means that we’re trying it out in humans to see if it works at all. There was a stage I clinical trial for safety in Ghana a few years ago where we gave the drug to people to make sure that it didn’t make their toes fall off or anything like that. We were surprised– just some nausea, headaches, rashes– nothing too crazy. Even 3 years out, there haven’t been any significant negative effects. Now we’ve got ten patients enrolled and they actually have bad liver disease, and we’ll see if they get better or not.”

“That’s crazy,” remarked Pooja. “And who, like, verifies all this? Is there anyone double-checking what you do?”

“Yeah, the sponsoring institution,” explained Hannah. “So for us, that was the University of Maryland. There’s something called the Institutional Review Board, and they require that you fill out a bunch of forms explaining everything that you’ve done and how you get paid and what your relationship to the people who are making the drug is. They had to review all of our methods to make sure that we were doing things properly in our clinical trial before we could move on to the next stage and test it in people who are actually sick.”

“And do you think they’ll get better?”

“Yeah,” said Hannah. “I watched it happen in mice back when I was an undergrad, so I’m pretty excited to see how it turns out.”

“And you said it was in Ghana– don’t you have some connection there, too?”

“Yeah, I started an NGO in college after I went on a few short-term trips and wanted to create something a little more sustainable. There’s a little medical clinic there in a rural area along the Volta River staffed by a nurse practitioner and a doctor comes to visit every few months. They do community health projects, vaccine campaigns, that kinda stuff. Someone local runs it now, but I still go back when I can.”

“Wow!” exclaimed Pooja. “You really have done a lot of cool stuff. Do you want to keep working in Ghana?”

“I’m not sure,” said Hannah. “Back in college, I wanted to go to med school and become a doctor so I could go back and be in the community there. But then I got involved with this research project and it kinda took over my life. And the lives of all the people in that community. And spending all this time with these transplant surgeons– they’re pretty cool people. I could never give up my advocacy stuff, but I really like surgery. And I really like being at a place where you have a lot of technology at your disposal. It’s hard to know what helps people the best– just sending some money from another country so local people can keep working, or being there and doing it yourself. Plus, it would take a lot of work and a lot of money to do anything surgical in that area.”

“I still haven’t ever scrubbed in to any surgeries,” confessed Pooja. “So far I’ve only shadowed Internal Medicine doctors. I guess I’ll have to try it. My roommate said that it was kind of tedious as a third year. You just kinda stand there and help hold things open or shut while the resident or the attending does all the work.”

“Yeah, I’ve seen that,” said Hannah. “It happens. But the things you get to do!”

“I see what you mean.” Pooja waited for a few seconds before turning her eyes back to the enormous stack of papers. “Come on, let’s get to work! We’ll never get to scrub in again if we don’t learn about astrocytomas. Blech.”

“Don’t we have an extra session today?”

“Oh yeah!” exclaimed Pooja. “I’d completely forgotten.”

“What is it?”

“Uh, I think it’s cultural competency in medicine or something.”

“What bullshit,” said Hannah matter-of-factly. “You can’t get cultural competency in medicine from sitting in a lecture hall.”

Pooja snorted. “But they’re gonna take attendance. We gotta go.”

“No, you’re right.” They picked up their large piles of notes and clumsily shoved them into their backpacks as they walked out of the study area into a long hallway lined with lockers. They trooped past several elegant glass displays of dissected organs, joining several of their classmates in a line filing into the lecture hall. The large room was bright and conservative, with long tables in two neat rows running the length of the room. Each pair of tables was on a lower level from the next, with the entire room sloping downward to a podium at the bottom flanked by two more tables occupied by several faculty members. Hannah saw Dr. Patel, Dr. Starck, and two others that she didn’t recognize sitting in front of a big whiteboard that had “Cultural Competency Panel” written in big letters. Above them was a large screen that their lecture notes, videos, and powerpoints were usually displayed on. Hannah cringed inwardly as Dr. Starck stood up and took a cordless microphone in his hand.

“Welcome to our first annual cultural competency panel!” he announced. “Despite amazing advances in science and technology over the last several decades, about 90% of the population believes in some kind of God and a very large number of people still identify with some kind of organized religion. The National Board of Medical Examiners has emphasized to us the overwhelming importance of preparing you while in medical school to talk to patients of all backgrounds, which includes different religious backgrounds. You could encounter Christian or Hindu or Jewish patients and being able to understand their beliefs is really important. For example, if a patient is a Jehovah’s Witness they will not accept any blood products because of their religion. I know, I know– it sounds crazy. But this is the sort of thing that’s really important to know in the hospital!”

Dr. Starck was a short man with a too-perfect head of thick white hair immaculately parted and extending out past his bald forehead. He had enormous eyes and his voice, to Hannah, had gone from suspiciously knowledgeable to overwhelmingly grating over the course of the year. She was not particularly pleased with the fact that he was basically responsible for everything that they had learned in second year. As her experiences with Dr. Bode had shown her, what she learned here was frequently similar to the knowledge necessary to diagnose and treat patients but rarely close enough to be useful. She suspected that today would not be much different.

Now, it’s very important to emphasize that all of us have our own personal beliefs and that these beliefs should not affect how you talk to your patients. But respecting the beliefs of patients means knowing what they believe and how it affects their care. So today I have brought Dr. Devinder Patel from the department of Surgery to speak about Hinduism, Dr. Ezra Friedman from the Department of Family Medicine to speak about Judaism, and Dr. Mohammed Al-Talib from the Department of Internal Medicine to speak about Islam. I will be discussing Catholicism.”

“Yikes,” whispered Pooja. “I feel bad for all the Catholics.”

“So I guess I’ll talk a little bit about what happens when you first become a Catholic. A lot of people just become Catholic because they were born into a family where everyone is a Catholic, and you grow up going to church and not really thinking about it too much. Then, when you’re around 13 you’ll go through some classes– called catechism– and that’s where you get instructed in all the different teachings of the Church and the rules of an arcane system designed to bring enlightenment. Kind of like med school!”

There were a few small laughs from the room. Dr. Starck didn’t let it slow him down.

“So then after you do those classes, it’s time to go through confirmation, which is where a lot of times you officially become a member of the church, which is a big deal. But before that, when you’re a baby, you get baptized into the church, where they put some water on your forehead as a way of saying that you’re covered by the blood of Jesus and a part of the church. It’s also important to know that in an emergency situation, you can baptize anyone. For example, if a woman has a miscarriage and wants to baptize the baby, in extreme circumstances the Catholic Church allows anyone to baptize someone else. So you might want to ask your pregnant patients about that if you might ever find yourself in that situation.”

He paused and nodded to himself, allowing what he clearly considered to be a useful insight to sink in before pressing on.

“When a lot of people think about the Catholic Church and medicine, there are all of these issues where there’s an official stance, but a lot of people have a culturally Catholic background and just aren’t particularly adherent. For example, with stem cell research there’s a lot of hubbub because Catholics believe that life begins at conception– and of course this affects how they think about abortion, too– and so there’s a lot of opposition to stem cell research based entirely on this one philosophical premise. And in some ways I guess it makes sense because if you have to have these particular moral codes, you have to pick some point at which life begins and it’s easiest to say that life begins at conception. Although, you know, there are some other traditions that believe differently, which I found out when we started planning this conference! But you’ll hear about that later. Anyway, as I was saying there’s an official Church teaching on stem cell research, but a lot of individual Catholics believe differently, and if you are ever in a situation where you might be talking about doing some kind of stem cell treatment on someone, you might find that a family member might object more strenuously than the patient because of issues they have with using stem cells.”

Hannah attempted to think of a situation in the near future where she might be offering a patient stem cells, but could think of none. Dr. Starck continued.

“There are a lot of cases where people might want to go along with Church teaching to satisfy a desire that they have, and it’s important that you help them feel like they’re not breaking their law. This can be an issue sometimes with sexual matters, too. Things like contraception are generally frowned upon, because it’s just not thought to be a natural use of sexual organs. Same thing with homosexuality. Obviously this is a big deal in recent years where there’s a big popular leaning in one way and the Church comes down the other way, and I think the general line is that this is the way that God made things. Some people you meet might be in conflict over these kinds of teachings and it’s important that you can be there with objective, scientific evidence to help them sort out what’s happening and what choice they want to make. You obviously can’t talk them into anything they don’t want to do, but you can be someone for them to talk to.

Hannah just kept looking at Pooja, shaking her head, and turning back to the front.

“I feel like I know less about Christianity after this,” said Hannah, barely keeping her voice down now.

“Yeah, I know. I hope that the other ones are better.”

“And lastly, a lot of times in Catholic teaching there’s this idea that you identify with Jesus in your suffering, and that can be really meaningful to a lot of patients. So if they want to bring in crucifixes or rosaries or whatever in their room, be sure to let them do that and participate in the traditions that are meaningful to them. And, uh, that’s about it. And now… I’d like to ask Dr. Friedman to speak!”

Everyone clapped unenthusiastically as the microphone was passed off, and a tall, thin man with a graying beard took it and stood. He smiled warmly as the class quieted down and then he began to speak.

“I am looking forward to seeing you all in a few weeks when you start your rotations. I was really glad to be asked to be a part of this panel because I do really feel like there is such a strong emphasis on just acquiring medical knowledge without connecting it as part of a patient’s story. For a lot of people, the 15 minutes or so that they spend with you is just one part of their life and there are so many things shaping how and why they’ve come to you. It was not long ago that the healers were religious leaders in some way– like the great Maimonides, who was a philosopher and a doctor– and for many patients, faith is going to play a role in their healing regardless of what you do or don’t do. When you walk into a patient’s room, you’re fulfilling an expectation and performing a ritual for that person. For some of them, you’re the only hope they have left and the only person who will listen to them confess their sins. So it’s important that you take listening to them very seriously. Because you have a whole bunch of magic potions in your pharmacy to make them well, and only a few of them are made by pharmaceutical companies.”

“Hmmm,” murmured Hannah, intrigued.

“One of the most important concepts that we encounter in Jewish medical ethics is summed up in the Talmud by saying that if someone saves a life, it is as if he saved the whole world. Helping others– no matter what the cost or what other rules have to be broken– is paramount, which is how certain Jews interpret the law as allowing them to work on the Sabbath. We have to be careful, though, in how we look at this, because I think it’s clear that our medical system focusing on extending life without thinking too often about the quality of the life that we’re artificially extending.”

“Wow!” whispered Pooja. “He makes a lot of sense.”

“Yeah,” whispered Hannah back. “More than Dr. Starck, anyway.”

“You also have to consider some of the practical considerations of practicing among Jews– many of whom live in Baltimore, although less in this particular area of the city. For example, because of the high rate of certain genetic mutations within the Jewish population, many communities where marriages are arranged will routinely test both members of the couple to find if they are carriers for diseases like Tay-Sachs before they even go on their first date– and only reporting if a match could produce a child with a disease, not what each person’s individual status is. So when it comes to issues of carrying genes for terrible diseases, you should approach the topic sensitively.”

Hannah found herself nodding along to what he was saying, refreshed not only that she was not hearing random bits of information that she might be tested on later, but also that someone was trying to help decode what role she and her classmates would play in a few months when they moved on. She settled in to listen a little more carefully.

Bzzzzt!

She looked down at her phone to see a text from Solomon.

24 hours post op. First patient is still alive.

Click here to proceed Chapter 3, which was was released on November 1, 2014.

Go to the discussion page.

Creative Commons License
Trousseau Syndrome by Matthew Loftus is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

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