Chapter 8: July 2011

 

Hannah  stared at Adam for a brief moment in the dim gray glow as she listened to the rain falling. He was lost in sleep under the disturbed sheets and peacefully enjoying this early hour. She whispered goodbye just before she kissed his forehead. In the dark, his lips murmured a hint of recognition before he drifted back to sleep. Hannah moved quickly but quietly towards the door, carefully turning the brass knob so as to not wake Adam. She closed it firmly behind her, tiptoeing down two flights of smooth wooden stairs before coming to her kitchen. The sun poured in through one small uncovered window above their stainless steel sink, flooding the small kitchen with an bluish-gray light.

She poured herself a bowl of granola with milk and spooned it into her mouth as she shuffled a pile of papers on the table. She checked the time and location to report for her rotation, even though she had already done so multiple times since she received the 3-punched folder with her name printed on it. University of Maryland Medical Center. Yellow Team Room, 12th floor. Behind the nurses’ station.

She closed the folder once again and slipped it into her backpack alongside several pocket-size reference books she had purchased for this day. She paced out of the kitchen into their living room, then hurriedly unlocked the front door and opened it. As she stared at the drizzle, she wondered for a second about her hair, which she had meticulously brushed today; and her face, which was covered in a gentle layer of make-up. She wanted to look professional and competent, as she had been instructed to do. Yet she also did not want to show up looking like she was headed to the prom with ostentatious eyeshadow and rouge, as she had noted some of her classmates did yesterday during orientation.

She decided that she would be all right on her bike if she wore her rain jacket. She carefully donned her white coat and slipped her jacket over top. She grimaced as she watched the edges of the white coat fell just above her hips and butt, which stuck out unattractively. She slung her backpack over her shoulders and carefully lifted her bike from its parking spot next to the living room couch, carrying it down the front steps. She turned and locked her front door’s deadbolt, then mounted the bike and pushed off.

The street was quiet except for the gentle patter of the rain hitting the car roofs around her. Her block was dominated almost entirely by staid, simple, red-brick rowhomes three stories high, with dirty gray marble porches out in front. Her bike slid just a little on the wet pavement as she turned a corner and rode past Hollins Market, a long rectangular building that matched the surrounding houses with its brick exterior. Hannah had wandered inside several times to buy fresh meat or fish from one of the busy, overwhelming stalls lit by harsh fluorescent lights overhead, but in general found the market experience unpleasant with loud music blaring from the prepaid cell phone kiosk and a decided lack of any fresh fruits or vegetables.

She pedaled hard down the street and turned again, finally reaching Martin Luther King Jr. Boulevard. There were far fewer cars on the street than she was used to; she had only ever made this journey at this time of day when she had an experiment running overnight at the lab. Now she was expected to be at the hospital this early– or earlier– for the rest of her clinical years. As she emerged from the shadow of the rowhouses on Baltimore Street, she noticed the sun just starting to peek through the gray clouds over in the east, just beyond the skyscrapers downtown. The rain was letting up even more as it turned from a light drizzle to a fine mist. She looked up the street for cars coming north and darted across the street to the brick median despite the clear orange hand on the crosswalk cautioning her otherwise, then waited another few seconds for several cars to drift by before she crossed the right three lanes.

Her bike moved quickly down the last block to the plain metal doors painted white facing the sidewalk. She dismounted her bike and swiped her student ID card on the small gray box by the door, which responded with a small beep as she pushed the plate opening the automatic door. Her bike was leaving a small, thin, wet trail behind her as she entered the building, but she figured it would dry before anyone else saw it. The large two-story lobby with its big staircase rising in front of her was empty; no security guards were yet at the desk. She lifted her bike onto her shoulder and carried it up the stairs, locking it to the railing overlooking the lobby from the second floor.

She smiled as she passed the anatomic specimens in the next long hallway and, instead of turning left at the lecture hall as she had many times before during her first two years, she turned right and again brushed her ID against the card reader on the wall. She pulled on the heavy metal door, which opened to a ramp. The long windows on either side of the bridge to the hospital were set high in the walls, so as she walked up the ramp she could just see outside, where the morning light was becoming even clearer as the rain disappeared. As she walked through the door at the top of the ramp, she emerged into the bluish-gray hallways of University of Maryland Medical Center.

She found her way to the rotunda elevators, joining an ever-growing crowd of blue scrubs and white coats. She smoothed her teal blouse fastidiously and looked over her khaki dress pants one more time for any stains that might have appeared since she last checked in the mirror this morning. Her black flats tapped the floor as the elevator stopped at every floor on its way from the third to the twelfth, where she exited alone. Only one hallway extended out; the other four sides of the rotunda; the others were marked with gold letters announcing the offices of the Departments of Anesthesiology and Orthopedics. Hannah walked down the hallway, her eyes glancing from side to side at the rooms with open doors and wondering if perhaps one of her patients would be in there.

She reached the nurses’ station, where a countertop ran from one wall to the other with patient rooms all around. Behind the counter was a tower full of dark blue charts with different names scribbled on the side; at every desk there was a computer and around each computer were 2 or 3 nurses giving each other report on the night’s events. Behind the nurses’ station, as promised, was a wooden door that read “YELLOW TEAM ROOM.” Next to this sign was a rather official-looking sign that appeared to have been pilfered from a psychiatry unit which read, “Warning! Elopement Risk! Open Door With Caution!” Hannah smiled as she turned the knob.

“Well, good morning!” exclaimed a young man in a long white coat and messy light blue plaid shirt with a yellow tie. His black curly hair erupted from his head in fits and spurts. “Are you joining us on Yellow Team?”

“Y-yes!” stammered Hannah. “I’m Hannah Wells.”

“I’m Saul Zimmerman,” he replied, offering out his hand and smiling enthusiastically. Hannah took his hand and shook firmly. “I’ll be your senior. Nice to meet you! Welcome to your first day of third year!”

“Thanks,” said Hannah. “Uh, is there a code to get in?”

“Yup! 1-2-3. Don’t tell any of the patients, we wouldn’t want them to hear us talking about them. Why don’t you stick with one of the interns for today and meet some of the patients, and then tomorrow you can start following your own patients?”

“Okay, sure!” said Hannah, glad that she had a guide for her first few hours in this strange new world. She was used to flitting in and out of the hospital with Dr. Bode or another preceptor who was teaching her, but she wanted more guidance now that she was going to be part of the Yellow Team every weekday and every other weekend for four whole weeks. She felt something gently slap her hand, which she quickly realized was a few sheets of paper stapled together and shoved into her palm by Saul.

She looked down and saw a haphazard series of columns relating patient information: name, birthdate, hospital room number, current medications, allergies, and a few cryptic lines relating the events of each day of hospitalization. Hannah was immediately fascinated by the stories that unfolded on the page before her and kept her eyes on the paper as Saul gestured for her to enter the room. Sitting at computers clicking away were Josh, Pooja, and two other people that she didn’t recognize. She walked over and hugged Pooja.

“Hey! I didn’t realize you’d be here!”

“Hey, Hannah!” replied Pooja, returning the hug from her chair. “Yeah, I’m doing my first sub-I in internal medicine.”

“How was third year?” asked Hannah. Josh moved his chair over just enough to join their conversation.

“Uh… long! Busy, too. I’m sorry we never got to hang out… you’ll see soon enough how it just kinda takes over your life. But it was good. I learned a lot. But now I’m glad to be a fourth year! And I can help show you two the ropes. Hopefully you didn’t forget everything you learned in your year off doing research…”

Josh shook his head emphatically. “Oh no, I still remember every step of the Krebs Cycle…”

Both girls laughed.

“Okay,” said Hannah. “What do I do?”

“Well,” explained Pooja, “For now Saul was saying that you guys will be with one intern– then you just adopt your own patients as they come in. He has to know all the patients, but writing their notes every day is divided between me and the two interns. You should really learn as much as you can about the patients– read their admission note, check their vital signs, find out as many details about their condition. You’ll have more time to read and study, so use it!”

Hannah and Josh kept nodding along.

“And… uh, have fun!”

“Okay,” interrupted Saul. “Josh, I want you to go with Samir and see patients with him. Hannah, you’ll go with Gwen.” He nodded to the interns sitting at computers on the opposite side of the room, furiously scribbling down lab values onto their sign out sheets. Hannah moved over next to the female intern, whose light brown hair fell perfectly in waves over her head. It bobbed every so slightly with each movement, likely held in place with bronchospastic amounts of hairspray. Hannah could not help but notice the large, glittering diamond on her left ring finger and her bright white skirt that rested comfortably above her knees.

“Hi, I’m Hannah,” she said softly.

“Oh. Hi. I’m Gwen. Nice to meet you,” replied the intern, not looking up from her paper. “You’re the new third year?”

“Yup, first day.”

“Okay, well, I just started last week but at least I’ve got my M.D. Ha ha! Let me finish writing down these labs and we’ll see some people.”

“O-kay,” Hannah said, trying to look at the screen without obstructing Gwen’s view. She had looked at the electronic medical record here a few times, but the labs were displayed in a rather small font in columns sorted by date that made it difficult to glance at.

“Goddammit, I hate this piece of shit EMR. They should upgrade all the computers to Macs and buy a decent system. At Hopkins we at least didn’t have to strain our eyes to see what the CBC was. Oh wait! This patient doesn’t have a CBC this morning.”

“Oh, I wonder why that is?” asked Hannah.

“Probably someone forgot. Every patient should have a CBC and BMP every day that they’re in the hospital. Wouldn’t want someone to bleed out or go into kidney failure on you while you’re responsible for their life.”

“Uh… I guess not,” mumbled Hannah. As she watched Gwen click and scribble, she began to question the wisdom of getting a complete blood count and a basic metabolic panel on every patient when most of them weren’t bleeding out or going into kidney failure. “So, uh, who are we seeing?”

“Hang on, lemme finish this one part…”

Hannah looked down at her list again, now trying to discern. She now noticed that each patient either had Gwen’s name or Samir’s written next to the medical record number.

“Okay, done!” Gwen pushed away from the computer with vigor. “Alright, let’s go.”

Hannah followed Gwen out of the room and past the nurses’ station.

“So, let’s see… we’ve got one guy up here, then this lady down on 10, and two on 3. It makes no sense how everything’s all spread out on the floors here. I keep getting lost all the time just trying to see my patients in the morning!”

“It’s, uh, pretty overwhelming,” said Hannah.

“No kidding,” said Gwen. “Okay, room 6. Here we go!”

They strolled into a darkened patient room where the two patients in their beds were separated by a thick greenish-gray patterned curtain. They walked past the first patient to the second near the window. He was a rather large black man whose snoring had been evident since they had entered the room. Hannah watched in muted awe as his chest rumbled with the vibrations from his throat, jiggling the gray wires that ran over the side of the bed and snaked into his gown. His nostrils flared dramatically with each breath in and his lips quivered as he exhaled. For half a second, it sounded like he might have been choking, but it was difficult to tell as Gwen gently shook him awake.

“Hey Mr. Wiggins, it’s Dr. Black. Remember me from yesterday?”

The patient mumbled something resembling, “Good morning.”

“Hey, how are you feeling today?”

“Oh, fine,” he said, letting loose an enormous yawn. “You know the gout been botherin’ me. Can I get some pain medicine?”

“Oh, sweetie, you’ll have to ask your nurse if you’re due. How’s your chest pain doing?”

“Oh, fine, I guess,” he replied. “You know it come and go.”

“Okay, and are you feeling any shortness of breath or headache?”

“Nope, I been feelin’ better since you gave me that Lasix,” he answered.

“Alrighty then, let’s take a listen to you.” Gwen immediately produced her stethoscope and began placing it on Mr. Wiggins’ chest, listening for a few seconds. Gwen then dramatically gestured for Hannah to do the same, prompting her hands to scurry to the pocket of her white coat and pick out her plain black stethoscope. Hannah hurriedly placed the earpieces in her ears and reached over the bed to place the diaphragm of her stethoscope over the patient’s massive chest. She heard the harsh, crinkling sound of his chest hair rubbing against the smooth plastic, and then beyond that, distant-sounding through inches of fat, the soft lub-dub of his heart valves opening and closing.

Hannah traced the path of the blood in her mind: into the right atrium through the vena cava from the veins throughout the body. Through the tricuspid valve into the right ventricle, which shut with a snap. Lub. Out the pulmonic valve as the right ventricle squeezed vigorously and into the lungs, then the pulmonic valve closed. Dub. Back from the lungs, full of whatever oxygen had managed to slip through his barely open throat and into the left atrium. The two-leaflet mitral valve opened and closed like the mouth of a talkative fish as the blood filled the left ventricle. Lub. Then another emphatic contraction as the left ventricle pumped the blood through the aortic valve to the aorta curving around the back of the heart and out to the rest of the body, closing emphatically as the rest of the filling cycle began. Dub.

“Okay, sit up for me, honey,” instructed Gwen. The patient did so, at which point she quickly switched her stethoscope around to his back. Hannah mimicked her on the opposite side, listening first to the superior part of his back and then the inferior. The gentle whoosh of air blowing in and out of his lungs was only disturbed by a very fine crackling sound at the bases. Hannah tried to imitate Gwen as she felt the patient’s wrist pulse, then watched as she swept the sheets upward. Mr. Wiggins’ massive, swollen legs were exposed.

“Looks like you’ve still got some swelling there!” Gwen observed, pressing her hands against the swelling to see where it ended and was overtaken by the rolls of fat in his thighs.

“Yup, still hurtin’ me down there. I need some of them Percocets.”

“Well, just press your call button, okay?”

“Okay, young lady,” he said, looking at Gwen’s skirt. He reached over and pushed the bright red button on the bedrail with one stubby finger. Gwen covered his legs with the sheet again.

“Alright, we’ll see you later when we round with the team,” she said as she turned away.

“Yes, ma’am,” he said, pushing his button again. Hannah followed Gwen out of the room, each of them squirting alcohol hand wash from a small bottle on the wall on their way out. The acrid smell pierced Hannah’s nose and her hands felt gross with the sticky fluid. She shook her hands in the air to help it evaporate as it killed the bacteria that she’d acquired from touching Mr. Wiggins.

“So, I’m not going to pimp you or anything, but I will try to teach you since we’re together today… what does that man need, pronto?”

“Uh… a sleep study for snoring?” asked Hannah.

“Bingo!” exclaimed Gwen, turning back towards the elevators at the end of the hall. “We’ll mention it in his discharge summary. I dunno who his primary doctor is. And what did you hear when you listened to him?”

“Um, I heard some rales at both bases.”

“Great! I guess a year of research hasn’t completely ruined you. I took a year off, too, to study cytokine adhesions in pulmonary edema. I wish it had made a bigger difference in the Match.”

“Oh?” said Hannah.

“Yeah. Maryland was my fourth choice… my fiance matched into radiology at Penn. He got his prelim year there, too. I was hoping we’d both end up at Hopkins, but oh well. Here I am. It’s just for three years and then I can do my critical care fellowship.”

“Okay,” said Hannah, not quite sure how to follow that comment. They stepped into the elevator, watching as the silver-gray doors closed slowly in front of them. She decided to ask a question.

“What’s Lasix?”

“Oh my gosh, you don’t– I mean, I keep forgetting today is your first day of third year. It’s a diuretic.”

“Does it have another name? They only taught us generics in med school.”

“That’s probably a good idea… except patients, nurses, and older doctors only know the brand names. Lasix is… furosemide, I think? Whenever I don’t know, I just search the name on my phone. It gets the fluid out, that’s all I care about! People come in on all this crazy chemotherapy and psych medicines and who knows what else. Do you have a drugs app on your phone?”

“Uh, yeah, but I’m still trying to figure it out,” admitted Hannah.

“Yeah, you should definitely sit down when you get home tonight and learn it well, ‘cause it’s gonna be your best friend,” admonished Gwen. “Do you know what you want to specialize in?”

The elevator doors opened and they began to proceed down another hall to the next patient.. “Well, I had thought maybe surgery, ‘cause of all the research I’ve done with Dr. Bode, but the more I think about it, the more that family medicine appeals to me. It’s just really important to ensure that everyone has access to quality primary care.”

Gwen rolled her eyes. “Family? You seem smarter than that.”

Hannah was about to object when Gwen turned suddenly into the next patient’s room. She was in a private room, sitting up in bed shaking her head softly, as if she knew what was about to happen and was already dreading it. She was a diminutive, white-haired woman whose hands twisted nervously in her lap, her face fixed with an expression of concern. Her pale white skin was wrinkled but not especially worn and her eyes seemed to dart from place to place in the room, but rarely on Gwen or Hannah. Her speckled white hospital gown hung neatly from her neck and went in a straight line across her knees as she sat up in bed.

“Good morning, Mrs. Redner!” exclaimed Gwen in a cheery sing-song that made Hannah instinctively grit her teeth. “How are you this morning?”

“Oh, all right, I guess. Still having that pain in my stomach again,” answered the patient.

“Oh, I’m sorry, honey. Did the Zofran help with your nausea?”

“No, nothing really helps with the nausea much. Do you know if the GI doctor is going to see me today?”

“He should come by,” said Gwen, putting her stethoscope to her ears again and listening to the patient’s heart and lungs so quickly that Hannah could hardly imitate her before the two started talking again.

“So can you point to where the pain is today?” asked Gwen.

“Oh, it’s right here, same place it always is,” answered Mrs. Redner, pointing to the center of her stomach, just a few inches above where her bellybutton would be. Hannah’s mind immediately tried to think of all the things that caused pain in the epigastrum: pancreatitis, stomach ulcers, aortic aneurysms, diverticulosis, diverticulitis…

“Okay, does it hurt when I press there?” asked Gwen as she pushed rather lightly where the patient was pointing.

“Ow! Yes,” she yelped. Her hand reached for Gwen’s, as if to push it away.

“Oh, I’m sorry,” said Gwen again, not appearing to mean it any more than last time. “Well, we’ll see what GI says and keep giving you medicine. Did you have any bowel movements last night?”

“Yes,” answered Mrs. Redner. “Just one, and it was loose.”

“Okay, well, make sure you keep drinking plenty and eating a little!” advised Gwen as she started to walk away. Hannah wondered if she should stay and ask more questions or just stick with Gwen. She decided that she could probably glean whatever information she needed from her signout.

The patient’s voice came back, dull and resigned. “Okay, goodbye.”

“See you on rounds!” said Gwen. They exited the room and quickly moved up several floors to see the remaining patients charged to her care for the day, including a young man with renal failure, an elderly woman with pneumonia, and two people with diabetic foot wounds. Throughout each encounter, Hannah tried to pay close attention to whatever Gwen was paying close attention to, asking questions after they had left the room that were informed enough to not sound stupid but still deep enough to give the impression that she was being thoughtful. She quickly realized that this was also a good way to prevent Gwen from asking questions that she didn’t know the answer to.

“So what do you think is going on with Mrs. Redner?”

“The nauseous chick? No clue. She’s a gomer. Take a look in the computer this afternoon– she’s been admitted to the hospital six times this year with the same complaint.”

“Gomer?”

Gwen laughed. “Oh, honey, you’ve got a lot to learn. Stands for Get Out of My ER. The emergency room doesn’t like dealing with these old people who never die, they just keep coming back with the same problems and getting admitted. They get lots of scans, they get lots of scopes, we give ‘em lots of medicines, they never get better.”

“Oh. Well, isn’t there a way to fix that?”

“How would you do that? They never follow up with their primary care doctor, if they even have one. And when they do, the primary care just gives them a bunch of refills on medications and sends them on their way.”

“It just seems like the system should be different. There has to be a better way.”

“When the patients start taking responsibility for themselves, there will be something different. Like those diabetic foot ulcer patients. They’re both at least 250 pounds each. And they’ve been that way for a while. People like that get warned over and over again that if they don’t control their sugars, they’re gonna start getting limbs chopped off. And do they listen?”

Hannah quickly questioned the judgment of responding to Gwen’s rhetorical question, but decided to do so anyway. “Well, sometimes they do. But they’re locked in systems of poor care delivery and bad food environments where they don’t even have access to fresh fruits and vegetables–”

“Sweetie, you know they’ve studied that whole food desert thing,” interrupted Gwen. “Even when you put a grocery store that sells apples and carrots in a so-called food desert, nobody eats any healthier. You can look up the research. You can talk about systems all day long, but nobody’s putting a gun to anyone’s head and forcing a Big Mac down their throat.”

Hannah, stymied by Gwen’s retort, fell silent quickly. Gwen opened another door in the middle of the hallway, moving into the stairwell so quickly that Hannah kept walking down the hall and had to double back to keep following. As they worked their way up to the twelfth floor, there was only the sound of Gwen’s pumps and Hannah’s flats clicking and clapping on the stairs.

“So, uh, with that first guy, the signout says ‘CP r/o.’ What does that mean? Is that like gomer?” asked Hannah, trying to break the awkward silence that had developed since her last line of questioning had been shut down.

Gwen laughed. “Almost as bad. When someone comes to the ER with chest pain and has anything resembling a risk factor for a heart attack, they can do an EKG and a set of cardiac enzymes in the ER. But what’s the problem with cardiac enzymes?”

“Um…” said Hannah, her mind sputtering as she tried to think of answer while Gwen stared intently at her.

“Think about timing,” she hinted. They were approaching the team room door again.

“Oh!” said Hannah. “Timing. Well, if you’ve actually had damage to myocardial tissue, you don’t always see cardiac enzymes rise right away. So someone could walk into the ER with a clogged coronary and have symptoms but a normal EKG and normal enzymes.”

“Exactly!” congratulated Gwen. “So that means we have to keep people until they’ve had three sets of negative cardiac enzymes. Then we usually have to do something to prove that they don’t have significant cardiac disease, like a stress test.”

“What kind of stress test? I know that you can exercise on the treadmill with EKG monitoring, or there’s something else…”

“Usually our patients can’t move their enormous… uh, posterior regions fast enough to do the treadmill. So most of the time we just order the nuclear medicine test.”

“And that works by injecting some kind of tracer that gets taken up in myocardium and then you scan their chest?”

“Something like that,” said Gwen. “I don’t know if I’ve ever seen any done.”

“Oh,” said Hannah as they reached the team room.

“Alright!” declared Gwen as she opened the door. “Write a SOAP note about one of the patients you saw today and you can present someone to the attending on rounds. You do know how to write a SOAP note, right?”

“Subjective, objective, assessment, plan!” recited Hannah quickly.

“Okay then, get some words on paper.”

Hannah took a seat at a small table at the back end of the team room next to Josh, who was looking between his own note that he was writing and a large textbook. She took a blank progress note that was clearly the descendant of many generations of copied pages with a faded University of Maryland logo in the upper left and dark gray lines running horizontally across the paper.  She stared at the blank note for a few seconds before peeking over at how Josh had organized his note. She copied his plain script, starting with “Student Progress Note” at the top and the date and time in the left-hand column. She then wrote carefully, trying to defy the stereotype of doctors and their poor handwriting.

S: Patient continues to complain of nausea and abdominal pain. She has had some relief from her nausea with Zofran. She has had two loose stools overnight.

She stopped and pondered for a few seconds, realizing that Gwen had not asked a lot of other questions this morning. She moved on to the next section, scurrying over to the computer for a few seconds to look up Mrs. Redner’s vital signs.

O: Tmax 98.1 P 67 BP 114/75 R 18 Pox 95%

General Appearance NAD

Lungs CTAB, no w/r/r

Heart RRR, no m/r/g, nl S1/S2

Abdomen Soft, mildly tender in epigastric area. +BS

Extremities No edema, 2+pulses

She hesitated as she reached her assessment, rolling her pen in between her fingers nervously as she wrote, one word at a time. Each one came slower than the next until she could write no more.

A: Patient is an 84 year old woman with hypertension and chronic nausea and abdominal pain of unknown origin. Despite numerous tests, the cause of the patient’s symptoms have not been found and she remains stable. Her symptoms are somewhat treated–

“Hey, are you ready to round?”

Hannah startled and looked up from her page to see Saul standing between her and Josh.

“Alright, Dr. Mardino is going to meet us up on the top floor and we’re going to do walk rounds. Let’s go!” His arms moved enthusiastically as he spoke.

The two interns grumbled indistinctly as they pushed away from their computers and gathered their notes in their arms as they headed for the door. They followed behind Hannah, Josh, and Pooja as Saul led them up a back stairwell across from the team room, bounding up the steps with vigor. Hannah turned to Pooja as they walked.

“So how many patients do you see?” she asked.

“Well, since today is my second day, they only have me carrying three… but they say I can take up to four or five if the service gets busy. All the rest are split between the two interns,” explained Pooja.

“So who does Saul see?”

“He sees all the patients on the service. He’s kinda responsible for knowing everything that goes on. The interns write all the notes and the orders and do a lot of the grunt work. And I’m supposed to have just enough responsibility to feel sorta independent, but not too much. And your job is to follow a few patients that you know really well and learn as much as you can about their medical problems.”

“Okay.”

They reached the top of the stairs and Saul held the tarnished metal door open. Waiting in the hallway was a short man with a full head of bright gray hair carefully slicked to one side, his arms folded across his chest and his dark eyes staring at the approaching team from beneath his enormous bushy eyebrows perched on his forehead. His long white coat fell perfectly straight in a wall around his body, each side of his lapel evenly spaced from his neatly tied blue tie.

“Good morning, Dr. Mardino,” greeted Saul.

“Morning, Saul,” he replied. “I see we have some new members of our team today.”

Hannah and Josh looked to each other. Hannah clutched her clipboard with her written note tightly against her chest.

“Why don’t you introduce yourselves?” asked the attending. His voice was sharp and insistent.

“Oh, uh, I’m Hannah. Hannah Wells.”

“And I’m Josh Ramirez.” He extended his hand to Dr. Mardino, who shook it.

“And you’re both MSIIIs?” asked Dr. Mardino.

“Yes,” answered Saul, even as the two students nodded. “They each took a year off, actually—Hannah did research with Dr. Bode in liver transplant, and Josh did a year of policy downtown.”

“Hmm, interesting,” said Dr. Mardino. “There’s certainly a lot of interesting things to do in the realm of research and policy. I have personally found nothing quite like the joy of clinical medicine. But we shall see. Who has our first patient?”

“I do, sir,” answered Pooja. “Mr. Paul is a 45 year old gentleman with no significant past medical history who initially presented with right lower extremity swelling, redness, and pain. He was found to have a blood clot in his leg.”

“He has a deep venous thrombosis. ‘Blood clot’ is appropriate to use with patients, but I expect proper medical terminology on rounds. For our new students, why is this unusual?” asked Dr. Mardino.

Hannah and Josh again faced each other, hoping that the other one might have the answer. Finally, Hannah spoke.

“Well, if you think about Virchow’s triad, I guess he doesn’t really have any of the three things?”

“Exactly!”

“Okay, young man, what’s Virchow’s triad?” Dr. Mardino turned to Josh.

“Uh, well it’s…” Josh began to stall. Hannah wished that she could spare all of them the awkwardness of watching him not have the answer, but they were both being watched too closely.

“Pooja?” asked Dr. Mardino.

“I looked it up last night after you asked on rounds. Virchow’s triad of thrombosis is stasis, endothelial injury, and underlying hypercoagulability.”

“And, as Hannah pointed out, when this patient presented yesterday with his deep venous thrombosis, he apparently had none of these factors. No recent long car trips or airplane rides, so no stasis. No surgeries or trauma, so no endothelial injury. And no known history of hypercoagulable state, with all of his labs for the genetic hypercoagulability factors negative.”

“Yes, sir,” said Pooja.  “Until…”

“Until?” inquired Dr. Mardino.

“Well, as I was getting to in my presentation, last night the night float intern came to see the patient because he was having severe abdominal pain. He wasn’t sure what to do, so he got a CT scan. It all happened around the time he signed out and the pain is better now, but… you remember that the patient had had abdominal pain off and on for the last several months with occasional nausea?”

“Yes, I do,” replied the attending.

“Well, on the CT scan there’s a large mass in the tail of the pancreas with surrounding lymphadenopathy.”

“Oh.” Dr. Mardino’s face, already quite serious, became more somber. “I didn’t see that when I looked up his labs this morning. That is unfortunate. Did the radiologist comment on the appearance of the mass?”

“Definitely suspicious for complex solid tumor. Possible malignancy.”

Dr. Mardino shook his head softly. “Well, then, today we are going to discuss how to best give bad news. I see we have a case of Trousseau syndrome.”

“What’s Trousseau syndrome?” asked Hannah.

“You’ll have to look it up,” shot back Dr. Mardino with half a smile. Hannah quickly felt chastened, realizing that she would probably have to be more careful about phrasing her questions in the future if she didn’t want to get that answer over and over.

Saul piped up. “Trousseau was a famous physician in the late 1800s who described thrombosis as a symptom of malignancy. He noticed that patients with cancer were predisposed to blood clots, thus the Trousseau syndrome.”

“And what is unusual about Trousseau syndrome?”

“Well, Trousseau himself was found to have cancer after he had a thrombosis. I can’t remember if it was venous or arterial.”

“Venous,” pointed out Dr. Mardino. “Thank you, Saul. Let’s go in.”

The team dutifully followed the attending into the room, forming a half circle of alternating short and long white coats around the patient’s bed. The patient was a square-faced white man with a neatly shaved head and ruddy skin. He was sitting up, his breakfast tray sitting half-finished on his bedside table next to a large card that had “Get Well Daddy” scrawled in crayon. He had been watching something on TV, which Dr. Mardino turned off as they came in.

“Good morning,” he intoned. “How are you today, Mr. Paul?”

“Oh, all right, doc,” answered the patient with a careless exuberance. “Had a terrible time with that pain in my stomach last night, but the morphine is working real good now. What’d my scan show?”

“Well, sir,” started Dr. Mardino as he sat on the patient’s bed, bumping into one enormous calf under the sheets. “I have some unfortunate news about your scan.”

The patient’s face turned from his previous joviality. “What’s up, doc?”

“Mr. Paul, there was a large mass found on your pancreas. We can’t be certain and will need to do more tests, but it may be cancer.”

“My God,” muttered Mr. Paul. “Oh God.” His burly hands clenched the sheets, tensing and relaxing slowly as he breathed deeply.

“At this point, we will do what we need to do in the hospital to stabilize you, but most of the answers will have to come from cancer specialists, who will see you as an outpatient.”

The patient shook his head gently, looking up occasionally at Dr. Mardino’s stern, unrelenting face that was contorted into some variation of compassion. His thick eyebrows curved sadly downward, and his lips that had previously been stretched horizontally were held open slightly with regret.

“Let me take a look at your leg,” he said quietly, lifting up the bottom of the sheet to expose Mr. Paul’s legs. The left one appeared entirely normal to Hannah, but the right one was obviously swollen and red from the ankle upward, tapering off just after the knee. Somewhere deep in the veins of that leg was a clot choking off the circulation and preventing his blood from returning to his heart, although more importantly it was also poised to break free from his leg veins and shoot up through his heart into his lungs. Hannah wondered how Dr. Mardino could somehow be managing both the immediate problem of the DVT and the nebulous, long-term issue of the man’s probable cancer in his head right now. She felt overwhelmed just standing there, watching.

“So, um, my wife will be in here later. Will you be able to talk to her?”

“Yes, just have the nurse page us and we can come back,” said Dr. Mardino. “We can talk more then. Are you feeling short of breath at all?”

The patient shook his head.

“Alright, I’ll come back.”

Dr. Mardino nodded to Saul knowingly, who in turn began to walk out of the room. The team shuffled behind him and out into the hall, where Dr. Mardino walked just out of earshot and then began to address them.

“There were a lot of things that were not ideal about that situation, but there are a few principles that ought to be kept in mind when giving bad news. You should be brief and give only the pertinent facts. When someone first hears about something like cancer, giving them 5-year survival statistics will only be overwhelming and confusing. You should use terms that laypeople understand. I’ll never forget when I heard someone inform a patient that they had a glioma of an increasingly aggressive nature– the poor woman spent the entire time nodding along, and then the next day asked why she was having headaches. You should give them time to process the grief, and make yourself available to answer questions. His DVT appears to be improving slightly and he can probably be discharged this afternoon, but we will have to make sure that he has follow-up with oncology. Since that tumor is only causing him and the poor night float intern grief, they won’t come see him in the hospital.”

He stopped and looked down, then back up. “And always– always! Sit down and look the patient in the eye.”

The rest of the team nodded dutifully in response to his instruction and they moved down the hall.

 

***

 

“Solomon?”

Rita’s voice gently roused Solomon from behind the wooden door, following her inquest with a short knock. He reached over and opened it, finding her standing in the doorway with a canvas bag slung over her shoulder. She was dressed in a khaki skirt and pastel-blue blouse with bright white heels that clicked gently as she moved into his office.

“Were you asleep?” she asked.

“I wish,” he muttered, looking back from her to his computer. “What prompts this visit? Got more patients for me?”

“Is that all you think about?” she retorted with a grin.

“Would you mind if it was?” he responded with a knowing smile.

Rita giggled. “Oh, give it up. I actually came by because I didn’t see you in the gym this morning.”

“Oh,” said Solomon nonchalantly. “I forgot that you keep track of these things. I was in surgery, actually. Someone’s brand-new kidney infarcted in the middle of the night and I was on call. I was probably in the middle of closing around 7:30.”

“And you’re still here at lunchtime?” asked Rita.

“Got clinic patients all afternoon. Busy schedule. Liver biopsies, follow-ups, y’know.”

“Okay. Did you eat?”

Solomon shook his head.

“When do you start clinic?” she asked.

“Why? Are you going to see my patients for me?”

“Ha! You wish.” Rita crossed her arms. “I still have a bunch of charts from this morning that I need to finish. And then I’m precepting.”

“Do you want to get lunch together?”

“I was hoping you’d ask!”

Solomon sighed. “I guess it’s better than digging through my desk drawers to find if there are any more granola bars that I hid in here. I do have all of these damn e-mails…”

“The e-mails will just have to wait. C’mon.”

Rita extended her hand, which Solomon took and tugged gently as he rose from his chair. She leaned over and pecked his cheek before scurrying out of the office in front of him. They left the clinic suite and strolled through the hospital until they reached the cafeteria.

“Do you want to eat here?” asked Rita.

“Not particularly,” answered Solomon. “Do you?”

“Let’s walk outside,” she suggested. “We could just buy something from one of the food carts and then walk.”

“Isn’t it hot outside?”

“It’s actually not that bad today. Not for July in Baltimore, anyway.”

“Okay,” said Solomon, his hands deep in his pockets. They began to walk towards the stairway that led out towards the street.

“You seem more distracted today,” observed Rita gently.

“Do I now?” Solomon raised his eyebrows suspiciously. “I hate it when you do this.”

“Do what?” said Rita with a hint of exasperation. “What am I doing?”

“You psychoanalyze me!”

“No, I don’t!”

Solomon pushed open the glass door leading to the street, emerging into the muggy, bright daylight. Cars raced past on Lombard Street and crowds of people in scrubs or suits moved in one direction or the other on the sidewalk. Solomon and Rita joined one group as they walked east toward the sandstone library building and the hot dog stand parked out in front.

“Well, it feels like you psychoanalyze me,” muttered Solomon.

“See, that’s better,” observed Rita. “It’s a lot easier to say that you feel like I’m doing something to you than to just wildly accuse me of it.”

“See, you’re doing it again! I mean, it feels like you’re doing it again.”

“I’m sorry,” said Rita, stopping to face Solomon in the shade beneath the hospital entrance, next to the glass revolving doors. “I… don’t intend to. I just want to learn more about you. I want to hear what you’re thinking. We go out on dates and have fun bantering about our crazy patients, but when it comes to talking about when you’re feeling upset or bothered or whatever, you just put these walls up.”

Solomon shook his head. “No. I don’t.”

“Okay, fine, you just leave me standing at this giant mysterious chasm wondering if you’ve got any feelings on the other side.”

“And then you use the same tricks you use on your patients to get them to tell you why they can’t stop drinking.”

Rita smiled. “Let’s get you something to eat.”

They crossed the street with a pack of students headed towards the library and stood in line in front of the shiny metal hot dog stand. In front of them in line was a woman who appeared not to have showered in several days who was meticulously counting out nickels and dimes to pay for her hot dog and soda.

“I don’t want to shut you out, Rita,” he said, his eyes looking towards his feet.  “I just…”

Rita’s eyebrows rose gently in expectation. Solomon took her hand.

“Everything just seems very nebulous. About us. And I think that when you pry, it just exposes the fact that I’m invested in something I can’t predict or outrun.”

“But that’s okay,” said Rita. “It’s okay to feel that way.”

“Can’t we have a relationship where we eat good food downtown and you expose me to high culture and then we go back to work? That seems to have worked okay for a year now.”

“Of course not!” chided Rita. “I know you like talking about work because it’s what you know. It’s the system you grew up in. It’s the only safe place you know–”

“There you go again,” interrupted Solomon.

“Listen to me,” implored Rita. “I’m trying to tell you what I see. Will you let me do that?”

Solomon breathed in deeply, then tried to exhale. At first, it sounded like his usual growl but then he transitioned to blowing out air as slowing as possible, emptying his lungs by pushing up with his diaphragm. He looked up at Rita. “Okay. Go ahead.”

They reached their place in the line and each ordered. Solomon got an italian sausage with peppers and Rita a gyro. They continued walking east, passing the old medical school building on the left with its simple windowed dome. They sat on the marble stairs beneath the Doric columns, watching as the traffic moved west on Lombard.

“Talk to me,” said Solomon, trying to make his voice sound as nonthreatening as possible. “I’m at least willing to listen. I actually can take feedback.”

“I know you can,” said Rita. “It’s part of how you’ve become so good at what you do.”

“Then go ahead.”

“Solomon, you’re brilliant and hardworking. You really care about your patients and you’ll come in at 4AM to do what needs to be done not just because it makes you feel like a hero, but because you want them to get better.”

“This is the part that they teach you in family medicine residency about leading off your criticism by saying nice things about someone.”

“Just shut up and listen like you promised,” she chided. “You’ve learned to thrive in your world. You had a natural talent for it, sure, but you worked your ass off to get to where you are. But that’s only one piece of the puzzle. It’s great to have a fulfilling career, but without strong relationships–”

“I have strong relationships,” interrupted Solomon. “I have great relationships with my colleagues. Even the residents and fellows. No matter how much I yell at them, they still love my teaching and I still love watching them become resilient surgeons.”

“It’s not the same, Solomon. You know that other people can be safe, too, right?”

“Any human being can ultimately hurt you. The closer they are, the more damage they can do,” he observed dryly. Rita’s face fell, and he felt a slight twinge of guilt at overstating his case but then brushed it aside.

“Really, Solomon?”

He nodded. Rita’s fists began to tense and he watched her eyes light up with anger as they flitted back and forth from the street to him and then back again. She then froze in place for a second before reaching for Solomon’s hand.

“Is that what you’re afraid of?” she asked. As he looked at her, he could see that her anger had somehow melted into compassion mixed with eager inquisitiveness, as if she had stumbled upon another clue to unlocking his behavior. Her question probed him, and while he felt like she was wrong, he didn’t want to completely disappoint her like he just had.

He shook his head. “It isn’t about fear. It’s about being used to living in a certain way.”

“Well, okay, then,” she bobbed her head side to side to emphasize her sarcasm. “Well, then…”

“Aren’t you proud of me for revealing something and psychoanalyzing myself?” he asked.

“Okay, congraaaatulations!” she exclaimed. “Good for you. So now what?”

“Why don’t I just tell you why I’m feeling lousy today and we can enjoy a moment of vulnerability together before I go back and stick a needle in some viscera?”

“Are you just trying to placate me now?”

“I wouldn’t dream of such a thing,” said Solomon with a smirk. “Besides, this way we don’t have to figure out everything that’s wrong with my life before 1PM when the onslaught of patients begins anew.

“So… tell me.” Rita adjusted her hair with a hint of nervousness.

“Well,” began Solomon, “It’s the study.”

“What about it?”

“I can’t find three of my patients. I’ve already expanded my trial and we’ve added twelve new patients at this site since we started, but three of the originals missed their one-year follow-ups. My statistician is not pleased. It’s fucking up my data.”

“You have a statistician?”

“I’d love to crunch all the numbers myself or get Hannah to do it. But the medical school employs one to work with anyone who’s doing research, and with Hannah starting third year… oh, that reminds me, do you know any students?”

“None as dedicated as Hannah,” said Rita. “Unfortunately.”

“Shit. Well, I might have the money to hire a post-doc or an M.D.-Ph.D. student. I’ll have to ask Kofi. Apparently their stock price is continuing to just rise and rise, especially now that people are actually buying Hepatolife and not just getting it for free as part of the research protocol.”

“Wait, people are buying it?”

“Yes!” Solomon grinned. “You can’t just walk into a pharmacy with a script. But after we got FDA-approved, the company set up a program where anyone can register themselves, get trained, and start prescribing. Some insurances are paying, some people are just paying out-of-pocket. They’re trying to keep most of the new patients in follow-up so they can be studied, but it’s getting big. I trained six transplant surgeons and a gastroenterologist on the process last week.”

“And the GI doc is… going to be operating?”

“He wants to see if he can implant the cells endoscopically. Drop a scope into someone’s stomach, go up the hepatic duct and place the regenerated cells. More power to him, I say. Verilife is trying to figure out if they should give him a bunch of money for his study, or wait until we get more long-term follow-up data from my study. In any case, things are going good. But if I lose everyone but Adam to follow-up…”

“Well, where are your patients going?”

“No idea. We call them, we send letters…”

“Do you know anything about where they might go? What they might do?”

“I could probably dispatch my new M.D.-Ph.D. down to Lexington Market and start checking any cardboard boxes.”

“Seriously, Solomon!”

“I’m being serious. Isn’t there some team of psychiatrists that do that?”

“Yeah, it’s called the Assertive Community Treatment team. They have a few cars and find the psych patients who can’t seem to ever show up for their appointments and just give them a depot shot of Haldol. Then they do it again in three weeks. Keeps people out of the hospital and helps them with a little bit of stability.”

“You seem to know something about this,” observed Solomon.

“I have a few patients who completely turned around because of it. A few of the residents rotated with them and loved it; it really makes a difference when go to people where they live.”

“I’ve been where they live,” said Solomon softly. “I’d prefer not to go back.”

Rita bit her lip. “I didn’t say that you had to. Just… in general.”

“Perhaps Hannah would go. She’s fond of lost causes.”

“She was a little heavy with the proletariat rhetoric in our clinical medicine group her first year, if I recall.”

“I got tired of arguing with her,” admitted Solomon.

Rita gave a gentle snort of laughter. “I’d say I don’t believe you, but knowing Hannah… yeah, I can see that scenario happening.”

Solomon crinkled the aluminum foil that had held his lunch and deftly tossed the ball into a trash can ten feet away. It disappeared into the center with a soft thud. “I guess I don’t have very many choices at this point if I want to keep my data set intact.”

“Well, had you anticipated what would happen when you enrolled a bunch of sorry souls who had already drank their livers to the breaking point once?”

Solomon turned back his gaze from the trash can to Rita. “Of course I did.” His words came out sharp and defensive. “We… the protocol specifically stated that they had to be clean for six months before they could enroll. We tested their urine regularly. We kept doing so. We gave them numbers for AA meetings. There would have been 12 in the original study but 3 of them couldn’t keep away from the bottle long enough to meet the criteria.”

“Not surprising. People have their priorities.”

“Some people seem very ill-equipped at figuring out what’s really important to them.”

“You’re telling me,” said Rita, her eyebrows quickly shooting up in a knowing glance. She bit her lip gently, waiting for her next sentence as if it needed extra time to formulate. Solomon wondered as she clearly mulled her words over what it was she was about to say. He began to worry that she might be taking the opportunity to ask him about his own life priorities.

“Yeah, I see it my patients all the time. But you thought that once you fixed these guys’ livers, they’d be cured of their alcoholism?”

Solomon felt relieved that she’d gone for a lesser target. “I’m a transplant surgeon, not a goddamn sobriety coach.”

“Okay then,” said Rita with a smile. “Forgive me for trying to tell you how to do your job.”

“I… fuck. Never mind. I…”

He hesitated. His long fingers clenched one another as he turned his next thought over in his mind. He saw her eyes looking at him and then looking away, eagerly awaiting whatever it was he had to say but trying not to pressure him.

“I… think you’re right. I should have planned for it better. All the work that went into investigating molecular effects of the drug and we could have prepared differently.”

Rita said nothing but took Solomon’s dancing fingers with her own, clenching tight enough that his hand was stilled.

“And…” he started. “I… want to know how you do it.”

“How I do what?”

“How you do it. How you stare into people’s eyes when they’re lying to you and you know they’re lying to you and you still pat them on the back and tell them that you’re going to help them get clean. How you deal with all the shit our patients carry around with them.”

“Solomon, I just… that was just what I was taught to do. I assume that anyone can change if they get their priorities in line.”

“That’s all it takes, huh? Believing they can change?” Solomon shrugged. “I don’t buy it. Too simple.”

“It’s perfectly simple. If someone orders their life around getting drunk and they’ll do anything for that next drink, then consequences be damned. And if their family member has ordered their life around keeping the drunk from getting upset, well, then, congratulations, you’ve got codependency. But if someone really decides they’d rather live than drink, they’ll stand in line and pee in a cup for the big doctor downtown so they can get his magic liver medicine.”

“Then why do they go back?”

“Because when the fog of alcohol is lifted, Solomon– or the fog of whatever people use to hide their pain– they usually realize that they started drinking because being a miserable drunk was preferably to the abusive or broken life they had before. And they have to find something else to live for besides just staying alive. Sometimes that’s keeping up with the magic liver medicine and the hotshot surgeon downtown. Sometimes it’s something else.”

Rita wiped her fingers clean with a napkin, which she then tossed towards the same trash can. A gust of wind redirected the soggy brown ball towards the brick sidewalk. Rita winced slightly and shook her head, getting up to pick up her trash and place it in the can.

“Well,” said Solomon emphatically. “They certainly didn’t teach us that in transplant fellowship.”

“It’s okay, They didn’t teach us how to dose cyclophosphamide in family medicine residency, so we’re even.”

Solomon chuckled and took Rita’s hand again as she sat down. “In that case, I’ll teach you anything you want to know about transplant drugs if you’ll teach me how to do that.”

“Sure thing!” exclaimed Rita. “Go find one of your missing patients.”

She leaned over to give Solomon a quick peck on the cheek and then walked away, turning at the foot of the brick stairs to head back towards the hospital.

 

***

 

Hannah rushed to keep up with Gwen, her short white coat flapping behind her as she scurried down the long hallway. The fluorescent lights shimmered above them as Gwen’s heels clicked a steady pace. Hannah was used to walking fast, but Gwen was on a mission to get this next admission done and out of the way before the end of the day. It was already 4:30PM and Hannah had learned by now that things sped up at the end of the day as the interns tried desperately to finish up their work so they could leave before it got dark.

“Alright, normally I’d let you take the history but we’ve gotta make this snappy so I’ll just do it for now and you can ask questions next time. You can chime in when I’m finished, ask about past medical history and surgical history… and get all of her medications written down. I’ll start writing my H&P while we’re in the room and you’re talking.”

“Okay!” said Hannah, trying to formulate any other suggestions for making the process faster. Hannnah felt awkward that she was probably slowing Gwen down more than anything else since it was still only the second day of her rotation.

“Alright, so the patient is in room 41… this way.” Gwen swiped her ID in front of a badge reader, which caused two large nondescript gray doors to automatically open outwards to the hall. Hannah followed Gwen into the ER, where a maze of patient rooms with glass doors and pulled curtains exploded in front of her. She had only been down here once or twice before, and every time she had felt totally overwhelmed with the constant beeping of monitors and various people in scrubs and white coats rushing past. Gwen snatched a chart from a circular shelf behind one of the nursing stations and flopped it open in her arms as she walked, scribbling on her history & physical form as she went.

They reached room 41 and Gwen yanked back the curtain to reveal a small young woman with light brown skin sitting in bed. Her hair was carefully coiffed in an afro and her high cheekbones were rather prominent in her thin face. She averted her eyes slightly when Gwen and Hannah came barreling in, turning towards her female companion in the chair next to her.

“Miss Fisher?” announced Gwen loudly.

“Yes,” the patient answered in a quiet, high-pitched voice.

“I’m Dr. Black and I’ll be helping take care of you in the hospital. This is Hannah with me, she’s a student on our medical team.”

“Okay,” said Ms. Fisher.

“Alright, so let’s get started. I heard you’re having some chest pain?”

“Yes, ma’am,” said the patient.

“What does the pain feel like?”

“It feels tight and squeezing. It’s really uncomfortable. I feel like I can’t breathe and I get nauseous.”

“Have you vomited?”

The patient shook her head no.

“And when do you get this pain?”

“Every time I take my pills.”

“Oh.” Gwen’s eyes narrowed. “Ms. Fisher, have you started any new medicines recently?”

“Uh, no, not really,” answered the patient.

“Do you have this pain when you eat or drink?”

“Sometimes. You know it’s so hard to tell.”

“And anything makes it better?”

“No, not really. They gave me some medicine here that helped. The liquid oxycodone…”

“Okay, well, yes, everybody loves oxycodone but have you had any dizziness, headache, fevers, belly pain, swelling in your legs, rashes, or change in vision?”

“No, ma’am,” said the patient.

“Okay, and do you have any other medical problems?”

“Just some high blood pressure and high cholesterol.” The patient’s eyes darted back and further between Gwen and the woman sitting next to her. Gwen was scribbling furiously on her form. Hannah wondered why her voice sounded so hesitant, but Gwen’s questions kept coming.

“And you’ve never had any heart problems before?”

“No, doctor.”

“Okay. Well, the ER told me there was a little change on your EKG. They’re concerned about you having a heart attack. Have you been exercising lately or getting these symptoms when you go up the stairs?”

The patient shook her head again. “I don’t really exercise and since I been feelin’ bad I ain’t gone up the stairs much. I guess I do okay with stairs.”

“Okay, Hannah, you can take over,” said Gwen.

Hannah startled slightly at Gwen shifting the responsibility to her, but clutched her pen tightly as she prepared to write. “Ms. Fisher, what medications do you take?”

“Oh, I take, uh, 10mg of lisinopril and 40 milligrams of pravachol every day. Yeah. That’s it.”

“And have you ever had any surgeries?”

Another head shake.

“Do you have any allergies to any medications?”

“Uh… yes. I do. To Bactrim. I get a rash and my throat closes up whenever I take Bactrim.”

“Alright, good to know. Any family history of medical problems or diseases that run in the family?”

“My momma got diabetes. That’s it.”

“Do you smoke?”

“No.”

“Do you drink alcohol?”

“Oh, no! Not alcohol. Just wine coolers every now and then.”

Hannah was confused. “What do you mean?”

“You know, I don’t drink no alcohol… like no hard liquor or nuffin’.”

“Oh. Okay. So do you drink beer or wine?”

“I guess I have a beer sometimes.”

“Alright. Do you use any other drugs that aren’t prescribed to you?” Hannah had so far only asked one other patient this question the other day, which had led to a simple guffaw and “of course not!” that almost made her feel silly for asking in the first place. However, the patient in front of her only nervously stammered and shook her head again. Hannah wondered if she should press the issue but she saw that Gwen had already moved in to start listening to the patient’s lungs with her stethoscope. Hannah dutifully followed behind as they listened to her chest, pressed on her stomach and throat, felt her pulses, looked in her eyes and mouth, and tested the strength in all of her limbs.

“Well, good news is that your heart sounds okay. The ER was worried because you had some minor changes on your EKG, but it sounds to me like it’s a problem with taking your pills. We’ll probably still do a stress test to check your heart, okay?”

“Okay,” replied the patient. She nodded her head to express her diligent attention to Gwen’s words.

“Alright, the team will be by to see you again tomorrow. Let us know if your pain is getting worse or if you can’t swallow liquids.”

The patient began to nod as Gwen quickly disappeared behind the curtain, Hannah trailing behind. Gwen found a spot at the nurses’ station nearby and began scribbling furiously on her form. Hannah stood next to her idly, trying to mimic Gwen’s documentation of the history and physical in her own words, taking her cues from Gwen’s attempts to mutter several teaching points.

“Fucking ER… they just admit anything over 40 with chest pain and want a stress test. She has the pain when she eats. It’s probably just some reflux, nothing critical.”

“Well, should we give her some medicine?”

“Of course! We’ll give her a GI cocktail– Maalox, Zantac, maybe a little lidocaine if her throat hurts, too.”

Hannah felt a tap on her shoulder and turned around. A short, red-face nurse stood at her side.

“Excuse me, ma’am, but the patient in 41 wanted me to let you know that she forgot something else she wanted to tell you.”

“Okay, thanks,” said Hannah. “I’ll go find out what it is.”

“Hurry up, I’m going to put in her orders down here so we can get out here before 7 today,” admonished Gwen.

Hannah nodded and quickly walked back to the room. The patient was sitting up in bed, clutching her chest with a fair amount of drama. Her companion, Hannah noticed, was gone.

“Are you okay, Ms. Fisher?”

“Oh, you can call me Yolanda. My chest just be hurtin’ so bad… but you guys got it under control. I wanted to tell you while my mother in the bathroom that I also take Isentress and Truvada.”

“Oh, okay,” said Hannah, pulling out her clipboard again. “How do you spell those?”

“Uh, well, I’m not totally sure,” said Yolanda quietly. “I ain’t got the bottle with me, neither…”

“Well, then I’ll try to look them up on my phone,” said Hannah. “You said Isentress and Truvada?”

“Yes, ma’am,” said Yolanda.

Hannah turned and hustled back to the nurses’ station to report her news to Gwen, who looked up from her writing and blinked furiously.

“She takes what?” Her tone was pointed and direct.

“Isentress and Truvada.”

“Hannah, do you know what those are?”

“They only teach us generic names.”

“Oh, honey.” Gwen shook her head. “Those are HIV meds. Sister in there has got the high-five.”

“High… five?”

“H, I, roman numeral… c’mon,” said Gwen with a grin. “King Henry the fifth disease. She could have esophageal candidiasis, CMV, HSV… this chick needs a scope pronto. Fuckin’ ER couldn’t find that out?!”

“She didn’t want to say anything while her mom was in the room.”

“Jesus Christ, it’s just HIV. I thought Magic Johnson coming out fixed that shit. Does she even take her medicine? We’re gonna need to check a CD4 count, she might need antibiotic prophylaxis… fuck. We are not getting out of here on time tonight.”

“Okay, how can I help?”

“Go back and find out everything you can about this chick’s HIV. Who her doctor is, how she takes her meds, all that bullshit. Kick her mom out if you need to.”

“I’ll do it!” said Hannah enthusiastically. She hurried back to the patient’s room and immediately turned to the patient’s mother.

“Excuse me, miss, but I just had a few questions that I wanted to ask Yolanda privately, if that’s okay.”

The patient’s mother shook her head and sighed gently.

“Well, all right,” she said as she pushed herself up from her chair and slowly ambled out of the room. “Where should I go?”

“Uh…” said Hannah, having no idea what the correct answer was. “You can, uh, ask the nurse. And if you can’t find her, I guess you can go back to the waiting room. Is that okay?”

“All right.”

Hannah turned back to Yolanda as soon as the shuffling steps had faded into the distance. “So I just wanted to ask you a few more questions about the other medications you take.”

Yolanda gave a forced smile.  “Aw, hon, you really gotta know about that?”

Hannah nodded forcefully. “ How long have you known about your HIV?”

“Don’t say that so loud!” scolded Yolanda, raising her voice for the first time. Hannah felt startled and gently reshuffled her papers as she thought of her next question.

“Sorry,” she murmured. “I didn’t mean… okay, so, how long have you, uh, had your diagnosis?” Her voice was lower this time.

“ ‘bout 10 years,” said Yolanda. “I found out when I was pregnant with my little boy. Took all my medications and everything the whole time, and he don’t have it.”

“Okay. So do you know what your last CD4 count was?”

Yolanda shook her head. “It’s been awhile since I checked.”

“Like, how long?”

Yolanda smiled sheepishly. “Maybe a year?”

“Do you have a specialist that you see?”

“Well, I was goin’ to Chase Brexton but then my family moved and it be farther than I was used to. I made an appointment a few weeks ago but my daughter got sick and we couldn’t make it.”

“So have they still been prescribing your medications?”

“Well… they called me in a refill a few months ago and I been takin’ half a pill every day to make it last while I’m waitin’ for a new appointment.”

“Oh.” Hannah tried to think of what else she needed to ask. “Do you take any… antibiotic prophylaxis?” She knew as soon as the words came out of her mouth that the medical jargon was going to be lost on Yolanda.

“Oh, I supposed to be takin’ Azithromycin but you know it makes my stomach worse.”

“So you know about antibiotic prophylaxis?” Hannah’s words tumbled out slowly, expressing her surprise at Yolanda’s familiarity.

“Oh, yeah,” said Yolanda emphatically. “I used to have somethin’ growing in my brain… like an abscess or somethin’ like that. I dunno, but they said it got better so I ain’t worried about it no more.”

“Oh, okay,” said Hannah. “Have you ever had any infections in your esophagus?”

“Well, they was concerned when I first started to have this chest pain a few years ago. They put the camera down my throat then and didn’t see anything. But y’know, it just keeps getting worse and worse and lately I ain’t been takin’ any of my pills…”

“What?!” exclaimed Hannah, cutting Yolanda off. “You haven’t been taking any pills?”

Yolanda raised her eyebrows and looked around, then smiled again nervously. “Well, I mean, sometimes I take ‘em. When my chest ain’t hurting too bad.”

“So what you’re saying is that you’re taking your medications irregularly. Don’t you know that can make your H– I mean, your infection meds not work?”

“Well, they said that but I ain’t been getting fevers or nothing, so I figured I was okay…”

Hannah shook her head. “We have to get a good plan together for you. So first thing is going to be doing another scope down your throat. You could have a really bad infection. Have you been coughing or vomiting anything up?”

Yolanda shook her head. “Nothin’ at all.”

“Okay. Well, we’re going to draw some more labs and try to figure out what’s going on. And then we’ll have to scope you as soon as possible.”

Yolanda nodded. “Whatever you say, doctor.”

Hannah rushed back to the nurses’ station where she had left Gwen, only to find that her blonde mentor had disappeared. Hannah nervously leafed through the notes she had made on the back of her copy of the patient list, wondering if perhaps she could figure out what Gwen’s next step would be. She stood in the hallway for a few impatient seconds, wondering if she should stay and wait or try to go back to the team room. She finally realized that she could call up to the team room and figure out her next steps.

Hannah picked up the nearest phone on the desk where Gwen had been sitting and quickly punched in the extension. Saul answered.

“Hello, Yellow Team.”

“Hi, it’s Hannah!”

“Oh! Hannah… I thought you were with Gwen. She just called me on her cell to tell me about the new patient. Did you find out more about her HIV?”

“Yeah, it sounds like she’s not really taking her meds very consistently,” said Hannah. “She usually goes to Chase Brexton but hasn’t had an appointment there in a while. I don’t know. It’s almost like she doesn’t realize that she has a fatal disease!”

“Hmm… well, that’s not good. Gwen is calling GI right now and then she’ll present to the attending. If the patient’s vital signs are stable, they may wait to scope her in the morning. Listen, you made a good impression with Mrs. Redner, right?”

“Yeah, we talked for a little while yesterday afternoon. Why? I thought she was getting discharged.”

Saul chuckled. “Well, Gwen wrote the order but I just got a call saying that she’s refusing to leave. Can you go talk to her?”

“Sure!” Hannah heard her voice disappear into the receiver, then felt a horrified tightness in her own chest as she wondered what she would say to the poor old woman.

“Alright, thanks!” Hannah heard the harsh shuffle and click of the phone hanging up. She sat with the phone still on her shoulder for a few more seconds, staring down at her list at Mrs. Redner’s name and information. She wondered what she would say– what concern or complaint would make anyone want to stay in the hospital. She put the phone back on its base and wandered back out of the ER and towards the elevators.

Up she went, nervously glancing around at the stainless steel walls and a faded poster encouraging all staff to wash their hands to prevent the spread of communicable diseases. She remembered that she hadn’t washed her own hands after seeing Yolanda. Who knows what sort of terrible bacteria were growing on her immunocompromised body?

She finally reached Mrs. Redner’s room and took a deep breath before going in. The patient sat upright with her skinny legs dangling off the bed, her arms crossed defiantly. She raised her eyes to Hannah, prepared with a glare that disappeared with surprise.

“Oh, it’s you.”

Hannah folded her list away. “Yes, Mrs. Redner. It’s me, Hannah. What’s the matter?” She walked closer, remembering that she had been taught to sit down if she could, especially for important or difficult conversations. She anticipated that this would probably be the latter, although she wondered if it would approach the former. She dragged a chair from the other side of the bed over so she could face her patient.

“Well, you all haven’t done anything for me and I’m going home and I still feel sick.”

“Mrs. Redner, I’m sorry that you still feel sick.” Hannah wanted to be empathetic. She felt like she was failing desperately as she pulled up a chair to sit down and face her patient. “But… the GI doctor looked down your throat and he said everything looked normal. You had another CT scan– you’ve had six now– that was normal. None of your labs have changed.”

“Then why I am so nauseous?”

Hannah thought back to what Gwen had said this morning as they discussed Mrs. Redner in the team room. That she was a lonely old woman who only had a decent conversation with another human being when she went to the hospital.

“Um…” mumbled Hannah. “I guess sometimes people can feel sick even though their bodies look normal.”

“But why is that?”

“Well… is there anything that has been more stressful or difficult for you lately?”

Mrs. Redner shook her head defiantly. “No, everyone always says it’s all in my head and I should just shut up about it! Well, I’m not going to shut up!”

Hannah reached out a hand to touch, finding the the old woman’s wrinkled fingers. Their eyes met for a few seconds before Hannah spoke.

“I think it’s a really good thing that you’re not going to give up. But I think you should try to think about how you can make your life better even if you do feel nauseous.”

Mrs. Redner shook her head, her gentle gray curls quivering as she did. “I don’t know what I can do if I feel nauseous.”

“Well, is there something you want to do?”

“I’d like to quilt again.”

“Can you still do that?”

“No.” Mrs. Redner clutched Hannah’s hand, then relaxed. “Well… I mean, I think I could try a few little things.”

“Do you have any friends or children that could take you to a quilting circle or something like that?” Hannah realized that she knew absolutely nothing about quilting, but she had to suggest something to keep the flow of conversation going in the direction she wanted it to.

“All my friends are dead. And my daughter… I haven’t talked to my daughter in years.” Hannah noticed that the sagging eyelids were starting to blink more aggressively, trying to conceal a growing redness and tears.

“Oh, Mrs. Redner, it’s alright.”

The patient shook her head again, this time releasing her tears with a gentle sob. “Oh honey, you don’t know. You don’t know.”

“It’s okay.” Hannah kept trying to recall the lecture she had received about talking with patients about grief. Just listen– that was all she could remember. Offer a tissue. Her eyes scanned the room frantically for a tissue box. She mouthed a silent, irreverent “Thank you sweet Jesus” as she spotted one on the nightstand. She reached over and grabbed the box, half-forcing it into Mrs. Redner’s lap.

“Oh, thank you, sweetie,” she said, taking a tissue and giving a long blow with her nose. “There… there is something. Something I’ve never told anyone.”

Hannah’s heart began to beat faster.

“What… what is it?” she asked.

“Well, you have to promise not to tell anyone,” said Mrs. Redner. “Do you promise?”

Hannah nodded. “Absolutely. Patient confidentiality.”

“Okay. All these years, you’re the first person to know.” Hannah watched as her pale pink lips quivered, beginning to tell the story.

“When my daughter was 16… well, all the time she used to get so upset when I would go out by myself. We used to fight about it and I felt like she was just jealous because I was getting dressed up in all my make-up and having fun. I thought she was just being silly and she was mad because she wasn’t as popular at school as she wanted to be. I should have known.”

“Should have known what?”

Mrs. Redner shook her head, then sobbed again. “I… I can’t say it.”

“What is it, Mrs. Redner? Tell me. It’s okay. Your secret is safe with me.”

“Well, when she was 16 she told me… it was her father. He… he touched her.”

Now it was Hannah who felt unbearably nauseous. She tried not to react too obviously, but her face was clearly overtaken with the same sensation as her stomach.

“I’m so sorry, Mrs. Redner. That must have been horrible to find out.”

“Well, he was a successful businessman, and he made good money. I knew that he’d been with other women, but… never anything like that. I wasn’t afraid of him, but I was afraid of what would happen… if I would get in trouble. She was so mad at me for not protecting her. So I told her that she was making it up.”

Hannah’s eyes again anxiously darted across the room, this time looking for a bucket to throw up in. She clutched her stomach gently and could only shake her head in sorrow as Mrs. Redner continued.

“So I finally divorced him, and I made sure she was never alone with him again. And she asked me, she kept asking me if I believed her. Every few years, she would call me.”

“And… what did you say?” Hannah let herself hope for a few seconds that there had been some sort of reconciliation between mother and daughter, that somehow in finally telling this story her patient would be free from the somatized symptoms that had plagued her for years and had led to endless procedures and tests.

Mrs. Redner wept loudly again. “I kept telling her I don’t know. I didn’t know if she was telling the truth. I got her away from him, isn’t that what she needed?”

Hannah felt her own tears welling up in her eyes. She reached for a tissue for herself and took a deep breath to try to stem the flow.

“Well… sometimes people need to feel safe in their mind, too. And part of that is vindication. Like trying to be affirmed. Like… I don’t know how to say it. I’m getting confused. I’m just so sorry that it had to happen like that.”

“It was so terrible. Why couldn’t she be happy with me?”

Hannah bit her lip. Against her better judgment, she looked down at her watch. It was already past 6 and she still had to help Gwen write up Yoland Fisher.

“Mrs. Redner… do you feel better having told me?”

The old woman nodded. “You’ll keep it a secret, right?”

“Yes,” said Hannah. “I’ll keep it a secret. Are you… ready to go home?”

“I guess I don’t have a choice,” said Mrs. Redner. “There doesn’t seem to be anything you can do for me in this hospital.”

Hannah shook her head, swallowing back to suppress the tears in her eyes and the acid in her throat. “I guess not.”

 

 

Chapter 9 will be released on May 1, 2015.

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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