Chapter 11: November 2011

Jessi knew that something was wrong the moment that her key slid inside the security door. It normally gave her some resistance as she tried to put it in and turn it, but it passed easily into the keyhole. She then could not turn it, as it was already unlocked. She wondered if perhaps she had forgotten to lock it on her way out– she had been in such a hurry to catch the bus in order to make it to Tanisha’s house in time to watch the kids that she had forgotten her cell phone.
She opened the security door and pulled out the key for the inside door, which took her key with similar ease. A feeling of horror gripped her chest, similar to the pressure that she felt whenever she walked too fast or climbed too many stairs and the clogged arteries in her heart could not deliver oxygen to her myocardium fast enough. She took a deep breath, wondering if she should even open the door.
“Lord, have mercy,” she whispered, looking behind her. The street was vacant and the only light came from a desolate streetlamp on the other end of the block. That was the alternative. She slowly twisted the doorknob and pushed the door open, standing on the step.
“Anyone in there?”
No answer. The kitchen light was on– she may have forgotten that, too– but she heard nothing from inside. She tentatively took a step in, pushing the door further open. It creaked as it drifted further open, bringing a rush of cold air from the street past Jessi and into the living room. She reached her hand inside and felt her way to the light switch.
The living room became gently illuminated by a single lamp next to the couch. Jessi gasped. The first thing that Jessi noticed was the missing television, as its presence on the wall opposite the door was usually noticed by most visitors when they first came in. The table next to the TV stand was knocked over, with magazines spread across the floor, glossy pictures of celebrities smashing against diabetic recipes. She whispered another prayer under her breath as she surveyed the damage.
She could see her cell phone perched on the kitchen counter, dangling precariously only a few inches from where she had left it. She wondered if she should risk walking the next block over in the dark to use her neighbors’ phone to call the police or if she should just make a dash for the phone. She stood in her doorway, paralyzed by the terror she felt, every gust of the wind making her shiver again in fear. Her right hand was imagining what it would feel like to dial 911; the rest of her body was frozen stiff.
“Who’s there?” a voice mumbled. She finally gave forth a shriek, which resulted in a commotion that she could barely detect out of the corner of her left eye. She turned to see a figure flailing on the couch, struggling to get up. She slammed the door and panted for breath, then began fumbling with the key to lock it from outside so as to give herself time to escape. The key slipped in her hand, falling to the concrete with a harsh clink. She screamed again as she turned and eased herself down each step as the door opened behind her.
She tripped, falling hands-first onto the cold sidewalk. Her palms burned as they scraped against the concrete, but the pain was barely noticeable in her terror. She rolled herself over awkwardly, trying to get a good look at her intruder before he came down the stairs. The large body, wider at the waist than the shoulder, stood silhouetted in the door and then began to sway.
“Jessi? You okay?”
Jessi sat up, pushing her raw skin against the ground again. She slowly rose, her chest heaving. Her lungs burned with every breath. As she stood up, she could see the man standing in the doorway much more clearly.
“Gainers, what the hell is going on?”
Gainers stuttered incomprehensibly, grasping for words and clearly not finding any.
“Gainers!” She clenched her fists and shook them as she started to climb the steps again. Gainers put up his hands and backed into the house as she did, shaking his head as if to ward her away. He stumbled and tripped over the couch, righting himself slowly as she reached the doorway and slammed the door behind her. Her mouth was curled in inexpressible anger and her nostrils flared, trying desperately to get enough oxygen into her lungs. She clutched her chest.
“I… well, some of the boys needed a warm place for the evening.”
“The boys?”
“Yeah, uh…”
“Which boys? The ones you play checkers with on the corner?”
“No, y’know, some boys been hookin’ me up lately…”
“Hooking you up!” Jessi roared. Her nostrils were now taking in the thick scent of beer. She could now see that there were several empty bottles on the kitchen counter and the floor.
“Well, they been lookin’ out for me…”
“Gainers, have they been helping you score drugs?” Jessi’s tone became slower and more deliberate. Each breath was still painful and her chest still ached, pressing in as if she had been trapped in a vise. Gainers was now only mumbling to himself.
“No, no, no drugs, just some food, no drugs, no drugs.”
“Did they take the TV, too?”
“I… uh… they, y’know. I don’t know.”
“Get. Out.”
Jessi thrust one hand backwards, her index finger pointed directly at the door. Gainers shook his head.
“Go!”
She bent over and grabbed his lapel, still moist with sweat and spilled beer. She could not lift him, but she tore his shirt as she tried. He yelped in fear, his legs scrambling on the floor towards the door. She reached for a beer bottle and swung it in his direction, missing by about four feet. The bottle landed with a clunk against the leg of the couch against the door.
“Go!”
She picked up another one and threw it at him, this time getting much closer but still missing. The bottle hit the door and shattered, breaking into a shower of green glass across the floor where he was writhing. He pulled himself up by the door handle and threw the door open, stumbling out to the security door. Another bottle whizzed by his head and gave a loud crash as it hit the door frame. As he reached for the handle of the security door, she lunged forward as if to push him out. He cried out as the door gave way and he tumbled out into the night.
He stumbled down the stairs, forced more by the strength of Jessi’s shouting than the strength in her hands as she pushed him. He tried to whip around to point an accusatory finger at her, but lost his balance on the last step and tumbled backwards onto the sidewalk. She picked up the keys from the top step, locked the security door, and then slammed the inside door.

***

“Hannah!” cried Dr. Chambliss, throwing up her hands in excitement as Hannah walked up the long ramp inside the University of Maryland Family Medicine clinic. The narrow walls were decorated with faint pink and green pastel patterns; Hannah noted that the handrails in the center of the wall and the white trim at the floor has been re-painted since the last time that she was here. She reached the top of the ramp, where Dr. Chambliss was holding a thick chart.
“So, you’ve finally made it to your family medicine rotation, huh?”
“Finally!” said Hannah with a nod.
“And you’re working with me to start off this morning? Just like old times in our clinical medicine group!”
“Yes, indeed!”
Dr. Chambliss smiled. “I’m glad you’re here, Hannah. Here, let me introduce you to my MA this morning.”
She turned around to face the computer station behind a tall desk, where a young woman wearing Thanksgiving-themed scrubs was sitting at a computer, clicking away. The walls around the crowded team space were dotted with doors leading to patient rooms on all sides; all but one had charts sitting in plastic sheaths attached to the front of the door, indicating that a patient’s vital signs had been taken and they were ready to be seen by the doctor.
“Angela, this is Hannah. She’s one of the new third years and she’ll be working with us today.”
Hannah extended her hand over the desk to shake. Angela, who was a slim, young African-American woman wearing a long weave interwoven with bright red strands, broke her screen-held trance in front of the computer after a long pause and then stood up to return the handshake.
“Nice to meet you, Hannah. Are you here with us all month?”
“I am,” said Hannah.
“You’ll have fun working with Dr. Chambliss. Just try to keep her movin’ and on time, y’hear?”
Dr. Chambliss laughed. “Oh, Hannah’s just as good as I am at listening to patients, so we may have some issues with that!” She turned back to Hannah. “You had orientation this morning with Dr. Friedman, right? So you’re all ready to go?”
“I guess so,” said Hannah. “Are all these patients in the rooms yours?”
Dr. Chambliss laughed. “Thank goodness, no! Dr. Kazic is also seeing patients here. You may remember him– he was a resident here and just became a faculty member in August.”
Hannah scrunched her face as she tried to remember. She had met a lot of family medicine residents during her first two years of medical school and couldn’t remember very many of them. Just as Dr. Chambliss opened her mouth to speak, however, she caught a glimpse of a tall, burly man with thick silver-and-black hair emerging from a patient room on the far side of the team station.
“Yes! Now I remember,” said Hannah. “Dr. Kazic took us around the hospital one day for our clinical medicine course. He taught me about egophony!”
Dr. Kazic lumbered over to where Hannah and Dr. Chambliss were talking. He clapped one large hand on Dr. Chambliss’ shoulder and extended his other hand to shake Hannah’s.
“Vazhir Kazic. It’s good to see you again. I think I met you back when I was a resident…” His accent was almost as thick as Hannah remembered. She did her best to return his firm handshake, but her hand felt almost swallowed up in his.
“Apparently, you taught her egophony,” chimed Dr. Chambliss.
Dr. Kazic guffawed loudly. “I’m so glad you remember! I think I was post call that day. I certainly don’t remember a thing besides your face. That and you wanted to stay and learn as much as you can!”
“I’m Hannah Wells,” she said. “I’m a third year and this is my first day on Family Medicine.”
“Good to have you here,” he replied. “First day again? Time flies. Do I have a student this morning, Dr. Chambliss?”
“I don’t know, you should have gotten a schedule,” said Dr. Chambliss. “Unless Barry forgot to give them out again.”
“Well, I’m sure I’ll find out soon enough,” said Dr. Kazic. He turned back to face the computer station where Angela was sitting. “Angela, I’m going to need you to draw some blood for me…”
Dr. Chambliss pressed the chart that she was holding forward into Hannah’s hands. “Why don’t you go in Room 3? Mrs. Brown is a patient of mine that’s here for her blood pressure follow-up, I’m sure she’d be happy to talk to you. Here’s her chart.” It was thick & heavy. Hannah nearly dropped it as she tentatively accepted the manila folder filled with white, green, blue, and pink papers.
“Isn’t there an EMR in the clinic? That’s what Dr. Friedman had us going through this morning…”
Dr. Chambliss sighed. “Yes, but for the patients who have been here for a long time, they’re still archiving all the paper charts and putting the information into the computer. So her old labs and notes are still in the paper chart, unfortunately…”
“Okay, no problem,” said Hannah quickly, as she usually did whenever she was assigned a task by an attending or resident. She quickly thought that she might very well have problems trying to look through a paper chart and a computer chart while having a conversation with Mrs. Brown. She then remembered Dr. Friedman’s advice from the morning’s orientation: face the patient during the whole encounter and figure out how to chart it later.
Dr. Chambliss quickly disappeared into Room 2. Hannah walked up to Room 3 and stared at the front of the chart. The front of the well-worn manila folder bore only a small sticker with Pauline Brown’s name, date of birth, and medical record number. Hannah flipped open the chart to find the last note from 9 months ago in Dr. Chambliss’ careful, large cursive script overwhelming the preprinted boxes for history and physical exam on the “follow-up visit” template. On the left-hand side of the folder was a medication list and problem list in the same handwriting.
Hannah looked up again at the door, knowing that if she did not enter soon, it would be clear that she was being overtaken by her anxiety about trying to gather enough information to the patient and then report back to Dr. Chambliss– the same anxiety that preceded every interview she did alone with a patient. All she had to do, she told herself, was walk in, introduce herself, ask if the patient had any concerns, and then go through the same review of systems that Dr. Chambliss had dutifully checked off on the last note– without, of course, staring at the chart the whole time instead of looking Mrs. Brown in the eye.
She knocked.
“Come in,” came a muffled voice from behind the door.
Hannah put a sweaty palm on the doorknob and turned. She walked in and quickly sat down on the rolling stool, remembering Dr. Friedman’s pearl from this morning about the importance of sitting down to talk to a patient instead of remaining standing for the whole visit. The woman sitting on the exam table was a thin, neatly dressed African-American woman. Her hair was gently pressed and she wore a gray suit with a skirt and black pantyhose. Her feet dangled anxiously, the edge of her black leather pumps brushing against the exam table every few seconds.
“Hi, I’m Hannah Wells. I’m a medical student working with Dr. Chambliss. Is it alright if I come talk to you?” Hannah extended one hand, still sweaty, to the patient, who gently shook.
“I’m Pauline,” replied the woman quietly. “It’s nice to meet you.”
“Nice to… meet you too,” said Hannah, turning quickly on the stool and placing the chart on the computer desk. The dull gray login screen for the EMR faced her; she promptly entered her username and password before remembering that she had vowed not to turn her back on the patient. As the EMR opened on the screen, she turned again, this time faster than before. Her hair billowed gently into her face as she quickly asked her next question.
“So, what would you like to discuss today?” A nice, open-ended question.
“Well…” Mrs. Brown’s eyes began wandering around the room. “Dr. Chambliss just wanted me to come in for a blood pressure check. I need a refill on my medicines.”
“Okay, which medicines?”
“Um, just my lisinopril-hydrochlorothiazide.”
“Okay.”
Hannah, realizing that she had nothing to take notes with, fumbled in the pocket of her short white coat for a piece of paper. She found a handout from this morning’s talk and scribbled “lisinopril-HCTZ” on the back of the page. She then looked back up at the patient, whose gaze had become fixed on Hannah.
Crinkling the page in her fingers, Hannah tried to avoid direct eye contact while she thought of what to say next. Dr. Friedman had said this morning that they ought to let patients direct the agenda of the interview, but Mrs. Brown didn’t seem to have much of an agenda besides getting her prescription and honoring Dr. Chambliss’ request to come in. Her thin hands fidgeted.
“So, have you had any bothersome symptoms or side effects?” asked Hannah.
“From the medication?” Mrs. Brown shook her head. “Been taking it for years. Always controlled my pressure fine.”
Hannah, realizing that she had not looked at the vital signs for Mrs. Brown, spun her chair around again as she realized that she would have to look at the computer to see them. She clicked through several screens to get to her patient’s chart, then stared at the numbers.
“Looks like… your blood pressure is not at goal today.”
“Not at goal?” Mrs. Brown’s voice rose with concern. “What do you mean?”
“Well, it’s just higher than it should be. The goal is less than 140/90, and today your blood pressure is 164/92.” Hannah rose from her stool. “But that’s okay, I can recheck it myself and we’ll see if maybe it was just a mistake with the automatic blood pressure cuff.”
“Alright,” said Mrs. Brown quietly.
Hannah pulled the manual blood pressure cuff from its perch on the wall as Mrs. Brown shed her suit coat, revealing a white blouse underneath. Hannah wrapped the dark blue cuff around her arm and velcroed it shut, then fumbled with her stethoscope and the inflating bulb until she had balanced the diaphragm of her stethoscope in the crook of her patients’ arm and had both earpieces in. She bent over so she could look directly at the gauge hanging on the wall, then twisted the knob between her thumb and first finger to close the valve before she started to squeeze.
Hannah’s nervous hold on her stethoscope caused indistinct scratching noises as she struggled to hold it still enough. The needle on the gauge rose in spurts until it reached 200, when she stopped squeezing and twisted the knob backwards to release the pressure. The firm clicks of blood escaping through Mrs. Brown’s arteries became audible right at 160, then disappeared somewhere in the 80s as Hannah let the air out of the cuff.
“So… still the same,” she said, pulling her stethoscope free of her ears.
“Well, I been under a lot of stress lately,” said the patient brusquely. Hannah watched her eyes, which were again turning towards another part of the room. There were defenses going up, but Hannah could not make sense of where or why.
“Did you take your medicine this morning?”
“Just like every other day.”
Remembering yet another pearl from Dr. Friedman’s lecture about taking a history, she decided to assess compliance in a non-threatening fashion. “A lot of people miss doses of their medication. Does that ever happen to you?”
Mrs. Brown shook her head. “Got an alarm on my cell phone. I take it with breakfast every morning before I leave for work.”
“Okay, well… do you eat a lot of salt?”
“Not any more than usual.”
“Uh, then… no other symptoms you’re having? Headaches? Blurry vision? Numbness? Tingling? Chest pain? Trouble breathing? Swelling in your legs?”
Mrs. Brown continued to shake her head. “No symptoms. Trouble sleeping.”
“Fatigue during the day or feeling tired?”
Hannah watched carefully as Mrs. Brown’s countenance changed. As she pondered her answer to Hannah’s question, Hannah took a deep breath and wondered where the defensiveness was coming from. Here was a professional black woman who perhaps felt accused of mismanaging her health by the young white medical student. Perhaps she could redirect the interview to something a little less tense for a few minutes and then get back to the blood pressure.
“Yeah, I feel tired a lot. I figure it’s cause I can’t much sleep at night.”
“How much sleep do you get?”
“Maybe 4 or 5 hours most nights.”
“I’m sorry to hear that,” said Hannah. Mrs. Brown made eye contact with her again.
“It sure ain’t easy. I just lay in bed and can’t sleep. Then I’ve got no energy for the next day and can’t concentrate.”
Realizing that she had just described three symptoms of depression, Hannah decided to ask about the other symptoms.
“Have you, uh, lost interest in activities that you normally find pleasurable?”
Mrs. Brown’s eyebrows raised slightly, then she furrowed her brow. “I guess. I just come home and make dinner for my kids– or we just order Chinese. I’m so tired that we don’t do much except watch TV. Not too much is– what’d you say? Pleasurable?”
“Yeah, pleasurable. Enjoyable. Things you used to like to do.”
“It’s just not the same anymore.”
“Okay. Do you have feelings of guilt?”
“I do.” Mrs. Brown gave her first nod that Hannah had seen. “I feel guilty for…”
Hannah, realizing that she was still standing, let the blood pressure cuff go and sat back down on the stool. However, when she looked up again she noticed that Mrs. Brown’s large brown eyes were becoming encircled by red streaks as tears began to form. Spying a box of tissues in the corner next to the sink, Hannah’s hand darted over and thrust the box forward. Mrs. Brown smiled and gave a small laugh at Hannah’s eagerness before taking a tissue and dabbing both eyes.
“I just feel like… my kids are teenagers, and I should be there for them, going to their games and helping with their homework. Everything’s just such a chore.”
Hannah nodded. “And you said that you have low energy and trouble concentrating. How about your appetite?”
“Oh my God, all I ever want to do is eat. I skip breakfast, but then I stuff my face all day long. I gained eight pounds since my last visit.”
Hannah almost verbalized a connection between weight gain and blood pressure, but bit her tongue. “Any, uh, psychomotor symptoms?”
Mrs. Brown furrowed her brows in confusion. “Psycho what?”
Hannah gave a small, awkward laugh. “Sorry about the doctor talk there. I mean, like feeling slower or faster. Or twitching a lot.”
“I’m always tapping my feet or something like that. Like I have a lot of nervous energy.”
“Okay. And… last question. It’s an important one. We ask everyone with these kinds of symptoms.” She took a deep breath. “Have you had any thoughts about… hurting yourself or others?”
Mrs. Brown began to shake her head again, but then stopped. She clenched the tissue in her hand, looking down at the floor and then up again at Hannah. “I’d never do that. My kids mean the world to me, and I know it would hurt them so much… but sometimes, you know, they get to fussing with me and I wonder if everyone would just be better off without me around.”
“I see,” said Hannah. Looking down at her paper, she saw that she had written out SIGECAPSS– a mnemonic she had learned back in second year– to guide her as she asked her questions. There was a check mark next to each one. She looked up again, where Mrs. Brown was blotting away another tear.
“Well, it looks like you have all the symptoms of depression, Mrs. Brown.”
“Depression?”
Hannah nodded.
“Well, I can’t say I ever thought of it like that. Just a lot of stress.”
“I know it can be a hard thing to think about, but there are a lot of good treatment options. Both cognitive-behavioral therapy and medication have been shown to be helpful in treating depression.”
“Oh, okay.”
“So… what would you like to do?” Hannah looked up eagerly, hoping that Mrs. Brown would say “both” and she could start sharing her knowledge about antidepressants. However, Mrs. Brown blinked suddenly, as if Hannah had spritzed her in the face with cold water. She began looking away again.
“Well, I guess I’ll just take the pill.”
“Um… okay. Well, there are a few different options…”
“Aw, you can just use whichever one you think is best.”
“Well, alright then. I’ll go talk to Dr. Chambliss about what she likes to use.”
“Okay, that sounds good.” Mrs. Brown crumpled a tissue gently in her fingers.
Hannah clumsily turned again to exit out of the program she had up on the computer, then rose to the door. She grasped the handle, wondering if there was anything else that she could say. As her fingers twisted the handle open, she turned back, trying to find eye contact again with Mrs. Brown.
“Thank you… for opening up and being honest with me.”
Mrs. Brown let another tear go. “You’re welcome.”
Hannah carefully moved out the door, taking a deep breath as she shut it behind her. Dr. Chambliss sat behind the nurses’ station, intently focused on a computer in front of her until Hannah approached and quietly said her name.
“Well, hi! How is Mrs. Brown?”
“Uh… okay, I guess?”
“Tell me what’s going on.” Dr. Chambliss moved her chair to face Hannah, intentionally turning her head away from the screen that had just been captivating her attention.
“Mrs. Brown, as you know, is a 48-year-old woman who is here for follow-up of her hypertension, but she’s also got all the symptoms of depression.”
“Oh, really?”
“Yes– and her blood pressure is not controlled, either…”
“Go ahead and give me the history first, please,” requested Dr. Chambliss.
“Oh, okay, yes. Well, I know you’re supposed to talk about her actual blood pressure with vital signs to start off the physical exam part of my presentation. And… she has no new complaints, denies any symptoms of elevated blood pressure. But when we talked about her blood pressure, she said that she felt like it was ‘stress’ and so I went through all of SIGECAPS. She was positive for all of them!”
“Hmm. She’s talked about some stressful things before, but it’s never been that bad. So which symptom is bothering her the most?”
Hannah pursed her lips. “I’m not sure… she mentioned sleep first.”
“That’s a tough one for a lot of people. Did you find out anything about her sleep hygiene?”
“What’s sleep hygiene?” asked Hannah.
Dr. Chambliss furrowed her brow. “You haven’t learned about sleep hygiene?”
Hannah shook her head.
“What do they teach you in your first 2 years?”
“Uh… lots of things about genomics. Apparently it’s the medicine of the future or something like that.”
Dr. Chambliss’ hands rose in exasperation, but she quickly put them down and rolled her eyes. “Well, it’s a good thing you’ve still got your Family Medicine rotation. Sleep hygiene is just the behaviors around sleep that are important in order to get good sleep– going to bed and waking up at the same time every day, minimizing the use of screens, keeping the bedroom cool, dark, and comfortable.”
“All the things we didn’t do when we were studying all the time.”
Dr. Chambliss chuckled. “Exactly.”
“Well no, I didn’t ask her about that.”
“Okay, we can do that when we go back. Sometimes just helping someone sleep better will help their depression or ADD or whatever other mental health issue they’re having. You should always ask about snoring, too– for sleep apnea. Makes hypertension worse, too.”
“Oh, right,” said Hannah. “They did say something about that in one of the lectures.”
“They’ve got that, at least,” said Dr. Chambliss. “So, what are the things that she’s stressed about? Is it her son?”
“Um…” Hannah pulled out her piece of paper with notes, scanning through her hastily scribbled words for anything she might have written that answered Dr. Chambliss’ question. She nervously looked back up at Dr. Chambliss, wondering if there would be anything else that she could mumble to take away the shame of having forgotten to explore such an obvious question. “I… didn’t ask.”
Dr. Chambliss smiled. “That’s okay. In fact, let me tell you now at the start of your clinical career… it is always okay to say that you never asked if you forgot.”
“Okay,” said Hannah. “And… I rechecked her blood pressure, which was consistently 160s/90s but I forgot to do any other physical exam.” Hannah felt her cheeks flushing. She had thought that she was prepared for this encounter, but realizing how many basic steps she had missed during her conversation was painful.
“So, then, what’s your assessment and plan?”
“Well, in regards to her blood pressure, I think we ought to go up on her lisinopril and check some routine labs, like her creatinine and urine protein to make sure she’s not having any kidney damage that’s making it harder for her blood pressure to control.”
“Good! She hasn’t had labs in a year, so she’d probably be due anyway.”
“And for depression… well, she’s not suicidal. I tried to explain about medication and CBT, but she said, ‘Just give me the pill.’ I’m not sure she really understood.”
“It can be tough to communicate those concepts to patients in ways that they understand. But you’ll learn that, don’t worry. Let’s go back in.”
Hannah took a deep breath. “If you say so. I made her cry.”
Dr. Chambliss smiled. “You’re going to get to see a lot of people cry in this job. It’s a privilege to be a witness to so much pain and to have people open up to you so that you can help them to get better. Don’t take it lightly.”
“Don’t worry, I won’t.”
Dr. Chambliss led Hannah back to the door, knocked once, and then burst in. “Pauline! It’s good to see you!”
Mrs. Brown rose from her seat on the table to give Dr. Chambliss a hug, which she held for a few seconds before whispering. “Doctor… I’m so sorry it’s been so long.”
“Oh, don’t say that! I missed you, but at least I got to see you with Johnnie a few months ago.” She quickly turned to Hannah. “I see her son– he’s 16 years old and he has a bunch of chronic health issues.” She turned back. How is he?”
“Oh, Lord, don’t get me started…” started Mrs. Brown as Hannah closed the door. “He done fell out and now they’re sayin’ he’s got epilepsy.”
“ Epilepsy? I’m so sorry. “ Dr. Chambliss’ hand rested on Mrs. Brown’s arm as their hug ended. “I haven’t seen him, I assumed he was okay…”
“I know, he needs to follow up with you now. But he’s got appointments with the neurologist and the psychiatrist and the endocrinologist to keep up with…”
“I understand. My job is to help keep all of them in line and keep you from getting too overwhelmed. But I know it can be hard when you’re in the middle of a diagnosis. So that’s been stressing you out lately? Hannah was telling me you’re under a lot of stress.”
Mrs. Brown nodded. “That… and my brother has all of these problems, his blood pressure is higher than mine, he doesn’t have insurance and he’s just waiting until January when the statewide single payer kicks in so he can get covered and get it all taken care of.”
“Are you giving him your medicine?”
Once again Hannah watched as their patient tried to look away, as if a more palatable question were hiding in the corner. “I ain’t gonna lie…”
“Listen, the two of you taking half as much medicine as I prescribe is gonna give all three of us a stroke. There’s a free clinic just east of Hopkins; they can at least write him the prescription for one time and I’ll start seeing him in January when Access Maryland takes over.”
“O-kay,” mumbled Mrs. Brown. “So, are you gonna give me a pill for my, uh, depression?”
Hannah winced as she heard the word, which was pronounced with obvious alacrity. Perhaps, she thought, for Mrs. Brown mental health diagnoses were stigmatized and Hannah had simply steamrolled her.
“That depends. What are you doing to take care of yourself? Time alone? Friends? Prayer? Exercise?”
“Don’t get much time alone. Haven’t exercised in a year. My friends are… too busy for me. I pray, but not nearly enough. The only thing I do to take care of myself is… eat lots of chocolate.”
Both women guffawed loudly, with Hannah joining in after a moment.
“Oh, Pauline, let me tell you, chocolate is a heavy-duty antidepressant but it has a few side effects. If you know what I mean.”
Mrs. Brown laughed again. “I do know what you mean. Heavy-duty side effects. So you ain’t gonna give me a pill?”
“Well, that’s up to you. A pill can only change a little bit of your brain chemistry and give you a little bit more clarity, and if your problem is that you’re up all night worrying about your son and your brother and who knows what else, a pill is not gonna do much.”
“So what’s wrong with me? I thought depression was, y’know…”
Dr. Chambliss looked intently at her patient as the words trailed off, somehow intuiting the rest of the sentence in the silence.
“Depression is just a word we use to describe feeling down or not being able to function at your best. You can call it whatever you want– stress, depression, feeling overwhelmed– and it has a lot of different ways that it shows up in people. It has a lot of causes, too– what’s going on in your life, your brain chemistry, all those things. It doesn’t mean you’re crazy, doesn’t mean you need to take medicine, and doesn’t mean that you’re bad. You just have to feel comfortable admitting something’s wrong and then deciding whether or not you want to get better.”
“So… I guess I need this cognitive stuff, then?” She pronounced cognitive with the same inflections that she had depression, as if it were a foreign food that had been placed on her plate and she had to eat it for the sake of being polite to her hosts.
“I do like therapy or counseling for my patients, absolutely. You can call that whatever you want– some people just call it someone to talk to. Do you have someone you can talk to, someone you can lean on?”
Mrs. Brown nodded. “My sister. She’s always there for me. I get worried sometimes that I’m a burden to her, but she’s been looking out for me. So… then I don’t need a therapist, do I?”
Dr. Chambliss finally sat down on her stool. “Well, sometimes people use therapists so they have a listening ear, but I prefer to have you talk to someone who can give you some tools and tricks to help you deal with your feelings instead of just sitting there feeling miserable all the time.”
Mrs. Brown took a deep breath in, appearing pensive. “I guess that makes sense.”
“I’ll give you the number for someone nearby and I’ll let you call when you’re ready. Is that okay?” Dr. Chambliss opened the EMR herself and started typing some instructions in to print out. Hannah looked back at Mrs. Brown to cover the ground that she had missed earlier.
“So your sleep isn’t so good, you were saying?”
Mrs. Brown shook her head. “Terrible. Can’t get to sleep, always feeling tired.”
“So, do you usually go to bed at the same time every night?”
“Not really… some nights I stay up and watch TV, other nights I’m helping Johnnie with his homework. But when I try to turn everything off and go to sleep, I can’t.”
Dr. Chambliss gracefully spun around on her stool. “The light from the TV will make it harder for your brain to sleep. Best to turn it off an hour before you want to go to bed.”
“And going to bed at the same time every night will help your body set a natural rhythm,” Hannah chimed in.
Mrs. Brown nodded slowly. “I’ll try it.”
“And as far as your blood pressure goes… I’ll just have you take your medicine every day and come back in a month. Sound good?” Dr. Chambliss rose and quickly donned her stethoscope, giving Mrs. Brown’s heart and lungs a perfunctory exam. Hannah followed behind, placing the bell of her stethoscope all over the patient’s chest so quickly that she barely heard anything.
“You ain’t mad at me?” asked Mrs. Brown.
Dr. Chambliss chortled. “Mad at you? Why would I be mad at you? If I got mad every time someone took their medicine the wrong way, I would be the one self-medicating with chocolate all the time.”
Everyone laughed this time. Hannah thought to herself that the entire conversation about blood pressure had probably been dominated by Mrs. Brown’s secret about her brother that Dr. Chambliss had somehow intuited. She began to chide herself for not thinking of it, but as the other two women laughed and hugged she felt her shame ebbing away, as if the warmth of their bond was seeping into her and melting the anxiety that she had felt since the beginning of their visit.
“And finally– I know Hannah already talked to you about this– you promise me you’ll call me if you feel like hurting yourself or anyone else?”
Mrs. Brown smiled and shook her head. “Oh, you know I got too many people dependin’ on me to do anything that stupid.”
“I know you do. That’s why I worry,” Dr. Chambliss’ smile did not break, but her tone did become more serious.
“Of course I’ll let you know,” said Mrs. Brown.
“Good! See you back in a month.” They hugged again and Dr. Chambliss headed for the door. Hannah shook hands with Mrs. Brown, who smiled warmly.
“Thank you,” she said.
“You’re welcome,” said Hannah. “And… thank you. I learned a few things this morning.”
“About crazy old black women?”
“You’re not crazy! Dr. Chambliss said so. And I’ve had a few-”
“Here’s your instructions!” peeped Dr. Chambliss as she bounced back into the room with a page that she had printed outside. “The number’s on there if you want.”
“Thank you, doctor,” said Mrs. Brown as she got down. “I’ll see you in a month.” She followed Hannah and Dr. Chambliss out of the room, then stammered just before they went towards the next room. They both turned around quickly to see her.
“I just wanted to say… Hannah was very good. Better than the last four doctors who saw Johnnie. I hope you give her an A.”
Hannah blushed.
“I know! She’s one of my favorites. And today is only her first day, would you believe it?”
“Wow!” She pointed a finger at Hannah. “You listen close to Dr. Chambliss, y’hear? She’s a pretty good doctor, in case you haven’t noticed.”
“Oh, I’m paying attention!” Hannah smiled and looked up to Dr. Chambliss.
“Alright, then, I’ve got two more patients waiting.” Dr. Chambliss turned to Hannah and then back to the doors as Mrs. Brown disappeared around the corner and back down the ramp to the waiting room. “The first one didn’t want to talk to a student– sorry, I don’t like it either– but the other one is a hospital discharge that I’ve never seen before and she was an unassigned patient in the hospital, so she’s a blank slate. Her discharge summary should have been printed out and left in the chart slot on the door.”
“Alright, I’ll see the patient,” said Hannah dutifully, walking up to the closed door that Dr. Chambliss had pointed towards. The chart slot on the front of the door was empty except for a billing sheet. Hannah turned back to Angela, who was sitting at the desk holding the phone against her ear with one hand and slumping her chin into the other. Hannah cautiously approached the desk and stood there for several seconds, not wanting to interrupt something important. Eventually, Angela spoke.
“So you’re saying it ain’t gonna work and you don’t know when it’s gonna work?”
Hannah, surmising that she was referencing the computer system, scurried back towards the room and decided to just go in. She knocked once, put her hand on the doorknob, and pushed the door open as her heart began to pound faster.
Sitting alone on the table was Yolanda Fisher. She looked thinner and lighter, her cheekbones more prominent and her tiny frame still hunched over. She raised her eyes but not her head to look at Hannah as the door opened, her mouth opening at first to say “hello” before transforming into an expression of muted surprise.
“I think I seen you before…” she said quietly. Hannah could not remember her voice being this hoarse.
Hannah nodded slowly. “We have met, yes.”
“You was in the hospital one time.”
“Yes.”
“You know, I been in the hospital so many times I couldn’t remember your name.”
“I’m Hannah.” She extended her hand to shake, which Yolanda shook gingerly.
“I’m Yolanda. I was just in the hospital for pneumonia and the family medicine doctors took care of me. So they said I had to come to the family medicine clinic to follow up. And that’s why I’m here.”
“Okay, how have you been feeling since you got out of the hospital?”
“Fine. Still been coughin’, but it ain’t as bad as before.”
“So, what symptoms were you having when you first came in?”
“I had bad pain in my chest. At first they thought it was a heart attack, then they said it was from pneumonia.”
“Okay, then,” said Hannah. “And have you been taking medicine for your H–”
As soon as she began to speak, she watched Yolanda’s eyes widen with fear. Hannah stopped speaking, bit her lip, and then opened her mouth again.
“–your… other disease?”
Yolanda looked down at her feet, which were dangling off the exam table. “Yeah.”
Hannah opened her mouth again to ask another question about when Yolanda had gotten out of the hospital, but hesitated. She recalled a pearl from Dr. Friedman.
“How do you take your medicine?”
Yolanda’s eyes went from her feet to the ceiling, pausing for a second on Hannah as if to ensure that she was still there. “Well… I, y’know… it’s in my chart.”
“Which chart?”
“The computer chart, the one says everything about me!”
The ferocity of Yolanda’s response startled Hannah. She finally sat down on the rolling stool.
“It’s important to hear from you how you take your medicine, because I’ve never met a computer chart that told me everything about a patient. Most people are more interesting and complicated than that.”
Yolanda smiled weakly. “I ain’t takin’ my medicine. Happy?”
Hannah smiled. “I’m happy that you’re being honest with me. It makes it a lot easier for us to work together. Why don’t you take your medicine?”
“Well, I’ll be honest wit’ you if you won’t be honest with errbody in whole damn world. Sorry. I don’t take it because it makes my chest pain worse.”
“Oh! Well, I’m sure we can figure out a way around that. And I promise to keep your information confidential,” said Hannah, extending her hand to Yolanda’s to shake. “You can trust me.”
Yolanda tentatively extended her hand and touched Hannah’s, then shook gingerly.
“Well, alright then.”

***

Adam lifted his palms from the armrests of the chair that he sat in, then drew them across his jeans to wipe off the sweat that had accumulated in the last few minutes. He stared at the entrance to his father’s office, a warm reddish-brown wooden door with KOFI FREEMAN inscribed on the gold plaque at eye level. Several copies of The Ghanaian Journal of Medicine & Surgery lay in a stack on the end table next to Adam’s chair; he had already flipped through it several times as he waited. He mostly reminisced about the question-and-answer game that he and Hannah had played as they drove, as all of the copies were the same edition that they had read together. He was unsure if another issue had ever come out.
He reached into his pocket and pulled out his phone, fingering it idly and hoping that perhaps he would get service this time when he turned it on, knowing that for some reason his father’s office was trapped in a dead zone of cell signal. He wished again that he had brought one of his books to study– the GRE was coming up soon and his father would probably be impressed to walk out and find him studying– but he had forgotten his bag on the table when he walked out of the house this afternoon.
The indistinct chatter from behind the door that had been going on since Adam had arrived stopped, followed by the click of the door handle opening. A large, bald man in a suit emerged from the office. Adam recognized him as one of his father’s bosses– he could not remember which one– but that his name was Mark.
“Adam!” he remarked, extending an enormous, ruddy fist. “Whatcha doing here?”
“Oh, just stopping by to see my father.”
Kofi came to the doorway. “We are discussing his future. I am hoping that today is the day that my son applies for medical school!”
“Great to hear. If you’re anywhere near as savvy as your father is in the biotech biz, you’ll go far.” Mark clapped Adam on the back vigorously. “Hepatolife still holding up good for you?”
“Thanks,” murmured Adam. “It’s, uh, still working like a charm.”
“Glad to hear it. You’re like the secret company mascot.” Mark grinned, clearly satisfied at the weight of his analogy.
Adam almost told Mark that he was tired of hearing that, but he simply smiled and nodded. “Yeah.”
“Well, have a great day!” Mark moved past Adam quickly, calling back to Kofi as he went. “Take your time with those projections, Chief. The board is gonna drill us pretty hard.”
Adam turned to Kofi as Mark disappeared down the hall. “Can I come in?”
“Yes. I am sorry to make you wait, my son. Mr. Warnick showed up just before you came and I could not delay him.”
“It’s no problem.”
“Come. Sit.”
Adam took a seat in his father’s office, which was not particularly spacious but larger than the tiny cubicle he remembered visiting years ago when the company had first begun. The wooden desk was mostly empty except for a closed laptop and a neat stack of papers. A bookshelf took up the entirety of the wall on the right, each shelf full of binders marked with years and a few drug names that Adam vaguely recognized. The other wall carried only his father’s diplomas and a picture of the Ghanaian Minister of Health shaking hands with his father in front of the hospital in their village.
“Adam. You said that you wanted to talk about your future.”
“Yes, father. I…”
“Have you finally decided to become a physician?”
“I… am putting in my application for the University of Maryland School of Social Work.”
“Not the University of Maryland School of Medicine?” Kofi leaned in slightly, as if to hear better.
Adam shook his head. “The School of Social Work.”
His father sighed, not releasing his gaze on his son. “My son, I have told you many times of my wishes for you.”
Adam looked at his hands, once again full of sweat. He began to silently repeat the script that he had composed earlier, telling his father that this was his passion, that he didn’t need to become a doctor to be great, that social work was an honorable profession, that he could become a professor. He felt nauseous with anger and frustration, his heart beating faster and his stomach turning like he hadn’t felt since the worst days of his liver failure.
“I will support your decision.” His father’s words startled him.
“Oh,” mumbled Adam as he looked up. His pulse did not slow down.
“I know that it has not been easy to endure all that you have suffered, and that life in America has changed you. There are so many good things about America, but I have been afraid that you would become more American than Ghanaian.”
Adam ran his palms along his pants again. “Father, you know that I… I will always honor you and my African identity.” He was not sure if this would satisfy his father’s wishes and he was not even sure that he knew how to keep this promise. He said it anyway and watched his father smile in response, adding more weight to his vow.
“And there is something else.”
Adam opened his mouth to speak, but didn’t.
“You have bought a ring.”
“How did you know?” Adam demanded quickly.
Kofi smiled again. “Your credit card statement still comes to my address.”
“Oh.”
“I will need to meet her family. They will have many questions for me the next time that I return home.”
“I’ve met them once or twice,” said Adam. “They’re, uh, nice, I guess.”
“Do you remember anything else about them?”
“They’re both teachers.” Adam shrugged.
“You know that this adds to the… difficulty. Marrying a doctor when you are a social worker.”
“I know.”
“There is much more for us to learn.”
“Yeah.”
Kofi rose from the desk and walked around to clasp Adam’s right shoulder. “I give you my blessing.”
Adam breathed deeply, then brushed his father’s fingers with his other hand.
“Thank you.”

***

Gainers stared at the bright lights above him, then moved his eyes to the clock on the wall. He gingerly lifted his legs from the stretcher and let them fall off the side, pushing himself off the thin mattress to sit up. He walked over to the beat-up supply cart in the corner and fumbled with the drawers, frustrated quickly when none of them opened. He punched a few buttons on the side of the cart in hopes of disabling the electronic lock, but the machine only beeped at him angrily. He stuck his head out from behind the curtain that had been pulled in front of his doorway.
“Hey! I been waitin’ in this emergency room for two hours in pain! Ain’t the doctor gonna come look at me?” he shouted to no one in particular. Hearing no response, he shuffled back into his room and laid back down on the stretcher.
The room was mostly bare except for the supply cart (which he had already tried to open three times), a trashcan, and a sink with a cabinet above it that held only towels, tongue depressors, and alcohol pads. And his voices. The room was full of them. They buzzed in the fluorescent lights above him and crept under the curtain from the sounds of monitors going off in other rooms.
“Maybe I can get some of my other medicine here,” he said aloud, trying to ward off the sounds that invaded his ears. Tonight they were indistinct, a vague foreboding of doom punctuated occasionally with the howl of derision that his sister had screamed as she pushed him out the door. He couldn’t remember what she had said then, but her scream was still impressed in his memory, indistinct but vivid.
“Sir?” said a voice. Gainers looked down from the ceiling to see a tired-looking black woman in scrubs holding a clipboard.
“Uh, uh, yes, ma’am, I’m Gainers.”
“Nice to meet you, Gainers. I’m Dr. Polk. I heard you say something about medicine?”
“Yes, I, uh, haven’t been taking my Haldol ’cause I got registered for that new insurance for everyone but I can’t get an appointment with my psy-chiatrist and…”
“Is that why you’re here?”
“Well, no, I’m here because I got some real bad back pain and I wanted to ask…”
“Well then, let’s talk about your back pain and deal with the medicines you’re out of later.”
“Okay, I’m sorry, I didn’t mean to–”
“Let’s just hear about your back pain, it’s five in the morning and I’ve still got patients to see.”
“Okay, okay, well the other day my sister pushed me down the stairs and my back just been hurtin’ real bad since.”
“Your sister… pushed you down the stairs?”
“Bitch ain’t got no respect for me.”
“Excuse me?” Dr. Polk’s eyes widened and the pitch of her voice rose.
“I, uh, mean, y’know, bitch pitch ditch pitch…” he stuttered, his words trailing off into incomprehensible muttering as his tongue began to fall into rhythm with the sounds he was hearing that Dr. Polk was not. She quickly interjected.
“Okay, are you incontinent?”
“Incontinent?”
“Have you peed or pooped yourself?”
“Uh, uh, no.” He had actually woken up soiled this morning, but could not remember the circumstances under which it happened and the episode had passed from his mind after he had taken a new pair of pants that had been hanging from the side of a dumpster on Mount Royal Avenue.
“Okay, do you have a fever?”
“Uh-uh.”
“How about any numbness between your legs?”
“Gotta big ball sack between my legs, I’ll let you see it if you like.”
“I’ll pass, thanks. Any new numbness or tingling in your legs or feet?”
“I’ve had numbness and tingling in my legs for years! And they ain’t never treated it right!”
Dr. Polk sighed and pulled a pair of blue nitrile gloves from a box on the wall. “Well, unless I’m smarter or luckier than all of the other doctors who treated you for this, I can’t promise you it’s going to be fixed tonight.”
Gainers rolled his eyes as the doctor knelt to the ground. “Swing your legs over the side of the bed and sit up,” she ordered. He complied, though he took his time to do so and savored a brief moment of satisfaction at her obvious annoyance.
She pulled his shoes and socks off unceremoniously, touching both sides quickly and asking him to describe the sensation. After satisfying herself that both feet were equally numb, she asked him to kick and pull back his lower legs before she quickly tapped both knees and ankles with the back of her stethoscope to test his reflexes.
“Looks pretty good to me,” she said.
“Ain’t you even gonna look at my back?” scoffed Gainers.
“It’s coming next. I just wanted to get the most important part out of the way.”
She pushed on his back in several places, eliciting yelps of pain from Gainers with even the lightest brushing.
“Can’t you be more careful?” he demanded.
“I am trying to examine you,” she growled. “You have tenderness all along your spine. You need an x-ray.”
“You can’t do one of them M-R-Is?”
“Thank God, no, I can’t.”
Gainers laid back on the bed, his legs still dangling off the side. “When’s it gonna be done? I’m in pain!”
“I’ll give you some ibuprofen. Do you have any allergies?”
“Ibuprofen.”
Dr. Polk’s sigh was pronounced, bristling Gainers. “What happens when you take ibuprofen?”
“Hives. Mouth swelling.”
“You’ve got to be kidding me.”
“Look it up. They gave it to me when I was here.”
“I’ll double-check. Tylenol then.”
“I got liver failure. Ain’t supposed to take it.”
“Fine, Tramadol– shit, you’re a drinker, aren’t you? I can’t lower your seizure threshold. Five milligrams of oxycodone it is.”
“Thank you.” Gainers did not look up as Dr. Polk left the room. The hum of the fluorescent light above sped up and slowed down until Gainers could hear high-pitched laughter coming from just beyond the ceiling tiles.
Gainers’ nurse appeared after a few minutes and gave him the oxycodone pill with a small plastic cup of water. He took the pill and laid back, closing his eyes and musing about how the light above him turned from a harsh white to an angry red. Soon, however, darkness crept in and he slept until they came to take him to Radiology.
He briefly stirred as he began to move, only really awakening when the stretcher banged against a wall as he rounded a corner. He tried to look up and see the face of his transporter, but all he could make out were the pale blue scrubs. He came to a large room where he was beckoned to stand next to the x-ray machine. He began to feel a pang of terror as new noises began to fire off from behind him, but he breathed in deeply and tried to focus on the sleepy feeling that the oxycodone had given him. Before he could open his eyes again, he was being ushered back onto the stretcher and into the hallway.
He saw Dr. Polk approaching and opened his mouth to speak to her, but was not sure what to say. She breezed past him in his moment of hesitation, at which point he remembered that he had wanted to ask whether or not she had verified his ibuprofen allergy.
The transporter brought the stretcher to a stop back in the room, where the intensity of the light continued to bother Gainers. He began to ask for it to be turned off, but quickly realized that the transporter had left as quickly as he or she had come. Frustrated, Gainers eased himself off of the bed and slowly walked towards the light switch on the wall.
“Well, Mr. Goodson, I got your x-ray results.”
Gainers spun his head to see where the speech had come from, wondering if it had not been from a person when he saw no one to his right at the entrance to the room. However, when he turned around he saw Dr. Polk standing beside his bed.
“What are you doing?” he asked.
“Watching you walk,” she replied. “Looks pretty good. Unlike your x-ray, which unfortunately shows a broken spinous process. Just the very tip.”
“Goddamn. I’m gonna sue–”
“Call me when it’s time for the deposition. I’m gonna give you twenty more oxycodones for now and you need to follow up with a spine surgeon; it’ll probably heal on its own but just to be safe I’ll give you the referral.”
“It’s broken?”
“Yes, it’s broken, so if you’re incontinent or can’t walk or get new numbness or tingling, come right back in, okay?”
“Okay,” nodded Gainers.
Dr. Polk spun to leave, then stopped as she reached the door.
“And you wanted Haldol, too?” She craned her neck so that Gainers saw only a sliver of her face looking back at him.
“Yeah. I take the 2.5 milligrams twice a day.”
“Are you actually gonna take it if I prescribe it to you?”
“Yes, ma’am.”
“And you’re sure that’s the drug you take. None of the new drugs, Seroquel or Abilify or Risperdal?”
“Don’t work. Only the old-fashioned Vitamin H!”
Dr. Polk laughed. “The nurse will bring you your scripts. Good night, Mr. Goodson.”
“Good night, doctor.”

Chapter 12 will be released on August 1, 2015.

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

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