David Waters: FIVE HEARTS • Cleaver Magazine

David Waters
FIVE HEARTS

Physician Notes

Patient Name: Barbara Fields

Chief Complaint: chronic yearning

History of Present Illness: This pleasant 38-year-old, well-developed, well-nourished woman—looking younger than her stated age—comes to the Emergency Department complaining of unrequited desire. She is oriented as to time and place and speaks in complete sentences. She claims that she found herself in the produce aisle of the Whole Foods on Franklin Street in full make-up and a black cocktail dress earlier this evening, compulsively feeling avocados for softness, complaining that she had not enjoyed a tomato with any taste for years. “Even heirlooms taste like cardboard,” she asserts. She claims the patter of the irrigation system upon the lettuces reminds her of a rainforest she has never been to. She states that her empty basket is a metaphor, but declines to elaborate further than “It’s trite and unoriginal.”

Physical Examination: Non-contributory. She lies on the exam table, watching me intently, wearing the traditional backwards ill-fitting medical gown, her nice clothes hanging from the peg on the back of the door. Her eyes are red and teary, perhaps secondary to irritation from her contact lenses. Pupils are round and normally reactive to light. Her red lipstick is still perfect, and she has a faint mustache. Not Frida Kahlo, very faint. Sexy, I think, but hey, that’s just me. “Your right armpit is shaven but your left one is hairy.” I try to make it a neutral observation, but it sounds like a question. “So?” she replies. I don’t say anything further, until she continues. “I was shaving them when I got a text from my boyfriend breaking up with me.” “Then it’s like a memorial?” She nods. I want to tell her that her boyfriend was a shit, but I strive to maintain an appropriate professional distance. Her heart and lungs are normal. I test her reflexes with my little rubber hammer; they are hyperactive. She is jumpy. Her nails, both finger and toe, appear recently manicured and are painted the same red as her lips.

Tentative Diagnosis: Heartbreak, type 2B

Discussion: Now that patients have access to their medical files, let me proclaim straight up that this is one attractive woman. Are you reading this, Barbara? I think of myself as a romantic person, and was touched by the asymmetrical hair distribution as a stylish, unique form of protest. That boyfriend is such a dickhead! I would never do that. I am unsure how to interpret the patient’s obsession with tomatoes. Is it an obsessive-compulsive manifestation, or an honest assessment of the current state of our vegetables? I would like to split a tomato and buffalo mozzarella salad with Barbara, our knees touching under a tiny café table, while getting to know her.

Disposition: Follow-up with her primary care physician. Offer psychotherapy. As I usher Barbara from my office, I notice the burgundy cloak and chalky face of Muerte lurking in the waiting room. She looks for the weak and flailing, and shows no interest in Barbara. I hope to avoid Muerte this night, for we clash too often for my taste.

Patient Name: not yet known; temporary pseudonym: Grand Poobah

Chief Complaint: uncertain; possibly chest pain

History of Present Illness: The patient is an unaccompanied middle-aged Asian man speaking rapidly in a strange language. He does not respond to English, or to the hospital translator’s attempts to reach him in Thai, Vietnamese, Korean, Mandarin, or the Chinese dialects Yue, Xiang, Min, Gan, Wu, and Hakka. The translator contacts Ms. April Lee, an expert in Korean linguistics, who promptly arrives and spends 30 minutes trying to communicate with him through both speaking and writing. Ms. Lee concludes that he is using a localized Korean dialect, and explains that the mountainous areas of Korea contain isolated villages where splinter languages persist. His wallet contains $848 and a small black-and-white photo of an Asian woman, but no credit cards or identity documents. Using gestures, I convince myself that the patient agrees that he has chest pain, and that it is worse when he breathes. He has a fresh surgical scar over his sternum, indicating recent cardiac surgery. I play a frenzied one-sided game of charades with him, attempting to glean further information, but fail.

Physical Examination: Asian male, looking about 50, with closely cropped hair, smooth hands with trimmed nails, tobacco-stained fingers, wearing a rumpled, pinstripe suit. The patient has no cellphone but carries a pack of Marlboro Golds and an orange Bic lighter. He has yellow deposits below his eyes and thickened Achilles tendons, signs that his cholesterol levels have been high throughout his life; in other words, hereditary hypercholesterolemia. He smiles ingratiatingly and continues to talk in a conversational tone despite not being understood.

Results of Testing: His blood sugar, hemoglobin A1C, and urine dipstick all indicate that he has uncontrolled diabetes. Is he taking anything for it? Who knows? A screen for illicit drugs is negative. His chest x-ray shows sternal wires from cardiac surgery, coronary artery calcification, and a small left pleural effusion.

Disposition: With my arms outstretched and my palms facing up, I shrug to the patient. He nods. I give him a copy of my report, along with the results of his tests. I show him out of the exam room. He sits on a bench in the park across from the Emergency Department, facing me, chain-smoking as the sun sets and the lights of the city blink on. When my shift ends at midnight he is still there, spotlit by a fluorescent streetlight, presiding over a growing pile of Marlboro Gold cigarette butts.

Discussion: I have never faced a situation like this. I don’t even know my patient’s name, nor how he survives. I can’t even tell him to stop smoking. Who does he think he is, strolling into my Emergency Department speaking some nonsense gibber garble, smiling like the Grand Poobah? Sitting in the park, smoking, watching me like I’m some sort of dicey character? Why won’t he go home? I don’t need him to expose my limitations. I am a turnstile in a broken system, dispatching patients to hospital wards, to outpatient clinics, to their homes, while this enigmatic outlier smokes Marlboro Golds in the park. Early in my career I suffered from Imposter Syndrome, the guilty notion that I didn’t belong in Medicine, or anywhere else for that matter. I thought one day I would be exposed as a fraud, and today feels like that day. I curse the Poobah and rush to the next patient.

Patient Name: Maya Jefferson

Chief Complaint: severe pain in chest and back

History of Present Illness: The patient is a 32-year-old Black woman in acute distress with severe chest and back pain. She is wearing a red strapless faux-leather floor-length dress with a slit from hem to thigh, and has an IV in her left forearm, through which she is receiving morphine for pain. “It’s tearing me apart, it hurts real bad,” she whispers. “You’re going to be alright,” I lie to her. I squeeze her icy hand and move to shield her from Muerte, who hovers behind me. This is Muerte’s first appearance of the evening. She inhabits the shadowy nooks of the hospital searching out the vulnerable and imperiled. She seeps under the doors of the ICU. She is hidden by her burgundy cloak, except for her gaunt face and cruel eyes. With time, all those who work in hospitals learn to respect Muerte. Part of Maya’s story is told by Mr. Ji’Ayir Green, her tuxedo-clad date for the evening. They were in the backyard at a formal party smoking crack when her pain began. The patient had not previously smoked crack but has a history of high blood pressure for which she forgets to take her meds. Rest of history deferred due to the urgency of the situation.

Physical Examination: Pertinent findings only: blood pressure right arm 180/50, left arm 120/50. Loud aortic diastolic murmur, grade 4/6, left sternal border.

Pertinent Imaging Studies: Couldn’t be worse. Chest X-ray: mediastinal widening. MRI: aortic dissection involving aortic valve, continuing past renal arteries; large tear in ascending aorta with re-entry in abdominal aorta. Echocardiogram: widened aortic arch, severe aortic valve regurgitation. Muerte cackles gleefully.

Hospital Course: Patient undergoes urgent surgery for aortic valve replacement and replacement of the ascending and descending aorta with a graft. Disseminated intravascular coagulopathy develops with persistent bleeding and hypotension, followed by cardiac arrest. Above Maya’s surgically opened chest in the harsh spotlight of the operating theater, Muerte in her burgundy cloak and Maya’s spirit in her red faux-leather dress tussle mightily until Muerte carries her off.

Final Diagnosis and Cause of Death: Acute aortic dissection, Type A

Discussion: Acute aortic dissection is just about the worst thing that can happen to you. The mortality rate if untreated is 40% in the first hour and 1-2% per hour for the next 48 hours, with most patients dying within the first week from aortic rupture. Surgery is successful in 85% of cases. Smoking crack induces huge swings in blood pressure, particularly in folks with untreated hypertension, increasing the risk for aortic dissection.

I go to the waiting area outside the operating rooms on the 9th floor. The pale green walls are bathed in blue neon that flickers in an irritating, irregular pattern. The leather couches are cracked, exposing their guts, the smell of sweat, and hospital despair. Ji’Ayir Green sits alone. His white tuxedo shirt is splashed with bright blood and his left eye has been punched closed. “You tried to kill my sister you motherfucker,” Maya’s brother had shouted when he arrived on the scene. He is a big dude, a former Big-10 defensive lineman. He attacked Mr. Green and was arrested. “He had no cause to do that. I didn’t make her smoke it,” he tells me. The Jefferson family clumps on the other side of the waiting area; Mother, Father, two Sisters, Grandma, and Auntie. I explain to them again what is happening. They have heard it already, but horrible news requires repetition before it sinks in. Maya is a grade-school teacher. She sings in the church choir. She has only gone out with Mr. Green a couple of times, her mother says. Muerte doesn’t give a shit about such details.

I go to Maya’s funeral. I wear my dark blue suit, an easy choice because it is the only one I have. I have never attended a patient’s funeral before. The church is full. Everyone thanks me for coming. Maya’s spot in the choir is empty. Her casket is open; she is wearing her black choir gown, yet my mind is stuck on her red faux-leather dress. The choir sings “Take My Hand Precious Lord,” and I lose it. It’s a song I remember from childhood, but here they sing it with passion and certainty, like the Lord is really going to take my hand. Maya’s story resembles a medieval morality tale, good girl makes one mistake and pays for it. Millions of Americans use illicit drugs every day and suffer no consequences. The risk of aortic dissection from smoking crack is very low. I can’t stop crying, I don’t know why, I didn’t know her.

Patient Name: Rita Buckle

Chief Complaint: shortness of breath

History of Present Illness: The patient is a 94-year-old retired librarian with a history of congestive heart failure. Her daughter and son-in-law, who care for her, dumped her in her ‘wheelchair’ at the Emergency Department entrance and sped away to Las Vegas for the weekend. She says they promised to pick her up Monday. This is the third time they have left her like this. She states that her breathing is worse than usual, but adds as an aside that she is saying that to get hospitalized. She has nowhere else to go. She used to enjoy ballroom dancing and Giants’ baseball games, but admits that her only pleasure now is her ‘wheelchair,’ an electric-blue Maxima 4-Wheel Ultra HD Scooter, with Rockette written in sparkly-gold script on the side. She boasts that it can hit 18 miles per hour on a straightaway and that she likes to feel the wind blowing through her few remaining strands of white hair. She has a long list of concomitant illnesses and another long list of meds (see below).

Physical Examination: compatible with chronic heart failure: elevated jugular venous pressure, rales at the bases, third heart sound, 2+ edema. Obvious frailty.

Abnormal Lab Tests: serum sodium, glucose, BUN and creatinine slightly elevated; serum potassium slightly low. Nothing surprising for an old woman with heart failure.

Diagnosis: chronic heart failure, no evidence of acute decompensation

Disposition: Ms. Buckle does not require hospitalization, but has been abandoned by her caregivers and has nowhere else to go. Will keep her as a non-admitted boarder until her family returns in 3 days. Will tune up her heart failure while she waits.

Discussion: I question Ms. Buckle about elder abuse. She says she looks after herself but her daughter makes her feel like a burden. “It never occurs to her that she might be old someday too.” She pauses, then adds, “It never occurred to me that I’d end up like this either.” The next evening I come in an hour early to talk with her before my shift. The head nurse requests that I ask Ms. Buckle to drive more carefully. She has been racing Rockette around the hospital, frightening staff and visitors. Dowager Stockwell, a senior member of the Hospital Board, filed a complaint after seeing Rockette whizz by while greeting a potential mega-donor and his entourage in the lobby. I find Rita under the portico at the hospital entrance, out of the rain, wearing a black Giants baseball cap backwards, wrapped in a mud-flecked hospital blanket. Muerte sits inconspicuously on a nearby bench. Rita smiles when she sees me, and I tip my head toward Muerte. “She’s been following me for weeks now,” Rita says, “but she’s getting closer and more insistent.” She pauses, then continues. “She frightened me at first, but now I welcome it. I’m ready.” Is it that simple?, I think. Who am I to mess with her decision? She has more compos mentis than most people her age. Muerte watches me with suspicion and curiosity. She is supposed to be scent-free because she is a spirit, but I smell damp ashes and rotting flowers when she is nearby. I launch into a mini speech that sounds as phony as the warranty on a cheap appliance. “Ms. Buckle, my task as your physician is to improve your quality of life. With careful titration of your heart failure drugs, your exercise capacity and well-being could improve.” My promise sounds hollow because I know that heart failure is not her main problem. “I also have suggestions to deal with your social isolation. You could ride Rockette to the senior center at Aquatic Park. It’s five blocks from where you live.” I can see she wants to reply, so I pause. “I used to go there to dance when I was mobile, but the men were sparse and ghastly.” Her words surprise and please her, like they have fallen from the sky, so she repeats them. “Sparse and ghastly.” I abandon my suggestions and ask earnestly, “Rita, how could we improve your life?” She answers quickly, “Make my daughter love me,” then, “bring Jack back.” When I look at her inquiringly she adds, “My husband Jack, he killed himself after Vietnam.” Rita tells me more about her life until I have to start my shift. I ask her if she will wait for me to return when I get a break. She hesitates, then agrees. As I leave I look toward Muerte, who sneers, so I give her the finger. When I return, Muerte is sitting close to Rita’s scooter and they have their heads together, talking. Rita appears slightly translucent, with a faint aura, almost shimmering, not something that a casual observer would notice, but a sign of imminent demise. Rita shoos Muerte away when she sees me. She has a request. “When I’m gone, I want you to find a young, paralyzed veteran and give him Rockette.” She smiles. “See if you can find one who looks like this.” She hands me a crinkled, faded photograph of a boyish soldier with a broad grin, his hippie hair blowing in the wind. “Jack?” I ask, and she nods, biting her lip. She clasps my hands and hangs on. I snuffle a few times. She thanks me. I tell her I must get back to my patients. She nods. I hug her and leave without acknowledging Muerte. Rita will be gone by dawn and I will find a vet for Rockette.

Patient Name: Me. I am the patient now.

Chief Complaint: I have thought carefully before selecting my chief complaint because that choice sends you down one path instead of another. Doctor, my problem is Weltschmerz. It’s a German word that translates as world-pain in case you don’t know.

History of Present Illness: The realities of Medicine do not meet my expectations. I am acutely aware of evil and suffering in the world. Weltschmerz covers that, but also implies that the world has worn me down. Too often I must deal with Muerte. She hovers, ready to pounce on my mistakes. I fend her off in skirmishes, but she always wins the war. I don’t get to play the knight in shining armor. Where is the satisfaction in that? I am happy when I make connections. I am happy to help. But yesterday I couldn’t even communicate with my Korean patient. I yearn to connect more closely with another patient, and hope to run into her some evening in the produce aisle at Whole Foods.

Physical Examination: Nothing relevant to see here. Move along.

Discussion: I am just an emergency physician. I am Everyman, except I am closer to the drama of life and death. I am on the Titanic like everyone else. I want to use my time dancing to the orchestra and swilling champagne, not standing at the rail, staring out in terror at the frigid waves.

Disposition: On my day off tomorrow, I will block the hospital from my mind. I will straighten up my apartment. I will walk through Golden Gate Park to the Japanese Tea Garden. I will drink matcha tea and eat a kazumochi cake. I will meditate by the lake. I will feel peace, then joy, then strength will flow back to me like an incoming tide. I am fortunate to be alive in a world full of beauty. Later I will have dinner with Deidre. I will not give a thought to whether the Korean Poobah is still smoking Marlboros in the park. I shall have sex with Deirdre, but will not think about Barbara Fields or Maya Jefferson’s red dress because I must keep Medicine out of my mind. I will fall asleep wrapped in Deidre’s warmth. I will not dream, and if I do, it will not include Muerte. In the morning I will make lattes while Deidre does Eggs Benedict. The breeze will push the fog back to the ocean and it will be a sunny day.

David Waters is a retired cardiologist who lives in San Francisco with his wife and Kerry Blue terrier. His work has appeared in or is forthcoming in Cleaver, The MacGuffin, Flash Fiction, Beyond Words, Amarillo Bay, Marrow, Umbrella Factory, 34th Parallel, Brilliant Flash Fiction, Chiron Review, and others. He teaches prose and poetry at The Writers Studio.