A History of the Present Illness (12 page)

13. When her son was a sophomore in college, her ex-husband collapsed in the smoking lounge at the Dallas–Fort Worth International Airport. Attempts at resuscitation were unsuccessful. At the time of his death, he had four children. His estate went to the three youngest.

14. Her husband was the only man she ever slept with. “Love,” she told her son, “especially romantic love, is an invention meant to distract the lower classes by compelling them to strive for the unimportant and unsustainable.”

15. When her son inquired how she could feel as she did about love, on the one hand, and study romantic literature on the other, she said, her accent thickening as it always did when she was annoyed, “You are too much focusing on logic and science.”

16. When, several years later, her son told her he'd been accepted to the University of California, San Francisco School of Medicine, she said, “I suppose you must learn for yourself that form is not always content's container.” He had no idea what she was talking about.

17. She was one semester short of her Ph.D. in nineteenth-century British literature when she was diagnosed with widely metastatic cancer. Her son flew home from San Francisco, where he was midway through his fourth and final year of medical school. Scans and biopsies revealed an aggressive, primitive tumor of unclear origin, for which there were no good treatment options. “Go back to school,” she commanded her son. “There is nothing to be done here.”

18. Upon hearing her fate, she took up walking. Before and after work and all day on weekends, she crisscrossed the small city and the university campus, sometimes venturing so far as the surrounding farms and fields, always in pain. When she became too weak to walk, her son took a leave of absence and moved home to care for her.

19. People he'd never heard of sent flowers, books, and a remarkable array of foods. The breads and curries of his childhood arrived from small towns in Illinois, Wisconsin, and Indiana, while neighbors and coworkers dropped off such exotic dishes as fried chicken with bacon stuffing, mashed sweet potatoes with marshmallows, and jello molds with canned pineapple. The less his mother ate, the hungrier he became, until one morning he could barely button his jeans.

20. She died sixteen days later.

21. Her son sat with the body, reviewing his every memory of his mother, and in the end he concluded that he had never seen her happy, only less sad.

22. In her top dresser drawer he found plane tickets to India in her name and his for the ten-day break between his medical school graduation and internship and also a stack of aerograms to which were stapled photographs of young women, the ones on top gazing right at the camera, the bottom ones with downcast eyes and demure expressions.

23. If she hadn't died that April, her son might not have married me, a fellow Indian who has never been to India, a modern girl who is both a doctor like his father and a romantic like his mother and so sometimes kisses her patients and admits that she loves them.

24. Her only child became a radiologist. He spends his time scrutinizing and analyzing those parts of people that remain
invisible to the rest of us. To this day, he claims strictly intellectual origins for his professional interests.

25. She never met her grandchildren, though the youngest, a girl, looks just like her. Whenever that child sleeps in, her son holds his breath, and when she laughs, he closes his eyes as a once-blind man might upon waking to the excruciating beauty of an ordinary sunlit morning.

Maurice Kasmarek was my second admission on the first day of my first real job as a doctor. I'd been hired as a hospitalist by the same large San Francisco health maintenance organization where I'd finished my training just two weeks earlier, and I marveled that the world suddenly and somewhat arbitrarily considered me fit for unsupervised practice. My inaugural patient that day, a twenty-two-year-old with cystic fibrosis, came in every three months carrying preprinted orders from her pulmonologist detailing every aspect of her care. I was fairly sure I'd admitted her at least once before during residency, but though she knew all the nurses by their names and significant others and children and even pets, she didn't remember me at all. When I walked into her room, she said, “Do you really even need to examine me?” I said I really did, and she said, “All right then, let's get this over with. But you're gonna have to read my chart to get the history.”

Maurice showed up an hour later and, after being wheeled across the street from oncology, refused to let the transport guys push him down the hallway to his room. “If I've got to
go into this place,” he argued, “at least let me get there under my own steam.” It took him twenty minutes to cover twenty yards.

I tracked his progress from the nursing station. “Look out, honey,” said the nurse beside me, who, despite his omnipresent five o'clock shadow, was rumored to be one of the locally famous transvestites, the Sisters of Perpetual Indulgence. “This one's a heartbreaker.”

Once Maurice caught his breath and settled in, I went into his room to do the history and physical.

“Mr. Kasmarek—” I began.

“Oh, hell,” he interrupted. “The name's Maurice. We're both grown-ups. Why don't you call me that?”

“Okay,” I said, though usually I'm a bit of a traditionalist when it comes to patient-doctor etiquette.

He raised the part of his forehead that should have had eyebrows. “So what's your name?”

“Chitra,” I replied. “But you can call me Dr. Agarwal.”

I waited a split second, and then I smiled.

“Ha!” he said. “You had me going. Yes you did. Bravo, Dr. Chitra, bravo!”

And so, in the first two minutes of our acquaintance, we became Maurice and Dr. Chitra, a compromise arrived at without any negotiation and a solution that pleased us both.

Nearly an hour later, in addition to the medical essentials, I learned that Maurice was twice divorced, had no children, and prior to the cancer had been a supervisor for Pacific Gas and Electric. When we finally finished the history and physical, I explained Maurice's medical condition to him in case they hadn't in oncology or in case the physician telling him,
uncomfortable him-or herself, had mumbled or obfuscated, and also because it was entirely possible that Maurice himself, not wanting to hear the bad news, had chosen denial or belief in divine intervention over the dismal facts. It seemed that he knew and understood his situation, but when I showed him the Preferred Intensity of Treatment form, hoping he'd choose comfort only, so I could page the palliative care team and get going on my next admission, he said he wanted everything done: chemo and radiation as needed, intensive care, even cardiopulmonary resuscitation.

“But it won't work,” I told him, referring to his odds of surviving CPR. “I know they're always saving people on television, but in real life, in your circumstances, I wish I could say it would help, but it won't.”

He grinned. “Sure it will.”

When he smiled, he looked eighty, not sixty: sagging gray skin, narrow ropes of withered muscle securing head to torso and elbow to shoulder, and indentations at his temples from all the weight he'd lost. Since he'd managed databases and distribution schedules, I tried to seduce him with numbers. “There's good data on this,” I explained. “If you have cancer and it has spread—”

“Metastatic,” he said.

“Right. Anyway, if your heart stops—if you're
dead
—even if we could restart your heart—which we almost certainly
couldn't
—there's a less than one percent chance you'd make it out of intensive care and
no chance
you'd leave the hospital alive.”

“Dr. Chitra,” he said. “Give it all you've got.”

I tried explaining again, but Maurice wouldn't change his mind. “Let me tell you a story,” he said, and pointed at the
chair beside his bed for me to sit down. I looked at my watch; I had at least two other patients waiting by then, but I took a deep breath and sat.

“There's a woman,” Maurice began. “No spring chicken, but not far into middle age either, forties maybe, something like that. Anyway, one day she lets herself into the front hall of the house she grew up in and calls upstairs to her father, ‘Dad, it's time. You almost ready?' She's a good daughter, you see. Since her mother passed, she does her best to take care of her father even though her cooking isn't what it could be and she's able to tolerate a whole lot more dust than her mother ever did, which the father's having a hell of a time getting used to.”

He checked to make sure I was listening.

“She gets no answer and calls again, this time raising her voice. Nothing. So she goes upstairs, taps her father on the shoulder, and, when he turns around, says, ‘Dad, for the fourth time, we need to leave,' and the father says, ‘Daughter, for the fourth time, I'll be there in a minute.'”

I didn't laugh.

“Don't you get it?” he asked. “It's the daughter who's deaf, not the father. But everyone just assumes it's the old guy that's got the problem. Dr. C., you disappoint me.”

“You're not that old,” I protested.

“You still don't get it.”

But I had understood the story; I just didn't see how it pertained to Maurice. Unlike the father in his story, he was sick, very sick.

Maurice's eyes seemed overlarge in his shrunken face. Radiating sadness and hope, he looked like one of those children on television where a voice-over says that for just five cents a day, you—comfortable, healthy, and wealthy American sitting on your couch—can save a life.

“I'll call your oncologist,” I offered. “There must be something else we can try.”

Maurice slapped his bed with one hand and smiled. “They told me you were smart!”

That time, I laughed. “And the clinic nurse told me you'd asked.”

Defying all my predictions, Maurice survived a first and then a second cycle of chemotherapy, though every time I tried to discharge him, he developed some complication that required him to stay in the hospital. One morning more than three weeks into his stay, he asked to see me. I found him not in the vinyl armchair from which he usually held court, but in his bed. Framed by the pillow, the whites of his eyes appeared yellow.

“How are you?” I asked.

“Never better,” he said so softly that I had to step closer to hear him. It was as if he didn't have the energy to force out the air required for speech.

“No nausea. Even the plumbing is A-OK. I'm gearing up for the next round.”

“Maurice.”

He managed an unconvincing smile. “You must mean the back pain.”

For a week he'd had worsening pain that he hadn't mentioned. I told him I'd give him a shot and send him downstairs for X-rays.

“Ha!” he said. “This is all a ploy to drum up business for your husband.”

Somehow, on a previous trip to radiology, Maurice had noticed that the radiologist and I shared the same last name, put two and two together, and then charmed my usually
circumspect husband into disclosing much of our family history, including our rocky early courtship as Atul's mother was dying of cancer in central Illinois.

“We're on salary,” I said.

“I hope you don't think that's an excuse for losing your sense of humor.”

“Cancer isn't funny. And you need an X-ray.”

“Don't be silly,” he said. “I've been sitting around this place for weeks. Of course my back hurts.”

Either he really didn't understand what the back pain might mean—which seemed unlikely—or he was playing tough guy again.

“Let me tell you a story,” I said.

Maurice shrugged. I pulled up the vinyl chair and sat down.

“A man goes to see his doctor because his knee hurts. The doctor asks the usual questions—when did the pain start, what makes it better and worse, and so on—then moves the knee up and down and back and forth. Finally he stands up and says, ‘The knee's fine. It's just everyday wear and tear. Try resting and icing it.' The man looks at him. ‘Doc,' he says, ‘my knees go everywhere together, and the other one doesn't hurt a bit.'”

“Easy for him to say. Lucky chump's still living his life.”

“Okay, but my point—”

“I get your point.” He looked out the window. “Knees—and backs—don't hurt for no reason. So probably the cancer's spread more. If that's the news, do I still get my next chemo?”

“If you're sure you want it. And maybe some radiation too.”

“Well then. Tell the hubby I'll be right over, and tell the boys downstairs I'm ready to be zapped when they're ready to do the zapping.”

*

In accordance with Maurice's wishes and because the oncologist said some response still wasn't completely out of the realm of possibility, he began the next round of chemotherapy that afternoon, despite the disease up and down his spine and in his liver and almost certainly in his lungs as well. My days off started the next morning, so I didn't see Maurice again until the end of the week.

“There's a woman,” he whispered. I was barely through the door. I hadn't even said hello.

“New. In a place like this.” He paused and took a deep breath. His hospital gown had come untied, and they'd forgotten to put in his teeth.

I walked quickly to the bedside and turned on the overhead lights. His eyes looked glassy and unfocused, the kind you sometimes see in dolls, which, however lifelike, never actually look like real human beings. He needed intensive care. I reached over his head and depressed the nurse call button.

“The woman waits,” he continued. “By the elevator. Person comes along. She lifts her skirt.” He stopped speaking and panted.

I pulled the oxygen tubing out from behind his pillow and tried to slip it over his head. He batted me away.