Brooklyn Zoo (32 page)

Amari and I made our way across the street. First on our list was an eighteen-year-old diabetic girl. She was in the hospital after letting her blood sugar get out of control, and not for the first time. Amari read the consult paperwork as we walked. She turned to me. “She has stomach pain. Her doctors want us to assess her because they think it’s psychosomatic, but that doesn’t make any sense. If she’s not controlling her insulin, of course she has a stomachache.” She shook her head and continued. “When they can’t figure out a cause for a symptom, they decide it’s psychosomatic, and then they call us.” She rolled her eyes again. CL was trying her patience.

“So if we suspect going in that the rationale for the consult is flawed, what do we do?” I asked.

“We have to go see her, and we can think about the case in other ways. Diabetes is easy enough to control for the average eighteen-year-old who’s been dealing with it for as long as she has. So why isn’t she taking her medicine? That will be our focus.”

The diabetic girl was effervescent, happy to have visitors. Amari introduced us and got down to business.

“Why aren’t you taking your insulin?” she asked.

It seemed like an obvious question, but apparently not one that her doctors had previously thought to ask. Hesitantly, the girl told us that she was Pentecostal and that the preacher at her congregation said in no uncertain terms that medicine was a no go. “I believe in healing,” said the girl. Amari took a deep breath.

“Are you familiar with the New Testament?” she asked. The girl nodded. Amari continued. “So you know that Jesus healed the blind with his touch. But it wasn’t the only way he did it. You’ve read that he mixed his saliva with sand and helped the blind man see that way? Jesus used medicine.”

“Huh,” said the girl. “That gives me something to think about.” She sounded as if she meant it.

“Nice story,” I said to Amari once we were in the hallway.

“What religion are you?” she inquired. It was a question rarely asked in my parts of the city, where a weak agnosticism was the polite thing to presume—if sometimes incorrectly. In East Flatbush, God was paramount, one more thing distancing me from the worlds inhabited by many of my patients. With a shrug I told her I was Jewish, because that is what I was, Jewish-with-a-shrug.

She said, “I’m a Christian, and I believe in healing. I’ve had experiences with it. But these religious men who tell their congregants not to take their pills are criminal. When they’re sick, they rush right to the hospital and take whatever their doctors prescribe, but it’s not what they preach.”

Amari and I climbed a flight of stairs and emerged onto another high-gloss floor with pale yellow on the walls to see our second patient of the morning, a woman with MS. The brief reasoning scrawled on the consult paperwork was “crying.” When we got to the woman’s bedside, she explained that she’d gone temporarily blind on the subway, spending an hour just sitting in her seat, nervously waiting for her vision to return. Upsetting as this sounded to me, what had really done the woman in was that her husband—who despite their fifteen years together knew little about MS—did not believe her and was certain that her lost hour had been spent in the throes of passion with another man. This made more sense
once she told us that she had five kids, the youngest of whom had a father who was not her spouse. Still, by the time we got there, her neurologist had already spoken to the wary man and assured him that his wife had indeed been struck temporarily sightless. Things seemed to be looking up.

“So how are you doing now?” I asked her. Amari had instructed that I should lead the consult.

“Wonderful,” she said. “My sister is planning a family reunion. My siblings stopped speaking when my mom died a few years ago, so it’s very exciting.”

It seemed an odd thing to say given the circumstances, but was it psychiatrically odd? Was she being tangential or just cooperative? I thought: Doesn’t she know why we’re here? But then I realized that
I
didn’t quite know why we were there. “Crying.” We established that she was employed, that she had deep attachments to her friends and family, and that she experienced only passing difficulty with her multiple sclerosis. Other than the tears, which were momentary and understandable, there seemed no reason to suspect she was any category of depressed, which was probably the diagnostic category most closely related in her doctor’s mind to “crying.” We wished her good luck and went to make a note about the consult in her chart.

As Amari was writing, the pager buzzed. She picked up a phone and called the CL office. Dr. Jonas, one of the attending psychiatrists I’d seen at the morning meetings, wanted us to meet her on the cardiac care unit to watch her assess for decisional capacity. Amari hung up and delivered another explanation in her weary tone. “One more reason doctors call us: when patients don’t want to take their advice. If someone doesn’t take their advice, they’re obviously crazy and in need
of a psychiatric consult.” She rolled her eyes again. If her eyes were her abs, she would’ve had a rocking six-pack.

We dashed down the stairs. I loved all this running from place to place. It made me feel so unquestionably useful. Side by side we descended to the cardiac care unit. The space was big and airy with glass-walled rooms and doors that slid open automatically. Dr. Jonas met us at the front. She was in her sixties and stylishly dressed. She spoke brusquely and only to Amari, as if I were not there at all. “Seventy-eight-year-old male insisting on discharge against medical advice. He had a heart attack a few days ago, and his doctors want to insert a stent. He doesn’t want it.”

“So how do we establish whether or not he has capacity?” I asked into the air. Maybe I was not supposed to look at someone so resolutely not looking at me?

Dr. Jonas nodded toward Amari, who explained: “Generally, the patient has to show us that he understands the procedure, why it’s being recommended to him, and the potential risks and benefits. With this patient, since he’s saying no to a procedure rather than consenting to one, we want to make sure he knows the consequences of leaving the hospital without having it done, and we want to document that he knows.”

The two of them went together to the patient, and I followed along. From his bedside hung a bag swollen with urine, and it made my stomach turn. I had not gone into psychology to deal with bodily fluids. The man in the bed was a youthful seventy-eight. He was olive skinned and lively, with nails like a lady’s. Dr. Jonas greeted him and asked if he remembered talking to her yesterday. “Of course,” he replied, looking down his nose to show his disregard for the question.
I’m not crazy
.

His physician joined us by his bedside. She was young and Latina, with a bleached-blond streak in the front of her dark curly hair and two silver rings on each of her thumbs. Later Amari would tell me that she was in a band. While we listened in, the doctor explained the risks of the stent procedure: localized bleeding from the catheter, kidney problems due to the dye, a bad reaction to anesthesia. “But none of these are likely because they didn’t happen with the last stent,” she emphasized. Apparently, they had a history. She continued with the benefits: the blockage in his artery could be cleared, reducing his risk of having another heart attack, which, she said, was almost inevitable without the stent. Her voice faltered on the last part. His refusal obviously pained her.

The patient cut in: “I’ve already told you I won’t do it! I’ve got something to take care of first, some business. I don’t want to talk more about it, because it upsets me. I’ll have the procedure in a month or two.” He folded his arms over his chest with a dramatic harrumph. Dr. Jonas asked him to explain the possible benefits of the procedure and the possible consequences of its refusal. He iterated both clearly. “I know I could drop dead without it. If that happens, it happens. We’ve all got a number. If you think you don’t,
you’re
nuts!”

We left his bedside, and Dr. Jonas told the doctor that she was sorry but that her patient did seem to understand the consequences of signing out AMA—against medical advice.

“Well, I guess we’re doing the right thing ethically,” his doctor said, trying to soothe herself. She walked away defeated, and we went to look for the chart.

“What if he had consented to the procedure, would she have called us to evaluate his capacity if she’d thought he was making a good decision?” I asked Amari, thinking of her
comment earlier, that doctors called CL only when they disagreed with patients.

Dr. Jonas took it upon herself to answer. “No, but the nurses would have. If they see doctors shoving consent forms at patients who can’t understand them, they tell the doctors to call psych.”

I headed back to the G Building at lunchtime reflecting on my morning. I found it all interesting and was having a good time, but it was hard to say what relevance any of it had to me, to what I knew or could offer or learn. Still, I’d been wanting a break from complication. If I was to be irrelevant somewhere, CL seemed as good a place as any.

Dr. Kapoor gave all his trainees a lot of room to maneuver, and soon he had me going around alone with the medical students. They were young and had memorized so much. I really couldn’t figure how they’d done it. They did not know a thing about graduate school in clinical psychology, though, and because I was called an intern, just like the first-year residents, they figured I was above them, instead of just outside their hierarchy altogether. Newly released from classrooms and not comfortable being in charge, they decided to rely on me. This was a nice change of pace, and so I nodded as if I understood when they spoke about patients with words like “hemiparesis” and “sepsis.” I went with the students Camille and Raymond to do a follow-up. All CL cases got follow-ups. The woman had a urinary tract infection and had become delirious as a result. Delirium was unfamiliar to me. It was a condition they saw a lot at CL, Dr. Kapoor explained, because it often appeared postoperatively and along with infections,
especially in the elderly. “It’s characterized by severe, rapid, and fluctuating changes in brain function. Attention waxes and wanes along with confusion. Delirious people sometimes have psychiatric symptoms like paranoia and hallucinations—usually visual, not auditory. We treat it with a short course of antipsychotic medication, and it usually resolves within a few days.”

When we got to the woman’s room, a sign outside her door warned us to protect ourselves against the germs inside because apparently she had more than just a urinary tract infection, and there was a cart holding paper hospital gowns. Camille handed me one. “People don’t always wear these, but I’m a little paranoid,” she said. Sign me up. I asked what we were at risk for catching.

“Nothing if you’re healthy,” Raymond said. “The danger is that you get spores on your clothes and pass them along to other patients you see who may be immune compromised.”

Inside, our consult’s roommate had a hacking cough, and I thought that we might get TB. One thing I’d taken for granted working in the G Building was that nobody was contagious. Our follow-up was surrounded by men in long white coats, attending physicians, and they paid us no mind. We would have to come back later to assess the state of this consult’s cognition. We left the room and stripped off the green paper garb. As we did, Camille got a call from Amari, who instructed us to meet her on pediatrics. Pediatric ward: the very juxtaposition of the words made me want to avoid it. My friends sometimes asked how I could take hearing about people’s problems all the time, but the kinds of problems I specialized in were largely self-generated and malleable. The rabbi marrying George and me was a chaplain on the pediatric oncology unit of another hospital. Those were problems I had
less aptitude to bear. Upstairs on pediatrics, miniature people wandered around in colorful hospital gowns, and my heart ached predictably. Camille and I met Amari (whom she and Raymond called Dr. Malou) in the small office behind the nursing station.

Amari explained that the four of us would see an eighteen-year-old with “end-stage renal failure.” I knew “renal” meant kidneys, guessed “end stage” meant grim. He’d had two unsuccessful transplants in the last five years, Amari told us, and was in the hospital being treated for an infection.

“What’s the prognosis for end-stage renal failure?” I asked.

“People live an average of three to five years on dialysis,” said Camille, “but that’s just an average. It depends on how his health is otherwise.”

“His doctors are worried he’s depressed,” said Amari.

We went to his room, but he was not there. “Dialysis,” the nurse told us. She said we could come back in two hours or that we could go see him in the dialysis room. I didn’t know what dialysis looked like, did not want to, but Amari was her usual exasperated self and said that she had no time to return in two hours. The four of us marched in a column to the appropriate room at the end of the hallway. Inside were two padded reclining chairs, each occupied. In the first was a girl covered completely by an afghan except for her pretty long hair. In the other was a boy, face exposed, plastic tubes thick with blood poking out from under his blanket. I tried to keep my eyes away from those tubes. He looked twelve and could not be our consult. I hoped that we would make a quick exit. Amari asked the boy his name, and it matched the one on her papers. Trying to hide her surprise—he really looked so young—she introduced us all and asked if we could talk to him for a few minutes.