Brooklyn Zoo (35 page)

Dr. Aronoff’s words lifted my bad feeling fleetingly. Warding it off felt like holding my chin above that bar. Still, the next night I got a high fever, and over the days that followed, I became sicker than maybe I’d ever been, ruminating with abandon whenever I woke up about my bad behavior and all those near strangers who reportedly disliked me as a person. Bad, bad, I was so bad. The stress of the year had finally toppled me, and also I’d been working in the medical hospital with a less than adequate appreciation for a frequent washing of hands. Two weeks before my wedding I was out sick an entire four days, my nose chafed beyond makeup’s repair. It was almost better by our blue-sky marriage day, and as George and I danced and toasted with our families and friends, we forgot about our training for the first time in many months. The next morning we left for Palm Springs, and a ten-day honeymoon all but vanished the rest of the chap from my skin.

WE TOOK THE RED-EYE BACK FROM LAX, AND OUT OF VACATION
time I caught the airport shuttle straight to the subway, hospital-bound. After morning report Dr. Singer sent me to follow up with a Mrs. Guzman. She was in her sixties, admitted after a stroke. Her doctors thought she seemed depressed, and my supervisor was honoring my request for a talking case. Her speech was slowed, and she couldn’t easily move her left side, but she told me she was mostly worried about her twenty-year-old son, who she said couldn’t take seeing her like this. I wondered if she was projecting. I encouraged her to talk about her son’s difficulty, and for a while she cried. Mostly I listened and asked her to elaborate. When it was time for me to leave, she asked if I could return the next day and I did. We talked some more.

In some ways it was easy, this work with the medically, as opposed to the mentally, ill. The bar was set so low. I only had to be willing to hear about their experiences. Across the general hospital—and I’d been all around it now—support staff
and doctors were telling patients not to have their feelings. “Don’t be sad.” These words fell on the wards as regularly as April rain. It made my blood pressure spike each time I heard it in passing. “I can’t tolerate your sadness,” I wanted to teach them to say instead, because it was more to the point and would also quickly give its speaker pause. Sometimes there were just things to be unhappy about. The
DSM
had a category for patients who were blue because of new and troubling medical problems: adjustment disorder (
DSM
code 309.0). Dr. Kapoor told me he preferred “adjustment reaction,” which is what the international disease manual, the
ICD-9
, called it. “Someone who has just had a stroke and goes around like nothing’s happened,
that’s
a disorder,” said Dr. Kapoor. Yet being not sad was often presented to patients offhandedly as the only acceptable course.

Dr. Singer soon had two more talking cases lined up for me, each eighteen years old. One had sickle-cell anemia. The other had been paralyzed by a gunshot. I went to Dr. Cherkesov to ask for some pre-session supervision because I wondered if there was something more active than listening I should be doing with these medical patients and also because she’d fascinated me in our meetings. Every time she opened her mouth a gripping certitude came out. It might be a dubious fact: “Horror writers get their most interesting ideas from suffering delirium tremens!” It could be inspirational: “Turn all negative experiences in your life into learning experiences and you will stop being scared!” And sometimes she intimated an almost magical intellectual prowess: “I know things I don’t know how I know them. I was born in U.S.S.R. I came here and someone asked me what is the tallest mountain in the U.S. and I knew it!”

She was a Russian Jew who’d gotten into medical school
in pre-glasnost Moscow against all odds. “They had quotas, only take 2 percent Jews in their class of five hundred. I got in by telling myself a tale that I would. The minute you make a decision, everything changes!” She told us that she and her husband spent weekends walking the streets of Brooklyn, six or seven hours at a stretch, to oxygenate their brains and fend off dementia. George and I spent our Saturdays the same way but in order to revel in the scenery—the Brooklyn Bridge, the incense plumes as they rose above the Atlantic Avenue storefronts. When I asked her for some general wisdom about working with sick people, Dr. Cherkesov declared, “If you don’t believe your patient has anything to live for, they won’t either!” which was the inverse of what I’d learned in graduate school and felt like a lot of pressure. She also gave me an article about demoralization, which it distinguished from depression in that the former cleared once its medical precursor did and was unlikely to respond to antidepressants (still, everybody was prescribed them).

I asked Dr. Cherkesov to explain sickle-cell anemia, which she said was an inherited disease of the red blood cells that caused pain and infection and organ and joint damage. She told me that the sickle-cell trait evolved in climates where malaria was common, and that while having two sickle-cell alleles meant trouble, being born with just one offered protection against that tropical disease. I went to see Alisha, herself with two alleles. The consult question was “eating disorder?” as her doctors could find no cause for her self-reported vomiting. But Dr. Singer said the real problem was that she was infuriating the staff with her angry outbursts and grandiosity. She’d refused to speak to Dr. Singer, but he hoped she might benefit from talk therapy and thought she might relent if speaking to a woman.

“I’m not crazy,” Alisha said when I reached her bedside and identified myself. She was a pretty West Indian girl in a skimpy tank top. She was skinny after losing twenty pounds in the past year, about which she seemed neither pleased nor concerned. She wanted to be a model and showed me an album with old pictures of herself, posing. She was fuller-bodied in the photos and said she liked herself better fleshy, as per the preferences of her culture. She told me she vomited from her pain, caused by the necrosis in her hip. “My doctors won’t do a hip replacement, because I don’t have insurance,” she said. Who knew if this was accurate—there was, after all, emergency Medicaid—but she believed it and was in a rage. She was an undocumented immigrant and near homeless, she and her mother having recently been evicted. They’d moved in with an uncle, who Alisha said was clearly unhappy with the arrangement. It was impossibly warm out again, and Alisha’d been left to sleep on his couch in the heat and her discomfort. Walking pained her, and she’d wet herself and her makeshift bed in the middle of the night when it hurt too much to get up, which made her uncle want them even less. Hospitalization had been a relief, though she would’ve preferred to be on pediatrics, where she’d spent long swaths of time since she was twelve. She was eighteen now, old enough that they could refuse to take her back. The nurses there felt she treated them poorly, though she swore to me that wasn’t true. She stopped talking and gave me a deep pout. Could I be of any help?

I went back to Dr. Cherkesov with the same question as Alisha’s (could I be of any help?). “She is your classic difficult patient,” said Dr. Cherkesov. “You need to talk to her doctors and nurses to help them understand the angry feelings a patient like this brings about. In psychology and psychiatry, we know our hateful feelings toward patients are only human, and we
can usually stop ourselves from acting on them. These other doctors are different: they think they’re supposed to be above that, and so patients like Alisha leave them feeling ashamed, which only intensifies their hatred. Normalize it for them and they will be able to better help her medically.”

“So just talk to them? Tell them to try to be patient with her?”

“And then go back to her and listen. She’s enraged because she feels helpless. Encourage her to reframe her helplessness. She does not have problems—she has challenges! With challenges she also has choices.”

“But does she?” I asked. She was basically a kid. She had a chronic disease. She was in the country illegally. She maybe had no health insurance. She didn’t have a home.

“You have to emphasize the possibility of options. Someone with a shovel has two choices—dig or don’t dig. If you don’t have a shovel, you only have one choice.”

The next day, at Dr. Cherkesov’s instruction, I went to the morning meeting on Alisha’s ward. “She doesn’t seem to have an eating disorder,” I said first, addressing the consult question. I explained my understanding of her to her young doctors, of her frightened desperation and her paralyzing helplessness. I explained that anger was a natural response that they could use empathetically. “Whatever frustration you’re feeling, she’s feeling it ten times over,” I told them. They said they’d read about “the difficult patient” in medical school and took deep breaths and vowed to be kind despite her provocations. They thanked me for coming and requested that I see her again. “Maybe she’ll be less difficult if she feels like someone who works here is really taking the time to listen,” one of them remarked. I almost looked over my shoulder. Worked there? He thought I worked there?

I went to see the gunshot victim. Dr. Singer had told me his name, Nicholas, and that he had a history of bipolar disorder. He was only eighteen, so the diagnosis suggested he’d had some kind of pronounced early problems, but what they were was anybody’s guess. It was so hard to trust the clinical thinking of the doctors who came before you, and when your own judgment was still forming, things sometimes felt hopelessly mysterious. Not that any psychiatric diagnosis mattered all that much for my purposes: I would see him only briefly to help him through a difficult time. In Nicholas’s room I found him with his mother and brother, clustered together tightly. She looked too young to have a son his age, and they were striking, all of them, with dark skin and darker eyes. Nicholas rasped that his throat hurt too much to talk; they’d just removed the breathing tube the day before.

“So what happened?” I asked his mother.

“He was an innocent bystander,” she said.

Bad neighborhoods, I thought, such minefields. Did his mother know—resent?—that I’d never had to walk them? I felt apologetic. Life was so unfair.

“His brother was with him,” she added. I turned to the boy. He was younger than Nicholas probably, but just.

“We were at the playground playing basketball. There were some guys we didn’t know, and one of them left, but he forgot this crazy ring he’d taken off to play. Nicholas picked it up and put it in his pocket—to give the guy later. The guy came back looking for it and thought Nicholas was trying to steal it. He took it, then left again. When he came back, he had a gun. He shot my brother in the chest and walked away.” The brother spoke matter-of-factly. He must’ve told the story
so many times by then, and probably it was a familiar one even before his brother became its protagonist.

“He seems more depressed today than yesterday,” his mom said. The shooting had happened just over a week earlier. The doctors weren’t certain he’d regain the use of his legs, but his mother assured me he would. I asked about his psych history.

“He’s never been right,” she told me. “He used to say weird things.”

“Like what?”

“Like that he wanted to die.”

“When?”

“When he was twelve or thirteen. And before that he used to see things, ghosts.”

“When did that start?”

“When he was two or three.”

“What was going on leading up to that?”

“His father was murdered in front of him.”

It had happened down south. It was drug or gang related or both, the mother was vague. The family had gone into witness protection, where they’d stayed for more than a decade before moving to New York to be near family.

“He got into the wrong crowd,” the mother said, as though he hadn’t been born into it. She told me he’d been convicted of arson a few years ago and then diagnosed bipolar by a psychiatrist who’d helped with his charges. Nicholas was in and out of sleep as we talked. I asked the mother and brother how they were holding up, and they reported on the business of that week: getting updates from doctors, trying to convince the boys who’d been witnesses to testify before the grand jury. “They don’t want to be snitches,” the mother said. “I told them this isn’t snitching. Snitching is working for the police. This is different.”

The next time Nicholas opened his eyes I explained that I thought he might want someone to talk to after all he’d been through and that I would come back to see him again soon. He said okay but added that he was fine and didn’t think he’d have much to say. Could this all be so inconsequential—a shooting, a paralysis—in the life of a kid who’d seen what he had? He spoke as if his circumstances were about what he expected for himself, which in itself seemed like something to talk about.