WHEN CRAZY GETS SICK

Geraldine is out of her cage again. She called three times on Monday before I could call her back, twice, that I know of, on Tuesday, and now, Wednesday, she, her son, and her psychiatrist have all called. It’s a bad sign.

I have a stack of papers in my hand. They seem to say that Geraldine is about to go into orbit if I don’t call her in the next five minutes, her son wants her transferred to somewhere where she can be watched twenty-four hours a day to see what goes into her body and what comes out of it. And the psychiatrist, as psychiatrists often do when the going gets tough, asserts that it has to be something medical that’s causing all this.

I have seen this picture before.

I call the son. Can’t you just put her in the hospital and watch her a few days, he says.

If there’s a good reason to.

But she’s in pain . . .

I know that doctors are supposed to be sensitive and understanding, that they are supposed to respond sympathetically to suffering and disease. And especially to the word pain. And I do. But she irritates me . . .

. . . well, let me put it this way. We just worked her up for her complaints of abdominal pain and constant nausea for the umpteenth time a couple of months ago. Getting her through the tests was a major undertaking for everybody concerned. She had a thousand questions about the risks of the CT scan, obsessive worries about gagging during endoscopy, strong opinions that damage to the delicate balance of her colonic milieu would occur during colonoscopy . . . she wanted to know ahead of time what we would do if we found this or that, which of course, I could not say . . . and when she got to the table she held us up for long periods of time while she was getting herself in the right state of mind for us to begin sedation. After trying many options and letting her try many, I finally gave the ultimatum: It’s right this minute, or I’m going home. At some point we just have to step up to the plate.

All the tests were normal. Which didn’t do a lot for her image as a person with a real disease.

Afterward the nurse who would have bet we’d never get the tests completed in the first place wanted to know if I had a degree in psychology. No, I’d just been there before.

So I’m telling the son about this. Everything was normal a little while ago, I say. She’s done this several times before, and I know it’s confusing because although it looks serious we almost never find anything wrong. The truth is, these blowups always seem to be connected to some major stress in her life.

But the son says that something’s got to be wrong.

What’s missing from this picture, I wonder. I’ve told him already about the recent negative workup, that I’d make time to see her tomorrow, and I would make certain everything appropriate was done.

He is unmoved. He says that he’s concerned about her taking enemas all the time to keep her bowels moving.

I say that her psychiatric medicines have made her constipated, and if she has to take enemas it’s better than having her go crazy.

But she’s coming off them, he says, because of the constipation.

True. And last I heard, two days ago, she wasn’t constipated at all.

But there’s the pain and the nausea.

I know, I know. And we have to evaluate that. I will do that. But you have to remember she always has pain and nausea. Ever since the first day I knew her, she’s had pain and nausea.

Yeah, but it’s worse.

It’s always worse and we’re always checking into it. But I’m not optimistic we’ll find anything.

Well, you remember my father.

I can’t recall that I do.

The doctors kept seeing him for his complaints over and over and never found anything. Then he died.

I’m tempted to say we all die. We all see doctors. There may not be a connection between the two. But it would only inflame the situation, and by that admission I know now where he’s coming from. This is a cookie from a bad recipe. He has a neurotic mother with a litany of unsubstantiated complaints and the memory of a father who died without a diagnosis. Bad combination. This guy will never be convinced.

And then I realize what has just happened. Responsibility, ker-plunk, has just been placed back in the doctor’s court. Service ace. No return of serve. The son—because his father died undiagnosed, because he grew up with his mother’s pathology and had a blind eye for it— for whatever reason, refuses to take responsibility, refuses to allow that his mother’s neurosis can be generating all this whoop-de-do, and chooses to rely instead upon the notion of a doctor’s oversight.

Then the psychiatrist comes in the picture: I’m worried there’s something serious going on here, he says.

We’ve been here before.

Yeah, but this is different.

How so?

Much more serious . . . somehow.

She’s off her meds. Doesn’t that make her out of control?

Sure. But I think—

Look, we’re already on it. I’ve talked to her with a plan and a map two days ago. Her greatest concern was not the pain or the nausea, but just that she would be allowed to talk to me again. I take that as a sign. And don’t you feel a bit used here? In any case, we’ve got the emergency room if she falls apart.

He’s not convinced my position in the matter is correct. But neither am I convinced of his. Now we have something in common. And I have the distinct feeling the tennis court has just added one more opponent.

And then Geraldine. Her turn on the phone.

Oh, Doctor Watts. Finally!

What can I do for you, Geraldine?

I haven’t eaten in three days. The pain is unbearable. The nausea. Can’t you do something?

Are you constipated?

No. I have diarrhea.

How about the psychiatric meds?

They’re stopped.

Did the medications I suggested do any good?

None whatsoever. I’m in such incredible misery.

Where is the pain?

All over.

In medical school I was taught that unlocalized pain was not likely to be caused by anything physical. Vague abdominal pain is psychosomatic until proven otherwise.

Where is the pain when it’s at its worst?

I can’t tell. It’s so bad it doesn’t even have a location. Why do I have to suffer so?

And I think to myself that these, without a doubt, are the most dangerous patients. They’re never really sick. Almost never, and there’s the rub. It keeps you guessing. The symptoms they have are for the most part not real. They invoke an inordinate amount of perturbation in their lives. The patients develop a support system that includes medical services that reward symptoms with much longed-for attention, family and friends who are all too eager to sympathize and to place the blame on anything but the one explanation that ties it all together. In short, everything falls in place to encourage and reinforce the problem. And in the middle of all that stands the physician who, frustrated by the hopelessness of it all, is apt to become just cavalier enough as to overlook the one time she really does get sick. And that, ladies and gents, would be a real screwup.

You’ll have to come to the emergency room, I say.

Oh, Doctor Watts. The last time I went there I lay around for five hours and they didn’t do anything.

Of course they did. They did what they were supposed to do, Geraldine. They examined you, did tests, X-rays. Made sure you were all right. That’s the whole point.

But I don’t want to go.

Look, Geraldine. If your pain is as real as you say it is, you’d kill for a chance to go.

Will you be in touch?

I always am.

But I don’t like ERs.

I don’t know anyone who does. But in precisely this situation it’s the right thing.

Will you call them?

I already said so.

Is it serious?

What?

Am I going to die?

I can’t help thinking that death in the abstract is a great deal scarier than the real thing.

Not yet, I said.

Will you talk to them?

Geraldine, why do I have to tell you five times . . .

And I realized this was Frustration Central breaking through like WLAC-Nashville on a stormy night. If it were still me, I would know better than to believe any objection of mine would change her behavior.

Okay, okay. I’m going, she said. The taxi is waiting outside. Will you call . . . ?

Wednesday afternoon, my day off. I am watering the garden with my twenty-month-old son, Gabriel. My wife comes to the catwalk with my cell. That’ll be the ER, I say.

Oh, hi, Doctor Watts. It’s Johnny. Let me get Doctor Austin for you.

Dr. Austin comes on. I’ve got Ger . . .

Geraldine McIntyre.

Yeah, that’s right. She’s . . . um . . . something.

How does she check out?

Well, her abdominal exam is completely normal. No masses. No tenderness. No abnormal bowel sounds. There’s nothing to suggest any pathology down there at all. She’s a little dry, probably from the diarrhea and not eating. We thought we’d hydrate her up with a couple of liters of IV fluids. Her labs are normal. No white count. Liver okay. She complains of constant urination, but her urinalysis is normal—no cells to suggest infection, no sugar to make her osmotically diurease. And her blood sugar is okay. I guess we just wanted a little background. How to handle this situation. She’s . . . I want to say . . . umm . . . well, how can I say this and be polite?

She’s crazy.

Yes, that word will do.

I hate to laugh at her expense, I say. But she’s probably the most neurotic person in my practice. She’ll disappear for a long time, six months or so, as if she’s been distracted by something else, and then she’ll show up with a bang and give us thirty calls a week. With the exception of the gall-stones we found and took out three years ago, there’s never been anything wrong. I didn’t want to tell you this in advance so as not to prejudice your workup.

Well, that’s kind of what we thought.

I had planned to see her tomorrow, but things sort of fell apart. I apologize, but I sent her to you. Crazy people get sick, too.

Yeah, but not this time.

Gabriel has been very patient with me. Now he holds up his green watering can and asks for a refill. He is naming things and blessing them with little sprinkles: flower, rock, chair. Can, he says. Toe. Toe.

Bless you, Gabriel, I say.

I will call Geraldine tomorrow. I will work her in between patients, lay my hand on her belly, let her, without showing any criticism I might feel, unravel and reravel again. We will sift through her complaints, which she offers like requests for something lost, filtering and weighing, reserving judgment, looking for the one true sign and wishing that somebody, early in her life, had blessed her, too.