There is something I want to tell you so we can agree that it matters. It’s about my last patient, the last for now, a younger woman with a slow encephalitis, a spreading inflammation in the tissues of her brain. In an early draft I had been calling her the woman with encephalitis, because giving her a name that can’t be her own felt so false. But now I am calling her Ada, and the false name is starting to fill up with her and hurt in another way. I miss her.
She had been fine, just fighting fevers once we had the seizures under control. But then she began to forget things, like the year or her address or the last thing she ate or the last thing she said. Despite all of our tests, we did not know why she was still losing her mind. After a while she was in a coma, and I would sit with her husband after a long day, wishing I were home. He told me how they met. There was only one chair in the room by her bed, so I sat on a step stool near his feet like a child. While he spoke, he laughed a lot and looked at his wife as though he could see through her into the past. All manner of things, I thought, can be well.
While she was awake, Ada had a view of the river and kept a set of binoculars by the window. In my downtime I would sit in a chair and examine the opposite shore. I knew from my walks outside the hospital that men fished on the banks along that river, and on the streets between delis and dollar stores, Dominicans played checkers on legless tables the players balanced on their knees. An old arsenal beside the hospital housed the largest men’s shelter in the city. During the day, shelter men would stagger the streets high on synthetic marijuana—just oregano or some other plant matter sprayed with chemicals made in a lab, labeled SPICE or SMOKING INCENSE and sold behind the counter in the delis. The men who smoked it had red-stained fingers and would freeze in place, dazed, and sometimes even stand stock-still in the street, as if they were dreaming. This was the neighborhood, but not what you saw from Ada’s window. Her view was a bland line of condos and trees shrouding paths along the opposite side of the river.
We were only killing time. Because her arms were black with bruises, and she couldn’t remember what any of the tests were for no matter how often we reminded her, she would shout and swear at the staff. When her husband couldn’t be there to redirect her, she would often end up tied to the bed for trying to get up or taking a swing at someone. And then, just as fast, like an amnesiac on television, she would come back to us, blinking, and ask, Where am I?
I don’t know what it means to suffer. I try to feel it out. When someone is dying and then they die, what hits you first is relief, permissiveness, a broad calm for a moment: world without end. Then some deaths just grab you by the throat, remind you of the balance of the game. Remember looking in the mirror as a child, saying your name? This face, you’d think, these hands. This house and yard and mother, going to bed without dinner on cabbage night, jumping from the roof of the shed. The bravery of it all, the obvious import. But this is how it ends: surrounded by strangers, your clothes cut off with shears, cold blue hands, and gone then, with your body humiliated and left alone to stiffen. In the trauma bay once I watched this, a cardiac arrest, the patient gone too long for us to be able to bring him back. A nurse got a shock from an ill-timed defibrillator and fell to the floor, unattended. I picked up his wallet—not the nurse’s, the dead man’s—which was worn from the specific ways he had handled it but was now done forever with being in his hands. When my great loss comes, I hope I scream like his wife and fall to the floor, not keep still and silent as my heart explodes in my chest.
The obvious, a poet said, is difficult to prove. The hard part is I want to tell the truth. Meaning what, exactly? We are schooled in taking, not giving, a history. We are taught to reach first for open-ended questions. How you ask can earn an answer closer to the truth. For example, you don’t ask someone if she drinks; you say, How much do you drink on the average day? You don’t ask if someone is compliant with his medication; you ask, How often do you miss a dose? We are told to normalize our queries about drugs, sex, and death by asking them to everyone. But in practice you will not ask a healthy young person or a child’s parents if they want to be resuscitated when their heart stops, and you will not ask a frail old grandmother if she has sex with men, women, or both. And we run tests, anyway, for the real truth. Try to lie on a serum test for syphilis. People will certainly surprise you.
We had a man once who smoked cocaine in his hospital bed while admitted for active tuberculosis. The doctors laughed about this, laughed at him, behind doors, in other rooms. What are we even doing here, they said, laughing, to one another—meaning this was not someone who was going to get well. On the other hand, who would?
Some morbid social scientists ran studies in a lab where volunteers took a test on an unrelated subject while the screen flashed small subliminal messages, pictures of skulls or graves, I guess, or words like death, some classic unsubtle memento mori. Afterward, in a variety of surveys, the subjects who were primed with death reminders showed some dark and predictable tendencies. They were racist, for example, and would behave with overt hostility toward people who appeared to be from different cultural or religious groups. The scientists let the subjects force the out-group strangers to take shots of sriracha, a validated measure of aggression known as hot-sauce allocation. They supposed that the provoked bigotry was the subjects’ way of making meaning, of asserting their belonging to a group that would be here after they die. The social scientists dubbed this terror management—our dull means of evading death’s aggressive senselessness.
I brought it up at a dinner party once. I had been invited out with two classmates by a dean to a club in town, a club for members only. The rooms had tall drapes on tall windows, leather chairs hunched around fireplaces, obscene martinis each served with a second metal glass. The dean, of course, was a doctor too, and occasionally wrote poetry. He had selected us personally for a discussion of the arts. I thought a poet-doctor should be as game as anyone for talking about death, but he wouldn’t even let me get started. The classmates, both men and poets too, talked the way we were meant to, about schools they had attended, traveling abroad, minor celebrities they all knew in common. On the tour of the club we took after cocktails, there was a painting, smaller than a breadbox, kept behind a little curtain to protect it from the light. Although the curtain was pulled back for us, I don’t recall the painting in the slightest.
I’d wanted to ask the dean how our terror might be managed in the hospital, where we walk around primed with death all day and care—it has been shown—more poorly for the poor and the disabled and people of color, groups from which doctors largely do not come. The dean and the poets and I all were white; in fact, everyone at the club that I could see was white except the man who served the enormous martinis. The dinner was one with courses and all kinds of forks and different wines to match the different meats. I had a drunk, underwater feeling by the time it was time to leave. I managed, I think, not to say much of anything.
The taxi drivers were on strike that week, so I walked fifty blocks home with one of the poets. He said he planned to become a brain surgeon. He was from an Orthodox Jewish family, but he wanted me to know he didn’t believe in all that and that he objected to anything he couldn’t prove. All sandpiles have the same slope, I told him, and no one knows why. Is that true? he asked. It might be. If not, there is still gravity, there is still time, still the way it sometimes seems to matter that any of us were even born. He said he had nearly died just before he was a teenager—leukemia—and while his family took his survival as a sign from above, he finished chemotherapy as an atheist. He wanted to know what I believed. These were the conversations I always started after being out drinking, though I never wanted to answer the kinds of questions I asked. He said he hated hobbies, hated leisure, hated music—any diversion without immediate use. His indulgences were cooking and the artful plating of food. And poetry, of course. I later learned that his was terrible, all literal and grim. He did have one about a barbecue that ended in a way I sort of liked: Some days it is hard to believe / everyone dies only once.
And just try to be a smoker in a place like this. When my classmates found me with a cigarette on the corners where I hid between lectures, they would avert their eyes or actually cross the street in silence. But a few of them—even June and the Texan, always after they had been drinking, with or without me—often sought me out and asked for one for a treat. Once I was on the corner with just the Texan, and one of the shelter men approached us. He must have missed last call, gotten locked out for the night. His speech was slurred but I gathered he was after a cigarette. He stood too near to us, swaying a little. I worked the lighter for him and he thanked me and left. And the Texan said, That was a close one. He helped lead a clinic where the students practiced taking histories and doing physicals on the homeless. He said he could stand the shelter men in the clinic, but on the street they made him sick. Is that wrong? he wanted to know, but why would I be the one to tell him?
The clinic was in a church basement in a Blacker part of town. It, too, was a club for members only. In our year, it was run by the Texan and a woman on a military scholarship—one way to afford the six-figure tuition. She did not have the teeth of a person raised poor, but why else would you join the military? I had applied for a spot at the clinic too. You had to write an essay. I did not know yet that you aren’t allowed to talk about poverty from the inside. You could only look back on it. I wrote about never having health insurance, knowing how it feels to be sick and afraid. But the clinic decided, the Texan said, to go in a different direction.
I voted for you, he said in earnest. But he had to let me know I’d provoked some ill will among my classmates, particularly the woman in the military. She was upset, he said, over something I had said in psychiatry class. They let you practice on them as well, the patients with psychiatric illness; they consent because they don’t know not to. They had brought in a small, middle-aged Ecuadoran man who stood before the class and answered questions about why he had been locked up. He was wearing pajama pants and a hospital gown with another gown over it backwards, like a cape. He had been escorted through the open air from the hospital to the lecture hall by a pair of student volunteers. His condition, his disorder, was that he tended to believe you were in love with him. You being anyone. And he lost his job after making passes at his boss, left his wife, and now had been tossed from his uncle’s house, for he had thought even that grizzled old man was in love with him. And he had an enamored and heartsick way of telling all this, because at first when he was locked up, he knew his doctor was in love with him, but now on the pills they made him take, he had a shake in his hands and no idea who loved him. The doctor leading the class, a man with slick hair and a keen interest in what’s called bench research, asked the man if he could have been mistaken about the boss, the uncle, the doctor upstairs. No, he said. They all did love me once.
So much of medicine is just learning the words for things. In psychiatry, for example, hallucination is perception without an object, while illusion is true perception interpreted incorrectly, like seeing tree branches as reaching arms or hearing murmured voices in the susurrus of running water. A delusion is a deeply held belief that is either false or at least—said the doctor leading the class—unshared by your community. This struck me as an odd caveat. I imagined any truth-teller, Copernicus or whoever, meeting the criteria for delusional disorder. Is the exception, I asked him in class, for religion? Is the delusion of chosen ones, of resurrection, of the reign of an all-knowing sky man somehow less insane if enough of us agree to share it? You don’t have to say things like that, the Texan told me later. The woman in the military was evangelical and offended. I have seen her in pictures, beaming in fatigues, posing with guns of all shapes and sizes, even the large lead-pipe ones that shoot rockets or grenades.
In a special section on brain pathology, I watched a fetus have an autopsy. The limp little body was draped over a chunk of two-by-four. The mother had contracted Zika, the latest virus, the one that makes fetal brains stay small and smooth and useless. And so they’d pulled him out, pulled it out, the fetus, therapeutically. The skull was split like an old tomato, and the little limbs lay limp, almost translucent, the perfect hands and fingers of someone who would never use them. The doctors who cut him up spoke over him about, I remember, the weather, a new pair of shoes, a rumor regarding a new pavilion. But can you imagine killing anyone you didn’t have to?
In case you ever wondered, when they take out your organs during an autopsy, they store them all together in a large plastic bag labeled with your name and hospital identification number. Your brain is fixed in fixative and placed in a Rubbermaid box like one might store extra pencils in. I asked where the parts go off to then, but the people I asked didn’t know.
I pray only in dreams where I am dying, and I often die in my dreams, or am dying, buried in rubble after an explosion or in a falling elevator or a crashing plane. But in waking life, I’ll still sometimes get an urge to pray, on the subway, say, in the tunnel parts that wind under rivers, or on the bridges, or when there is smoke in a station, or when the lights go out on the train, or when some man on the train starts yelling, yelling at me, looking in my eyes until I look away: Fucking cunt, fucking bitch, I’m about to blow your head off. Just as an example. There is one prayer I know will be answered: Lord, let me suffer a lot and then let me die. But I know also Our Father and some psalms; I know faith is the substance of things hoped for and that the evil of the day is sufficient thereof. And I am jealous, sometimes, of the lives of my peers or patients or families who find comfort in icons or in saying the rosary, who keep from collapsing in the face of tragedy by leaving some book with heavy pages open significantly on the bed. It’s too easy to dismiss the comforts you cannot have.
After the dinner at the club, the very next day, I got called to the office of that dean. Because I was afraid or for whatever reason, I put it off for weeks. When I did go, I found he did not want to see me but had left for me a copy of a poem written by a woman who had been born and also buried in the city where I was born. It said, among other things: The doctors should fear arrogance more than cardiac arrest. I didn’t know, and didn’t ask, if this meant him or me.