23

Rounds started a few minutes later. Donuts were passed around, and my ears pricked up when the overnight intern, Lalitha, presented Dre’s case.

“A congenital infection left her without vision before she reached adolescence,” Lalitha said, as she tied her dark hair into a ponytail. “She was infected with HIV a decade ago and since then has lived a life of almost implausible hardship, bouncing from one abusive relationship to the next, rarely living at the same address for three consecutive months.” Dre had not taken any of her pills for months and, based on some preliminary laboratory information and physical exam findings, appeared to have neurosyphilis, a severe neurologic complication of untreated syphilis. The disease can cause the brain to see and hear all kinds of unusual things—from mysterious voices to symphonies—and the diagnosis is made via spinal tap, which Dre was refusing.

Dre had provided Lalitha with some of her medical history but not all. Large gaps existed regarding the way she’d contracted HIV, what infections she’d encountered, and what medications she was currently taking. Dre had informed the overnight team that the information would be provided on a need-to-know basis because she wasn’t convinced that all of the intrusive medical questions were necessary. And she was refusing HIV medications, which made me want to know more about her. Why would someone turn down potentially lifesaving treatment?

I thought about how neurotic I’d become after acquiring my own set of pill bottles. I didn’t want people at work to know how or when I was taking my medications, or what the pills were doing to my insides. Every time I swallowed a pill, it felt like I was ingesting a tiny hand grenade, one that would explode when I least expected it, leaving me doubled over in abdominal pain or rushing to the bathroom to shit my brains out. I didn’t want other doctors to know that I occasionally excused myself from rounds because I thought I was going to vomit, or that my bowel movements fluoresced, because I didn’t want to be judged. Perhaps Dre thought she would be judged, too. Perhaps she just wanted to be left alone.

There was something about her, however, that made me think she could be reasoned with. Maybe it was that moment when she’d touched my face, maybe that was her very literal way of reaching out to me. Perhaps I was someone she wanted to connect with. My mind started to race with possibilities. If I could engage with her in a way that was comforting, or that she respected, I might be able to get through to her and unlock the details of her medical history the way O’Connell would. Someone needed to; whether she knew it or not, Dre was a very sick woman. Without taking HIV meds she might be dead in months, and if she had neurosyphilis, things could get even more complicated. The more we could find out about her, the better. But that would come from sitting with her, talking with her, getting to know what made her tick. It would not come from reading a textbook or from snitchin’.

“Excellent presentation,” Dr. Chanel said when Lalitha had finished. “Anyone have anything to add?”

Ashley glanced at me and put her hands to her face, fighting back laughter.

It was time to snitch. Now that I’d told Ashley, I had no choice. “Yes,” I said. “I was called to see the patient this morning because she had something that looked like marijuana in her shirt pocket.” Collective nods. “I gave it to the nurse manager.”

“Very good,” Dr. Chanel said. “Shall we go see the patient?”

Apparently this nugget of information was inconsequential. But how was I to know? I wouldn’t tell Dre that I had mentioned the drugs to others. Walking down the ninth-floor hallway, Chanel again put her hand on my lower back. “You doing okay?”

“Hanging in there.” This was situationally true but a lie in spirit. I was a throbbing ball of anxiety, having returned to full teeth-grinding mode in the last eighteen hours. Thinking about Dre’s dilemma was a useful distraction but hardly a cure. A thousand thoughts threatened to spill out of me in response to Chanel’s simple question, but this wasn’t the time or the place to be a patient. I was on rounds and we had work to do.

“Let me know if you need Zofran,” she said, referring to the powerful antinausea medication. “Expensive, but it works.” She gave me a hint of a smile, and I returned it.

“Thank you for getting me through everything,” I said softly, recalling the slew of curse words I’d spat at her the day before. I’d spent the first month of my internship standing in awe of Baio, the man who could handle any clinical conundrum, but in Chanel I saw something unique, something I admired just as much. She had functioned as a sounding board, and let me feel comfortable saying or doing anything in her presence. If I wanted to have a meltdown, I could, and I knew she wasn’t going to think any less of me.

“I’ll let you inform the patient of our plan,” she said softly, running her fingers through her side ponytail. A moment later, our team formed a horseshoe around Dre. Heads gradually turned in my direction, and I cleared my throat, wondering how familiar I should be with her in front of the other residents. I had heard such intimate details of her troubled life, but we’d really only exchanged a handful of words and they were all about marijuana.

“Is that you, Em?” she asked.

I blushed at the nickname. “I’m here. With the entire team, actually. Before we get started, would you prefer to be addressed by your first name or last?”

“Just call me Dre,” she said.

After summarizing our interpretation of her case, we examined her one by one. Her neck was exceedingly stiff, so rigid and tender she couldn’t touch her chin to her chest, and she was mostly numb below her shins. I had hoped to examine her pupils to look for one of the hallmarks of neurosyphilis, but she told me she’d had enough of being prodded and wanted to take a nap.

“The long and the short of it,” I said as I put my penlight back into my white coat, “is that we’re worried about you. You need a spinal tap.” Lalitha had explained this to her overnight, but I wasn’t sure how much of it had registered.

“No, thank you,” she said, closing her eyes.

“And you need to get back on your HIV meds.”

“No. Thank you.”

I turned to Dr. Chanel for guidance; she raised her eyebrows as if to say, “Go on.”

“You need the test,” I said firmly, “and you need the meds.” Perhaps it was just a matter of persistence.

“No.” She folded her arms and again turned away from me. “Not happenin’.”

How could I reach her? Did Dre realize what she was up against? Maybe not. Maybe that was the problem. “You could die. Honestly.”

“Fine,” she said, “let me.”

I opened my mouth, but nothing came out. She had short-circuited my one ironclad logical point. Let her die? What was I supposed to say? I could treat her HIV and what appeared to be neurosyphilis, but how was I supposed to treat whatever made her favor dying over taking the pills?

Standing before her, I felt the glare of my colleagues. Chanel must have sensed my cognitive dissonance. She sat down on the edge of the bed. “Can we talk about this later, one-on-one?”

“You can talk,” Dre said, “talk all you want.”

“Very well,” Chanel said. “I’ll come back later.”

We stepped out of the room and discussed the approach to this difficult patient. Everyone agreed that a multidisciplinary approach would be necessary, incorporating psychiatry, social work, nursing, and potentially a host of other specialists.

As we discussed options, I went over the interaction again and again in my head. Why had my approach foundered? Could what I had said even be described as an approach? All I did was explain the scenario and try to scare her into compliance. I had assumed the specter of death would be enough. It was more than enough for me. In less than a day the pills I was taking had already begun to liquefy my insides, but I’d take pills that rotated my head 180 degrees before I’d give myself over to fate when it came to HIV. If I was going to get through to Dre, I’d have to figure out how she saw things.

The challenges I encountered on the HIV floor were so different from what I’d dealt with in other areas of medicine. There was a right way to do chest compressions, a proper way to adjust a ventilator. Do this and don’t do that. The skills I needed on the HIV floor—tact, patience, empathy—were more abstract. But the stakes were just as high; if I failed to acquire these traits, patients could die.

What if something else was going on with Dre, something I’d missed entirely? Maybe there really were voices in her head telling her not to take the pills. Then what? Could we force her to accept treatment? The ethics of medicine were bewildering.

“Tough crowd,” Ashley said, patting me on the back.

“Yeah.”

“Give it another shot after lunch. She likes you.”

“She hides it well.”

“I saw the way she let you paw her face.” I’d noticed a change in Ashley’s demeanor toward me. The drill sergeant act had been cast aside; in its place was someone who was treating me with kid gloves. I couldn’t tell if that was a good thing.

We walked back to the conference room and finished rounds. As Lalitha, who had been up for more than twenty-four hours, presented the next case—flawlessly maintaining the role of exuberant, compassionate, put-together intern—I stared at the small clock on the wall, counting the minutes until I was due for my next dose of comic book villains. I thought of the burnt-orange football and of the astronaut pill. The medications tasted rather bland, except for ritonavir, the sweet one, which was encased in a sugary capsule and tasted like a Flintstones vitamin. I wondered if Dre took any of these pills, or if she’d forgotten what medications she was on and felt embarrassed. I was tempted to leave rounds and show them to her, but I wasn’t sure what she’d be able to see. Was it wise to show a legally blind woman a handful of pills and ask if they looked familiar?

As Lalitha began drawing on a marker board, I felt for the pills in the pocket of my white coat, rolling each one back and forth in my fingers, wondering exactly how long they would be a part of my life. It was a mistake to think about my own condition when we still had patients to discuss, but I couldn’t help it. Dr. Chanel said I had to take the assortment of medications for a minimum of four weeks but possibly longer. Possibly forever.

—

“Your luck continues,” Ashley said after rounds. “Today is intern report.”

I shook my head. “What’s that?”

“I hold your pager for an hour while you have lunch with the other interns and vent.”

The thought appealed to me, mostly. I had so much I wanted to say and discuss. Were others slogging through internship the way I was? Or were they gliding effortlessly, as I imagined Carleton would. I still hadn’t met all of the interns—spending three years in a pod of four would undoubtedly have its benefits, but the isolation also seemed a significant drawback. Of the group I had started the year with, I’d probably spoken to only half. I had shared a beer with only a handful and rarely seen anyone let their guard down. We were all trying to fit in as real doctors while maintaining our pristine, gilded personas. It was exhausting.

“If nothing else,” Ashley said, “it’s an hour break.”

I slipped out of the conference room and headed down a long corridor, feeling my stomach rumble along the way. It was almost time to pop the pills. Replaying my appeals to Dre, I considered new tactics. Good cop? Share my own experience? Beg.

I entered the standing-room-only intern report, where a youngish physician—a chief resident named Dave—stood before a marker board addressing close to forty seated interns. In his left hand was a butterfly needle and in his right was a tourniquet. I scanned the room for familiar faces as I meandered toward the paper plates, soda, and pizza.

“Seven needle sticks already this year,” Dave said loudly, adjusting his glasses. “Far too many.” A few eyes from the crowd looked in my direction as I took my first bite. “This should really be second nature by now.” I felt a swirl of anger when his eyes met mine. This was supposed to be a venting session, not a harangue. “We’re going to review the basics of drawing blood today,” he went on. “The key to this, as in any procedure, is to focus. You can’t be in a hurry and you can’t be sloppy. Take pride in your work.”

I felt like he was talking directly to me, suggesting that my mishap had something to do with a lack of respect for the profession. But as I processed the words and looked out at the room, I also felt a sense of relief. I wasn’t the only one. My colleagues were sticking themselves, too. In theory, we weren’t even supposed to draw blood—the hospital hired professional phlebotomists to do that. But if one of them failed to find a vein or was unable to convince a patient that the blood test was necessary, we were called in for mop-up duty. There had been no orientation seminar on how to draw blood, no guidebook or instruction manual. As with so many other things, we had been forced to figure it out on our own.

I scanned the room, looking at each intern’s face, searching for a glimpse of discomfort or anguish—a sign that someone else was dealing with the fallout of a needle stick. But what I mostly saw was exhaustion. As the greasy pizza was devoured, I caught several interns surreptitiously tapping their hips, checking for pagers that, for this solitary hour, were not there.

A hand grabbed my arm. It was Ariel. Her tangle of frizzy red hair was now in two pigtails like Pippi Longstocking. “Let’s go,” she whispered, ushering me out of the room. “Wendy’s.”

We walked down the hall in silence, finishing our pizza. It was the first real food I’d eaten since the falafel cart. Ariel smiled and gently patted me on the back, like I was a child and she was encouraging me to eat.

Due to our call schedules, I’d spoken to Ariel more on rounds than in private. She knew almost nothing about me and I knew exceedingly little about her, but I suddenly felt like we were old friends; we had shared a lot of experiences as pod mates, enough for her to feel protective of me when intern report promised to be more anxiety-making than calming. I appreciated that she was getting me out of the hospital. “The way I figure it,” Ariel said when we stepped into the empty elevator, “you could teach that class.”

“Thank you for saving me.”

As the elevator plunged toward the lobby, I felt an anger bubbling up inside of me. Sure, there had been six other needle sticks this year, but how many of them had involved HIV-positive blood? How many interns had been handed a sack full of HIV pills to hide in their lockers? How many were worrying if they’d be able to have a child without passing on the virus?

The wave broke as we exited the hospital. “Fuck!” I blurted as we walked down the street together. “I feel like fucking shit! Fuck!”

Rather than ducking my words, Ariel leaned in and intentionally bumped shoulders with me. “Fuck and shit?” she asked. “I hear that’s bad.”

“Fucking shit.” I laughed. “Also bad.”

We walked south along Broadway, mostly in silence, and reached Wendy’s a few minutes later. “Two double cheeseburgers and two Frosties,” I said, assuming my companion was not a vegetarian. I imagined Ariel in her previous life as a consultant, having a steak lunch with clients in midtown, discussing profit margins.

“Still have your appetite, I see.”

“Sort of.”

“I can’t imagine,” she said, “what yesterday must have been like.”

“I don’t really want to talk about it.”

“Neither do I,” she said as we brought our food to a small booth. We toasted Frosties and reflexively felt for our absent pagers.

“You ever watch Saved by the Bell?” I asked, still thinking about Dre’s marijuana and my decision to report it.

“Once or twice.”

“There’s this scene,” I said, preparing to quote what was arguably the show’s most famous line, “where one of the girls, Jessie Spano, gets hooked on caffeine pills and has a meltdown. She starts crying and screaming I’m so excited, I’m so excited, I’m so scared.”

Ariel dipped her pinkie finger into her Frosty and smiled. “Matt, are you having a Jessie Spano moment?”

Ariel was a soft touch; she could shoot the shit with anyone. As the weeks went by, I was discovering that there were two types of interns: those who had gone straight from college to medical school to internship, and those, like Ariel, who had not. The latter group seemed to have a distinct, more comfortable way of interacting with patients. I thought about the way she had delivered the new HIV diagnosis to the young woman. It was a difficult spot to be in, but she’d handled it well. Better than I would have, certainly. Her approach was less frantic, less forced. Perhaps it was simply age and maturity, or maybe it was something else.

As we ate our food, I thought about telling Ariel about the needle stick—as if going through each painstaking detail would help me move on. But the words didn’t sound right in my head—it felt like I was seeking pity, or looking to sensationalize a mistake. Ariel wasn’t my therapist and she wasn’t my doctor.

“You know,” I said, looking out of a large window, “this stuff we do all day…it’s a weird job.” She nodded. “It’s like it could be a movie. Or a TV show. Or a book.”

She grinned.

“And sometimes,” I went on, “a lot of the time, actually, I just feel like things aren’t clicking.”

“I know what you mean.”

She had graduated at the top of her class. I wasn’t sure if she was just humoring me. “Really?”

“Yeah.”

“Sometimes I worry I’m a hazard—to myself, to the patients.” I suppose I did want to talk about it. The needle stick had further undermined my self-confidence, and it was eating away at me. I needed to tell someone so I wasn’t dealing with it alone. “I don’t feel that way all the time, but sometimes I do.”

“We could drop you in one of those hazmat bins.”

“You think I’d fit?” I asked, raising an eyebrow.

“Matt,” she said, putting down her burger, “it was an accident. You heard: seven sticks already.”

“And,” I said, “I have to wonder, temperamentally, if this job is—”

“Hold that thought,” Ariel said as she stood up. “Let’s get another round.”

We got back in line and reviewed the menu—there was something decadent and mischievous about ignoring medical advice and gorging ourselves on double cheeseburgers and Frosties. I imagined thousands of tiny French fries clogging my arteries.

“I feel like…” I considered the proper way to phrase my vague unease. “This sounds silly but…I feel like I’m a wall that needs to get painted. And every day a bit of paint gets splattered on me.” Ariel grinned. “It’s like every time I see a new patient or a new case, a bit of paint gets splattered.”

“What color paint are we talking about?” she said, popping a French fry into her mouth, “just so I’m with you.”

I looked at the ketchup packets between us. “Red.”

Now we both grinned.

“A lot of days,” I went on, “I see the same shit—heart failure, pneumonia, blood clots—and the same parts of the wall get painted. But there are these huge blank spots on the canvas. Reading about cases does nothing for me. I fall asleep before I can finish a page. I have to see it in person or it never happened. But what about rare diseases? What’ll happen when I’m the attending and I’m confronted with a dying patient and a constellation of symptoms I’ve never seen before?”

“I feel the same way,” Ariel said flatly. “Can’t learn medicine from your sofa.”

Ariel might have been humoring me—I imagined she had glided through her rotations much in the way that Carleton would—but I doubted it. It felt like she was similarly in search of a way to learn everything about everything.

“And now, of course, I’ve got other shit on my plate.” I shook my head and glanced down at my finger. “I still can’t believe it.”

“We’re all dealing with something.”

I waited for her to expand on the thought. I wanted to know what she was dealing with. Had she made mistakes? Been talked down to? Or yelled at? Was she befriending patients like Benny? I hadn’t seen any of that, possibly because I was so wrapped up in my own world, just trying to get through each exhausting day.

I waited and waited but Ariel didn’t elaborate, and I wasn’t sure how much I could push. I wondered if her reticence had more to do with giving me the chance to vent or with keeping her cards close. It would’ve been the reflexive thing to do. Even intern report, ostensibly a place for new physicians to let their guard down, had turned into a remedial tutorial on the basics of phlebotomy.

Ariel turned her head to look outside. She again felt for her absent pager.

“Anyway,” I said, breaking the silence, “I can assure you this damn needle stick is singed into my brain forever. And I will never, ever forget the side effects of HIV meds.”

“I bet.” She raised her Frosty. “You’re going to be okay.”

“You think?” Lie to me, I wanted to say, lie to me if you have to.

“One day this’ll be just another splotch of blood on the wall.”

“Paint,” I said, smiling as I dabbed my right index finger with ketchup. “Let’s stick with paint.”

Ariel glanced at her watch and we stood up; playtime was over. We had pagers to retrieve and patients to see. And I had a date with a bagful of HIV pills.