“My gift to you,” Ashley said, handing me my pager ten minutes later. “Thing never stopped buzzing.”
“Gracias.”
“How was intern report?” she asked.
“Fine,” I said. “Listen, I’m gonna give it another shot with Dre.” On the walk back from Wendy’s I had tried to think more about how to break through to her. I hadn’t come up with much, but I felt momentarily invigorated by my lunchtime heart-to-heart with Ariel. “I think what she needs is some tough love.” I imagined what Ariel might say to Dre. “Or the opposite. I really have no idea.”
“I wanted to talk to you a bit more about her. Something that didn’t come up on rounds.”
“Of course.”
Ashley pulled out a sheet of laboratory data. “Do you think she needs dialysis?”
I scratched my head. “Someone mentioned kidney disease, but I’m not sure she needs dialysis.”
“Why not?” She batted her hazel eyes. “Walk me through your thought process.”
“It’s going to be a short walk.”
“Try.”
“Her creatinine is almost three,” I said, referring to the blood test that reflected kidney function. A normal value hovers around one. “Not great but not horrible.”
“Fine.”
I recalled the handful of patients I’d taken care of with kidney failure. “Dialysis is usually an emergency.”
“Sometimes. But not always.”
“Okay. I mean, she looks stable. Sick but stable. I can call and arrange dialysis, certainly.”
“When you call, you have to make a case for it.” She put her thumb and index finger together and stared deep into my eyes. “The nephrologists are busy and it’s a pain in the ass to dialyze someone. You gotta have a leg to stand on. What’s your argument?”
“I’d say her kidneys are only marginal and to be on the safe side we should do it.”
“Wrong!” She made the sound of a gong. “Never say ‘to be on the safe side.’ We’re in a hospital—that’s a given.” She took a large swig of her latte. “Remember your med school lectures on dialysis?”
“Vaguely.”
“It can all be distilled down to this: A-E-I-O-U.” She motioned to my breast pocket, and I pulled out a pen to take notes. “A. Acidosis—is the patient’s blood acidic? If so, dialysis. E. Electrolytes. If an electrolyte is severely off—”
She pointed at me.
“Dialysis,” I said.
“Good. I. Intoxication—did the patient ingest something toxic like moonshine or overdose on something like lithium?”
Dialysis had always confused the shit out of me. Was it really this straightforward?
“O. Overload. Is there fluid overload—too much liquid on the lungs?”
Her approach on this recalled Baio’s, and I knew I wouldn’t forget it. The truth is that complex decisions are often made using simple mnemonics. Linguistic shorthand wasn’t encouraged at Harvard—information needed to be mastered before it could be abbreviated—but Ashley had just simplified a series of baffling medical school lectures on dialysis into a mouthful of vowels.
My pager went off in mid-scribble. I glanced down at it.
THE GREAT MUSTACHE RACE—YOU IN?
I tilted the pager out of Ashley’s line of view. “U. Uremia,” she said quickly, “and that’s it. A-E-I-O-U.”
“Wow.”
“Next year, the Ash Safety Net disappears,” she said, putting a warm hand on my shoulder, “and the Republicans take over. You’re on your own. That said, you’re doing a good job. Just try to relax a bit.”
I no longer felt like deadweight, and she no longer seemed like an annoyed babysitter. Was it because of the needle stick? Or something else? She knew I stayed late and arrived early, that I cared deeply about my job and that I wanted to get better at being a doctor. Perhaps I had earned her respect and she felt invested in me as a member of her team. Or maybe she just felt bad for me. I wanted to know what had changed, but I couldn’t figure out how to ask.
“All right,” I said, standing up, “thanks for that mnemonic. Time to joust with Dre.”
“Good luck.”
“Any final words of wisdom?”
She stood up and clasped her hands together. “Get on your knees, Matt, and grovel.”
“Seriously?”
“I don’t know. What would you want to hear?”
As Ashley scuttled away, I stared at the Impressionist seascape hanging on the wall and racked my brain. How had I been talked into unsavory things in the past? Fear, deceit, alcohol, and money came to mind—tactics that weren’t appropriate here. I’d jumped at the offer of HIV medications, but that scenario wasn’t really applicable either. My biggest fear was skydiving. How could someone talk me into jumping out of an airplane? They couldn’t. I wouldn’t even consider doing it. What would Jim say to Dre? Or Baio?
I had a new tactic in mind, one that was risky and would potentially leave me exposed, but I had a hunch it might work and I was running out of options. I simultaneously knocked and opened the door to Dre’s room a few minutes later. “That you, Em?” she asked.
“How do you always know it’s me?”
“Smell,” she said, leaning back in bed.
“Seriously? What smell?” I glanced at my armpits.
“I’m playin’! It was just a hunch.”
I sat on the edge of the bed—doing so really did force me to listen. “So,” I said, taking her soft left hand in mine, “you were about to say you’re ready to get back on the meds.”
She pulled her hand back slightly, but I didn’t let go. “Nope.”
“Please.”
“No, thank you.”
I hadn’t yet asked her what she was so afraid of. Death? That couldn’t be it. Without the medications, she would die. Sure, I now found myself dealing with diarrhea so aggressive it occasionally left bloodstains on the toilet paper, but there was no other option. I tried to put myself in her shoes, but where did that leave me? In her position I’d take the pills. “Help me understand what’s going on.”
“I’m impervious to your advances, Em.”
I returned to my own fear. No amount of begging or reasoning could get me to strap on a parachute and take that leap. The only way I’d do it is if you pinned me down against my will and shoved me out of the plane. But here I was, in free fall. Could we forcibly administer HIV medications? “I’d like to explain where I’m coming from. What we know about your condition and what we still need to figure out.
“Wasting your breath, Em.”
But the skydiving analogy didn’t seem apt. In truth, I was far from a model patient—I routinely ignored the medical advice to wear sunscreen despite my family’s history of melanoma—but why?
“Sometimes,” I said, considering what to say next. “Sometimes we do things…”
And then I went for it. “I take HIV meds,” I said quickly. “I’ll take them with you.” It felt good to say it. I said it again, this time slower and louder. “I’ll take them with you.”
“Oh, please.”
“I will. I swear. I take them at home.”
“Try again.”
“I’m serious.”
She squeezed my hand. “I’m blind, not naïve. Not—”
“I give you my word.” Was this manipulative? Did it matter?
“You have HIV?” She felt for the remote control near her pillow.
“I might have HIV.” I inched closer. I could feel my voice about to quiver, so I whispered. “I stuck myself the other day with a needle. The patient had AIDS. And…”
“And your fingers are crossed.”
“Yeah.”
She shook her head. “Ain’t that the shit.”
I cleared my throat. “Do me a favor. Just take one pill, one time.”
I took both of her hands in mine like we were reciting May-December wedding vows. I had a vague sense that I was making progress. She was engaging more with me than I’d seen with other doctors, most of whom she immediately waved away. It wasn’t much, but it was something.
I wondered what exactly she saw, staring at me. “Fine,” she said. “One pill. One time.”
“All right!” If Jim O’Connell could see me now! If there had been a wineglass I would’ve stepped on it. I suspected Dre was in denial about her illness, and I wanted her to break through that. I wanted her to become angry, I wanted her to pass through the stages of grief and accept that she had a very real, very treatable condition. I didn’t care if she used marijuana; I didn’t really care if she sold marijuana. I just wanted her to acknowledge what she was up against and realize she could win. Until that moment, I would remain frustrated. But here, I saw an opening.
“And if that goes okay,” I said exuberantly, “we can do two. Two pills.” She had at most a few months before it was too late. “And then, three.”
“I said one pill. One time. Keep talking and I might change my mind.”
I let go of her hands and stood up. “Wonderful. See you tomorrow morning.”
Dre and I still needed to confront the spinal tap and to get her there, to get her to agree to the procedure, I would undoubtedly have to go deeper still, searching for other ways to connect with her.
Walking out of her room, for the first time, I felt like a real doctor. In the words of Baio, it was fucking cool.