THE charts of patients waiting for a physician were stuffed, two and three to a slot, in the rack under the clock in the nurses’ station. Walking into work at three o’clock that afternoon, I’d threaded my way through hallways clogged with people leaning against the ends of stretchers, slumped over in wheelchairs, and sitting cross-legged on the floor.
“How many are waiting to come back?” I asked Joanne, who was in baggy blue scrubs and white running shoes with navy blue stripes.
“Fifteen, maybe sixteen.”
“Anybody need to be seen right now?” I didn’t want to start on the routine patients if someone with a more acute problem had just been brought in.
“Not really.” She gestured to the rack. “The sickest should be at the front.”
I nodded. Starting a shift so far behind can be disheartening because most of the patients are resentful and angry by the time I meet them. You can’t blame them—they’ve been ignored for hours in a chaotic, noisy ER. Their stretcher may be eight feet away from someone vomiting at full volume, with only a curtain between them to filter the deep, gushing sounds of misery. Or they may be next to someone with gastrointestinal bleeding, the rich fecal stench of rotting blood billowing into their space, making their eyes water and stomachs lurch. The ER is a miserable place to watch a clock.
Until I got off duty at eleven that night I’d start each interaction with an apology for the wait, hoping the hard scowls of impatience would soften, the arms crossed tightly over the chest begin to relax—at least enough for us to start talking, the first step in addressing the concern that had brought them in. Then I’d try to move forward through the problem. Even that can be tricky: after waiting for hours, people feel entitled to as much time from the doctor as possible. Every illness has a story, and some people insist that every detail be heard; any attempt on my part to walk in, get the essential information, and then hustle on to the next patient is just further evidence that no one really cares about them.
On a good night, I can take pleasure in shifting gears frequently and smoothly as I move from room to room, patient to patient. On a bad night, I just dig in and hope to dig out, knowing that no matter how bad it gets, my shift will be over in eight hours.
I grabbed the first clipboard and glanced over the paperwork. The patient was eighty-two, and had been sent in from the nursing home for evaluation of a fever. Great. Just great. I’d been hoping for something simple—something I could knock out and keep moving, start chipping away on our backlog. Most nursing home patients have multiple medical problems, and their list of medications can go on for two or three pages. Just sorting out the drug interactions could take hours. Fortunately, that was the nursing home doctor’s job, and all I had to do was figure out why my patient had a fever. Still, I was tempted to put the old man’s clipboard back, find something quicker. But I’d eventually have to see the patient, so I clicked my pen, noted the time on the chart, and walked toward his room.
Since 89 percent of elderly patients who come to an ER with a fever have some sort of infection, that was the obvious place to start looking. I could almost order the appropriate labs and X-rays without even seeing the patient. The most common infections are in the urinary tract, or the respiratory system, or involve the skin. If I could keep it on autopilot, I could see the patient, quickly get the work-up started, and move on.
Nursing home patients often carry unmistakable stigmata of chronic illness—pale, skinny legs are drawn up into an inflexible fetal pose, and a clear plastic tube snakes out from under the adult diaper, draining an opaque sludge of urine. As often as not, synthetic lamb’swool booties have been strapped to their feet to protect them against the bedsores that form under the unyielding pressure of immobility. The bare toes extending past the booties have thick yellow nails that need to be trimmed.
So, I was surprised when I met my patient: an alert man, with carefully parted white hair. He wore a dark blue robe with baby blue piping that matched his eyes. Sitting propped up on the stretcher, he looked more like a well-rested guest on an ocean liner than a man marooned alone in an ER. His large, knobby hands were folded in his lap; his legs were crossed at the ankles. He wore cordovan leather slippers.
“I’m Paul Austin, one of the ER doctors. I’m sorry you had to wait.” The old man’s handshake was firm, and brisk.
“You-all are busy.” He smiled.
“Durham on a Friday night.” I smiled back, grateful for his understanding. “How can I help?”
“Don’t know, Doc.” He shrugged his shoulders. “I feel fine. The nurses out at the rest home said I have a temperature.”
I pulled the stool closer to the stretcher, sat down, and asked him questions about coughs, nausea, vomiting, diarrhea, and urination with burning. He answered each in turn. As I finished the physical examination, I told him we would check some labs and a chest X-ray, and then come back and talk with him.
He nodded. Then softly, pleasantly, he said, “My wife died.”
I stopped.
“She was sick for four years. Last year, she was in the hospital over 300 days—302 out of 365. She kept saying she didn’t want to go to a nursing home.” He looked at the wedding band on his finger, and rubbed it with his right thumb, as if to polish it. “I took those vows, for better or worse, in sickness and health, and I’ve kept them. I’ve walked that fiery path.” He looked back at me. “I had no idea it could get so rough. I never did put her in a nursing home. I stuck by those vows, but it was hard. Each and every day was hard.”
I wanted to take a minute to listen, to offer more than the thin sliver of time his problem required. But I can rarely sit for more than a minute or two, unless I’m telling someone bad news. If someone’s just died in the ER, and I’m talking with their wife, or children, or father, I’m obligated and forgiven for squandering a few minutes on a problem that can’t be fixed. Otherwise, I need to keep moving. When the ER’s clogged, I have an abiding fear that in the waiting room there is a young woman with “routine vaginal bleeding,” who actually has a pregnancy in her fallopian tube, and it’s about to rupture, causing her to bleed to death. Or maybe a man with a “routine headache” has meningitis, an often fatal infection of the brain. Meanwhile, I’m chatting with a patient.
“Nine days ago, she passed on to glory,” he continued. “It was a beautiful funeral. My daughter set it up, and it was just like my wife would’a wanted it. And then three days later, I was in this very bed in this very emergency room, having a mini-stroke. That’s when I saw a vision of the devil on that wall right there.” He pointed toward the opposite wall, his bony wrist sticking out past his pajama sleeve. “It was plain as day. And he’s a beautiful man. He’s an archangel. The Bible tells you he’s a beautiful man, and it’s right. He just glows.” The old man put his hand back in his lap. “And just when I was seeing that vision, a preacher friend of mine came to visit. He said, ‘Hold strong, ’cause you’re walking that fiery path.’ That’s exactly what he said, ‘You’re walking that fiery path.’ And I said, ‘I know I am, and the devil is on the wall right there.’” The old man paused. “This preacher stands six foot six inches tall. He’s been married fifty-seven years. Him and his wife’s first home was an old chicken coop in Winston-Salem. But they stayed with it, and they’re married to this very day.”
I liked the old man. The rackful of charts could wait for another minute or two. Joanne was good, and she’d call for me if she needed me.
The old man stared at the white tile wall as if he expected another vision. Then, softly, he began to talk again. “Well, when that preacher walked into the room, the devil just faded off that wall like he hadn’t never been there. And I ain’t seen him since.”
The man’s eyes looked straight into mine. “But I’ve kept walking that fiery path. I’m walking it, and I kept those vows, but I never knew anything could be so hard.” He looked away, to the wall, then down to his hands in his lap.
“Sounds like you did the right thing,” I said, staring at the blank wall. I admired the way he’d stood up for his wife, but I didn’t know what to think about his vision of the devil. The old man spoke with such calm and clarity, I hesitated to ascribe his vision to dementia. Maybe it was from the high fevers he’d been having, or the stress of his wife’s death. Meningitis was possible, but there were no other signs to suggest it, so I couldn’t see doing a spinal tap. Other than the vision of the devil, his mental status had been absolutely clear. And who’s to say? Visions of Jesus have been seen in pancakes and tortillas; why not the devil on a tile wall? “I’ve got to get your work-up started,” I said, “but I’ll be back to talk with you soon.”
I scribbled the standard orders for the evaluation of a fever of unknown origin. His hospital chart came up from medical records. He’d been spiking fevers for the last six days of his hospitalization. He’d been running a fever when they transferred him to the nursing home thirty-six hours earlier. His blood cultures and urine cultures were all negative.
When his labs, urinalysis, and chest X-ray came back normal, I went back to talk with him. “Sir, I’m not sure why you keep having a fever. You don’t have pneumonia, or any other serious infection I can find. I think it’s okay for you to go back, and I’ve spoken with your doctor. She’ll check on you in the morning. Okay?”
“That’ll be fine.” He smiled and nodded, as if he’d known my efforts would yield no answers.
He didn’t mention the devil, his dead wife, or the fiery path he’d been walking.
I stood, transfixed by this calm old man. Perhaps someday, when I’m an old man wearing a robe with blue piping and cordovan slippers, I’ll walk a similar fiery path. Then I may understand what he’s tried to tell me. But I was only forty-two, and standing there in my scrubs and stethoscope, I had no insights to ease his pain. I couldn’t even tell him why he had a fever.
The overhead speaker crackled. “We need a doctor in room twenty-seven. Now.”
“I’ve got to go.”
He raised his right hand in a tremulous benediction.
I forgot the old man as I scrambled through the rest of the shift, grateful to make it to eleven without running across an ectopic pregnancy, or a case of meningitis.
I got home from work after midnight, and tiptoed upstairs. In my sons’ room, John had kicked his covers into a tangle around his feet, and Sam was at the end of his bed, without a pillow. I straightened them up, tucked them in, and went to check on Sarah. Her breathing was as quiet as moonlight.
In our room, Sally slept curled on her side. The contours of her hips and shoulders glowed in the streetlight filtering through the curtains. I undressed, and slipped in beside my wife. Lying naked in the pocket of her warmth, I thought about the old man, and the fiery path he’d talked about. I tried to imagine living alone and sleeping by myself, without feeling the mattress shift as Sally moved, without the soothing whispers of her breathing. What had the old man been trying to tell me, beneath the cool fluorescent lights of the ER? I’d kept my focus on his fever, even though he’d wanted to talk about the vows he’d carried and the loneliness he’d been left with. Had he just needed to unburden, or was he warning me of a path that could explode into flame, even as I walked it?
Sally and I planned to grow old together. If our marriage succeeded, someday she’d bury me, or I’d bury her. That’s how it works. One of us would wake up the next morning and lie motionless in bed, bewildered by the inevitable loneliness that had always seemed impossible.
Sally shifted in her sleep and murmured something I couldn’t understand. I eased my head down into my pillow. There was nothing I could do about the old man’s loneliness or the warning he’d tried to give me, so I did the only thing I knew to do—I moved closer to Sally’s warmth. The subtle, complex scent of her sleeping body calmed me. I slowly breathed in, and out, hoping that sleep would come quickly.