Monday

“Ms. Milford here is a little slow on the Aristotelian dialectics,” Sammy said. “I suggest you proceed to the physical exam, Dr. Brenfield. I’m sure the interns will gladly immerse themselves in the myriad minor details of Ms. Milford’s mannered life.” Despite Sammy’s bison-like lack of grace, his words really were true: as the attending, all Graham really needed to know was whether this ulcer needed surgical intervention or whether IV antibiotics would be sufficient. The interns could sort out the rest. Graham bit his lip and tried to ignore the odor as he started the medical interview. Cherry Milford’s answers to Graham’s questions were slurred and incoherent.

“Where’s the ulcer?” Graham asked the patient. Cherry Milford’s index finger, with its dirt-encrusted, ragged nail, wove sluggishly in the air until it landed tentatively in the region of her left thigh.

“Allow me,” Sammy said, grabbing the edge of the sheet. “This is the pièce de résistance.” Sammy slowly pulled the sheet back with exaggerated drama, and Graham grew impatient. He just wanted to eyeball the ulcer, and was expecting the usual quarter-sized wound that most of these skin-poppers inflicted on themselves. But when Sammy folded the sheet all the way back, Graham let out a low whistle. This wasn’t an ulcer; this was a crater.

The entire length and breadth of Cherry Milford’s thigh, from the crease of her groin down to her kneecap, was a scooped-out mass of gravelly pink-white-gray tissue. If Cherry Milford had the strength or inclination to sit up and bend forward, she could probably nestle her entire forearm in there, elbow to fist. Over the years Graham had seen his share of cutaneous injuries from skin popping, but nothing held a candle to this. This was one for the record books, even by East Memorial standards.

“How long have you had this?” he asked, incredulity overtaking jadedness. Even the caustic vinegary smell of it temporarily receded in his consciousness; he just couldn’t believe what he was seeing.

Cherry Milford shrugged in slow motion. “Dunno. Sort of started a while back. I shot up there and it got a little craggy.”

“A little craggy, eh?” Sammy asked. “Didn’t you notice that your entire thigh had practically disappeared?”

“Ms. Milford,” Graham said, trying to focus the patient’s attention. “This is a serious ulcer. We’re going to start IV antibiotics, but we might need the surgeons to clean this out. Do you have allergies to any medications?”

But the particulars of medical treatment were apparently beyond Cherry Milford in her current state. Her eyes were already closing and petite snores gave way to full-throated snorts and snuffles. The anodyne aspects of heroin worked in Ms. Milford’s favor, buffering Sammy Chen’s words as well as the rest of the world from her consciousness.

“A little craggy, eh?” Sammy repeated, as he and Graham tugged the curtain shut behind them. “Jeez Louise—you could probably store a pair of sneakers and an order of take-out Chinese in that ulcer.” He shook his head in amazement. “You know, there are probably real-estate opportunities here. A little redecorating and it’s a perfect starter apartment. You can rent out anything in this city …”

“I’ll get plastics to take a look at that ulcer,” Graham replied, feeling the need to sound as business-like as possible. “Maybe even ortho—there’ll probably be raw femur sitting in there once all the debris is removed.”

“Like I said,” Sammy said, “the prom-queen.”

“I see you’re in a mighty charitable mood today, Dr. Chen,” Graham said, folding up his list and pressing it into his pocket.

“I’m telling you, man, we had a run of shooters-with-fevers last night.  What are these guys mixing up their drugs with—toilet water? With my luck Ms. Milford will shoot her panoply of viruses straight to the kidneys and end up in my fucking dialysis unit. Another $500 dialysis catheter wasted on piss-poor protoplasm.”

“Glad to know you’ve recommitted yourself to the care of the needy and the vulnerable in our city.”

“Fuck off, Brenfield,” Sammy said, giving Graham a quick left-hook to the abdomen. “Gotta cover yourself, brother,” dropping the tenor of his voice.  “Someone could pop your spleen if you’re not faster on the draw.”

Graham knew that Sammy wasn’t a complete cynic—there were plenty of doctors who were unabashedly derisive about scumbags, assholes, and gomers who populated the East Memorial ER. Sammy actually cared about doing the right thing for his patients, but he had no patience for what he perceived as self-destructive behavior. Sammy Chen’s dialysis patients could count on superb clinical care, but they had probably learned to get their emotional succor elsewhere.

Graham left Sammy and walked toward the ER nurses’ desk, tugging his fingers through his wiry brown hair. Sheila said that the parts that were graying made him look distinguished. Graham thought they made him look like a guy who was spinning headlong through his thirties with neither a handle on life nor a 401k.

“It’s sexy,” Sheila told him. But all the men in her investment firm with that sexy, graying look were also pocketing millions of dollars in bonuses and sporting double-breasted Italian suits. Graham was still working for East Memorial Municipal Hospital, the same crummy inner-city hospital at which he’d done his residency, and his salary contribution to their marriage was only marginally more than when he was an intern.

He just couldn’t muster the enthusiasm and business interest that was required to build a private practice. He’d applied for gastroenterology fellowships toward the end of residency, but didn’t get into any of the good programs. Sheila would have considered moving out of Manhattan if he’d gotten a spot at Mass General or UCSF, but not for the Kerrville VA in Texas. Staying on at East Memorial was just simpler—Graham knew the routine, and the interns did weekend coverage for his patients. Besides, he wasn’t even sure he wanted to be a gastroenterologist. It seemed that everyone in his residency class marched lock-step toward medical specialties like cardiology and GI, and Graham simply puttered along with the flow toward specialization for lack of a better plan.

But did he really want to spend his life threading tubes into people’s intestines or coronary arteries? Sheila no doubt wanted to be married to a Park Avenue cardiologist, but now she was stuck with a general internist at a city hospital in a non-gentrifying neighborhood in Brooklyn. The staff doctors at East Memorial were city employees like everyone else at the hospital, which meant decent benefits and lousy salaries. How many other women at Sheila’s firm, he wondered, had husbands who possessed union memberships instead of stock options? Sexy indeed.

“Dr. Brenfield,” came a warbly, desperate voice. Graham turned around. It was Hamdi, one of the interns on his team. Everyone called him Hamdi, even the patients, because nobody could swing their mouth around Dr. Hamedian Avarhamian. Hamdi looked perpetually harried, even at 7 a.m. But by late afternoon, as it was now, he seemed on the verge of a nervous breakdown. Raggedy clumps of jet-black hair fell across Hamdi’s thick-rimmed glasses. His last haphazard shave three days ago and his hooded, droopy eyes made him appear like he was permanently ensconced in a shadow. Hamdi’s white coat was misbuttoned and the left side hung six inches lower than the right. His stethoscope was dangling out of the left pocket, scraping the floor as he walked. Hamdi never wore anything but scrubs, usually mismatched blues and greens.

Hamdi was the type of intern who was petrified at the prospect of being caught unprepared, and thus lugged every possible portable medical paraphernalia, book, card, and cheat sheet with him to shield against the infinite number of challenges lurking in the wards. Despite the fact every nurses’ station on every floor was adequately equipped with supplies for IVs and blood draws, Hamdi’s pockets were crammed with blood tubes (red-tops, blue-tops, speckle-tops, purple-tops), alcohol swabs, iodine swabs, gauze pads (2x2s and 4x4s), tourniquets, IVs (22 gauge, 20 gauge, 18 gauge, 16 gauge, and even 14 gauge in case he happened upon someone who was exsanguinating and needed an IV the diameter of a Bic pen).  Two needle-nose clamps were clipped onto the top two button-holes of his coat, sporting rolls of cloth tape and paper tape. The third buttonhole was home to a rubber-nosed reflex hammer. The other pockets bulged with EKG attachments, sputum cups, index cards, laminated cards of medical protocols, pocket books of formulas, rulers, calipers, stampers, and spare beeper batteries. However, three pockets-worth of medical paraphernalia were not enough to assuage his existential intern angst, and so Hamdi also carried in his hands an overstuffed, drug-company-dispensed clipboard advertising the second-costliest ulcer medication, an assiduously dog-eared copy of the Washington Manual of Medical Therapeutics, a hot-pink three-ring binder (touting the latest broad-spectrum antibiotic) from which papers were spilling out at every angle, last-year’s hospital phonebook, and the takeout menu from Chi-Chi’s—the local Mexican fast food joint run by Koreans who’d developed an impressively efficient way of turning out the dirt-cheap, passably edible chicken fajitas that were Hamdi’s daily salvation from the unrelenting intern paranoia that he was just nanoseconds from inadvertently killing, maiming, or otherwise harming one of his patients.

“What’s up, Hamdi?” Graham asked, seeing in Hamdi a little bit of himself when he was an intern.

Hamdi shook his head heavily, panting, and the metal clamps and reflex hammer hanging from his coat jangled. It took him a minute to catch his breath. “Yalena told me to go see the skin-popper, but I’ve been with the fever guy for an hour trying to get an IV in.” Hamdi’s face tautened as he said this, as though this were just the latest in a long day of death and destruction.

“Not to worry,” Graham said, suppressing a desire to pat Hamdi on the head like a wayward puppy. “I already saw Milford, already paged plastics. Why don’t you run along and take care of all the rectals on 16-West?”

Hamdi pursed his lips grimly. “Nope, Yalena’s already paged me. Got to review all the admissions with her.” He consulted his scut list, then marched away. The slight limp of his right leg could sometimes be masked when Hamdi was calm and focused. But when he was stressed and overwhelmed—as he was now, and indeed most of his waking hours—the limp was more pronounced. His left leg took on the business of ambulating forward, and his right leg swung around like the free arm of a compass. This lent a rhythmic cadence to his stride, an accented downbeat followed by a more measured reply. After four of these syncopated couplets, Hamdi plunged into the ER cacophony, head bent down as though there would be no passage unless he rammed his way though.

Graham jammed his hands in his pants pockets and then followed Hamdi back to the procedure room, where the team was conferring over the list of admissions with Yalena. Yalena was a reasonably competent second-year resident, with a placid demeanor that only partly obscured an iron resolve to get ahead. Selections for chief residents were made toward the middle of the second year of residency, and Yalena—though she wouldn’t say it aloud—was determined to be one of that select group of four.

Yalena’s face was a pale orb with little in the way of contrasting features. Her eyes, lashes, and lips were nearly the identical color as the rest of her skin. That and the complete absence of wrinkles, freckles, smudges, scars, birthmarks or moles gave her face an egg-like smoothness that seemed almost unnatural. Her perfectly straight brown hair was always pulled back from her face in a tight ponytail. A wide black elastic headband was positioned exactly at the hairline at the edge of her forehead, so that her hair didn’t seem to “appear” until several inches back on her head. This added another element of odd featurelessness to her milky visage.

Yalena’s head was always slightly cocked upward, as though she were trying to see upward over the horizon. When she walked, this gave the impression that she was leading with her nose. Her pale, close-lipped smile straddled the border of angelic and condescending, but her attitude on a call day—which Graham respected and appreciated—was all-business.

“Okay,” she said, tapping her list with her trademark fountain pen, “there’s a chest pain, an altered mental status, a lupus flare, and a diarrhea guy. Rumor has it that there’s a GI bleeder in the works. I’ll send the medical students to check out the lupus case. Hamdi, you eyeball the diarrhea guy and make sure he’s stable. I’ll check on the altered mental status lady and see whether she needs a spinal tap. Dr. Brenfield, do you mind seeing the chest pain guy?”

Graham nodded his head. He much preferred sharing the workload upfront with the team. He could skip the niceties of academic discussions and touchy-feely connections. Basically, there were X number of admissions to which he’d have to sign his name as the legally responsible physician, and he’d just as well get them over with as soon as possible.

“Oh, and the guy from this morning with the possible pulmonary embolus…,” Yalena called out to Graham as he began to walk away, “his lung scan came back as “indeterminate.” I kept him on heparin anyway, just in case.”

“You think he really has a blood clot” Graham asked, turning back to Yalena.

Yalena shrugged. “Maybe. But better safe than sorry. I figured we’d leave on him the blood thinner for now, until we work up other possibilities.”

“But there are side effects to heparin,” Graham said, feeling himself shift into educational mode. “He could bleed.”

“Not if we monitor it correctly,” Yalena replied, snapping her fountain pen closed and sliding it neatly into her pocket.

“A hundred thousand people die every year in this country from adverse medication reactions,” Graham said, looking from Yalena to Hamdi. “One hundred thousand. We kill patients all the time with our treatments. Just keep that in mind, guys, as you go about your business. Everything we do in medicine has the potential to do harm.” Hamdi looked faint.

Graham and his team plowed through their roster of admissions for the day. By 10 pm, most of the patients were “tucked in,” as the expression went. The obese 76 year-old Puerto Rican man with crushing chest pain was in the CCU after the cardiologists stented open his clogged right coronary artery.  The obtunded 91-year-old, transferred from a nursing-home with “altered mental status” had been found to have a urinary tract infection, and broad-spectrum antibiotics were already flowing through her spindly veins. The winsome, 24 year-old Honduran woman with a flare of lupus nephritis was leafing through Vanidades fashion magazine and chatting on her cell phone while the nurses set up her cyclo-phosphamide treatment. The 36 year-old white gay man with profuse AIDS-related diarrhea was still pouring out diarrhea, but was actually feeling better, thanks to the aggressive IV hydration. The 53 year-old guy with the possible blood clot turned out to have a pneumonia and was now getting antibiotics instead of blood thinners. The 64 year-old alcoholic with bleeding duodenal ulcers had just been scoped by the GI fellow, when a code was called down the hall from where Graham was sitting, writing an admission note, in the 16-North nurses’ station.

Usually, Graham let the residents handle the codes—the residents being far nimbler in their recollection of ACLS protocols—but being so nearby he felt obliged to at least check it out until the rest of the team navigated East Memorial’s unreliable elevators to get to the sixteenth floor. “In the bathroom,” one of the nurses shouted to him, pointing the way. Graham barreled his way in, and there on the gray tile floor was Cherry Milford, crumpled under the sink, a syringe still poking out of her cavernous thigh ulcer. A respiratory technician was hunched near the commode, trying to stabilize Milford’s airway.  “I can’t do it here,” he grunted. “Help me get her out.”

Graham and the technician dragged Milford’s slack body out of the bathroom and heaped her onto a bed. “Shot up in that disgustingly infected ulcer,” the technician said, strapping the oxygen mask over the patient’s mouth as the code team arrived and sprang into action. “Pathetic.”

The full code proceeded—chest compressions, electric shocks, breathing tube, central lines, blood gases, ampules of epinephrine, atropine, Narcan, bicarb—but it was clear that Cherry Milford was dead. She’d managed to OD in the bathroom of East Memorial just as she would have done in the hallway of the crack house or an unused subway entrance. The only difference was that she had been discovered by a nurse and so her corpse was subjected to a host of “life-saving” procedures. From the first time the Paris Academy of Sciences recommended, in 1740, that mouth-to-mouth resuscitation be administered to drowning victims, resuscitation protocols had been elaborated specifically for otherwise-healthy patients who experienced an acute insult to their well-being. The current Advanced Cardiac Life Saving algorithms on display at this moment had been developed for the cardiac patient who experienced a sudden arrhythmia that could be shocked back into normalcy. They had not been developed with the likes of Cherry Milford in mind.

“Suicide,” the technician commented to Graham, who stood at his side watching the oxygen being forced into the breathing tube. “Self-inflicted death by needle. Pathetic.”

It was pathetic, Graham thought. It was pathetic that a leg nearly eaten away to the bone was not a deterrent to snarfing up more drugs; it was merely a vehicle. It was pathetic that Cherry Milford’s body was so sapped of biological reserve that the thousands of dollars of equipment and medications being used in this code could never revive it. It was pathetic that the scaffolding of society was so porous that entire lives could slip through and self-destruct. It was pathetic that Graham’s dead patient was exactly the same age as he was. And what was most pathetic of all, was that despite all of these swirling thoughts in his head, what Graham was most agitated about was that he still had one more admission note to write before he could get out of the hospital.

(excerpt from unpublished novel, “Malignancy.” Originally appeared in “2 Bridges Review” pg 86)