Telltale Hearts, page 6
“Okay, Raskin. We’re trying to look out for your welfare too.”
I gave one of the bottles to Craig and bent down to pick up the other two into one arm.
Raskin turned his head toward me as I was exiting his room and complained, “A million bottles on the beach, and I had to pick hers.”
“Maybe we need to give him more lactulose, or even neomycin,” I said to Craig in the hallway, implying that Raskin’s increasing verbal ejaculations might be a manifestation of liver failure’s toxic effects on the brain.
“I don’t think this is hepatic encephalopathy,” he said to me. “The things he’s saying… they’re too cogent. It’s like there’s some story inside his head that he’s trying to get out. But I can’t figure it out.”
The next morning, Craig didn’t show for 7:30 a.m. rounds. I paged him to find out why he was late.
“Meet me in 5R,” he said, bubbling with enthusiasm, even joy. “I’m with Raskin. And I figured it out!”
Raskin, in the ICU? I trotted to 5R and saw Raskin aglow in an ICU bed, still in four-point restraints, but now wearing a full face mask with high-flow oxygen.
Craig got up from behind the nurses’ station and approached me.
“Hey. So, last night—no, early this morning—he went into acute kidney failure and his O2 sat dropped to the 80s. His repeat chest x-ray showed progression of the PCP. The night float moved him here, which made sense because, well… he’s kinda crashing.”
“Did you start steroids on him?”
“Yeah, I started them a few minutes ago, and I called Renal to see if they’ll be willing to dialyze him. Doubtful, don’t you think?”
“Yeah, doubtful.”
“But whatever. That’s not the thing. The real thing is that I figured it out. I figured him out.”
“What do you mean?”
“Okay. Think about it. All this talk about ‘Master this’ and ‘Master that.’ And Major Nelson. And Roger Healey. And astronauts and bottles? And Jeannie?”
“Yeah, what about it?”
“They’re all characters in the show I Dream of Jeannie. Which means he’s been replaying episodes of I Dream of Jeannie. Feeding us lines—word for word—from the show. Remember, he lay on his couch for three months, maybe longer, just watching reruns on KOFY 38? While getting smashed?”
He tapped his forefinger to his temple and said, “All that’s left up there is a set of scripted reactions that come from those episodes. Think about it. It’s incredible. Admit it: I’m a genius.”
“Okay, okay,” I replied, unable to hold back my chuckling. “So, either you just figured out how the subconscious and toxified mind of a man dying of liver failure and AIDS works, or you just proved to me that you watched way too much bad TV as a kid.”
“How about we say yes and yes to that?”
THE SHRILL OF THE WHISTLE
I was the intern on call at San Francisco General again, a lowly infantryman in the trenches on the front. We were making our morning rounds on my current load of patients, whistle-free for now. My attending physician was a gentle man, about forty-five years old, an infectious disease doctor whom I presumed had no choice but to become an expert in HIV. He was a fountain of knowledge. I attempted to push away the anxiety that I was feeling, the sense of impending doom, so I could try to soak up as much knowledge as I could. I looked at him closely as he spoke. He was a feeble man. He walked slowly, his hair looked like it had fallen out in clumps, and his skin was mottled. While his mini-lecturing was comprehensive and insightful, his memory for the details of our specific patients seemed paradoxically spotty. As if he were more interested in the diseases than the people. He carried a clipboard with him wherever he went, writing down every detail as we moved through our patient panel.
As rounds ended, I pulled aside my resident, Frank Massey.
“Frank, what’s up with Dr. Edmunds? I mean, he’s super chill and knowledgeable, but he doesn’t seem to have a grasp on the details of each patient. And he carries that clipboard around, always writing stuff down. Is he just a hands-off attending? A big-picture guy, leaving the details to us? Plus, I don’t know about you but, to me, he doesn’t look good. Every step, every word, seems to take an effort.”
“Yup. You got a good eye for an intern. You want the truth? You and I are running this service, my friend. Edmunds is sick. I heard a rumor—I can’t confirm it, but I think it’s true—that he’s got AIDS. And now lymphoma, status post-chemo. And that he refuses to go on medical leave. He sees this as his mission in life, at least what is left of it.”
“Holy shit. That both freaks me out and at the same time is super inspiring. Do you think he’s competent to do this? I mean, his memory seems questionable.”
“Let us be his working memory. I’ll make the call if I see anything going awry. And let’s keep this on the down-low, okay?”
My resident, Massey, was gay. Openly so, and in moments of levity, almost flamboyantly so. On our call night, in between hospital admissions, while eating “midnight meal” with my co-intern and two medical students, he would tell us about the experience of being gay in Indianapolis, where he was from, versus being gay in San Francisco. This gave me an opening to ask him a question I’d always wondered about.
“Frank, I’ve always wanted to ask: How do you guys know if someone else is gay? I mean, let’s say you want to come on to someone. But you have zero idea if they’re gay. So, it could either end up in a romantic night or a punch in the face. How do you guys navigate that? Do you have some inside signals?”
Massey burst out laughing, his cereal exploding out of his mouth.
“Dean, Dean, Dean. Are you serious? Yes, we all pull out little red bandannas from our back right pockets and flutter our asses like peacocks. Others have a quiet little dog whistle they blow that only we can hear. Those are our subtle signals.”
“No, seriously, I’m just curious. Because not every gay man looks and acts like the stereotype,” I say, trying to recover some face.
“Really? Okay then.” He turned to our group of four that he supervises. “You people wanna know too, I presume? Well, here’s the million-dollar answer: We’re just like everyone else. We’re no different.”
He turned back to me and asked with a smile, “How do you know if someone is interested in you? How do you even know whether you should come on to them? In your case, I presume, we’re talking about a woman. Fine. So how do you know?”
“Well, I just assume, you know, playing the numbers, that she’s into men.”
“But that’s not how it works, is it? It’s not whether she’s into men. It’s whether you think she might be into you and whether you have a shot, right? And then, after you make your move, you reassess, no? Based on her body language, based on what she says in response to what you’ve said and how she says it. And based on the light in her eyes, the sparkle. Sometimes you guess wrong, but other times you guess right. Which means that sometimes you score and sometimes you get a slap in the face—real or metaphorical. So, in answer to your very sweet and incredibly naïve question, it’s like I said: we’re no different from you.”
I was about to ask a more important follow-up question to learn how he assessed the potential HIV status of any potential sexual partner, but our escapade into the mysteries of gay romance in the early 1990s was interrupted by the simultaneous whistles of his pager and mine. x8020. The Mish.
BRIGHT LIGHTS, BAD CT SCAN
The next morning, we were making our post-call morning rounds with Dr. Edmunds. We admitted nine new folks on top of the twelve we already had, and with Edmunds at the helm, our progress was painfully slow. Edmunds was rightly most concerned about a middle-aged HIV-positive woman—reported to be a prostitute—who presented with altered mental status. She was somnolent and only sporadically responded to sternal rubs or other forms of physical stimulation. The rest of her neurological exam was normal, and her lumbar puncture had some protein and a few white cells but otherwise was not diagnostic. The syphilis test from her cerebrospinal fluid was pending. We had her on meningitis-dose antibiotics and antifungal medications just in case. The rest of her lab evaluation had been pretty much normal, and her urine tox screen for illicit substances was positive only for cocaine.
“I’m worried about her. This is going to turn out to be something weird,” said Edmunds at her bedside. “In HIV, it’s often either a common problem presenting in an uncommon fashion, or an uncommon problem presenting commonly.”
He paused to let us ponder that statement.
“If her kidney function’s good, I would add in high-dose acyclovir to cover for herpes encephalitis,” Edmunds said. “Continue all the meningitis meds. And call Neuro again to see if they can do an EEG. Herpes in the brain can give you stereotypical waveforms in a temporal lobe or two.”
He then turned to me. “And what does the CT scan show?”
I looked at Massey, and he discreetly nodded.
“I think you just wrote it down, Dr. Edmunds,” I reminded him as gently as I could. “She got her CT scan at 5:00 a.m., and we’re waiting for the formal read. They said the attending radiologist would get in about now, so I can run down now and see what they found, or we can finish rounds if you prefer and then I can go.”
“Right. I’ll let you decide since you know your other patients better than I do.”
This dying man had grace.
Massey confirmed it was up to me and said he could cover me for a few minutes on rounds if I wanted to check the CT scan. I decided to feed my curiosity and Edmunds’s concern and break from rounds.
The CT neuroradiology room was the opposite of the patient-facing areas of the hospital. Here, everything was dark, cool, and quiet. Organized, peaceful. A backlit x-ray display panel was the only source of light. Three doctors in pristine white coats sat in a row in reclining office chairs, facing the panel. It was covered with black sheets of developed film placed into a vertically rotating carousel that rolled through the series of images at the press of a foot pedal. One of the radiologists—presumably the attending—held a small hand recorder into which she was dictating her current interpretation. She was killer smart, sarcastic, and more than a bit intimidating. I had heard she was the best neuroradiologist in the country and that she had written the textbook on HIV-related radiology of the central nervous system.
“What can we do for you?” her resident asked.
“Yeah, thanks. Medicine Service 3. Ward 5A, Bed 13. Medical record number 01077633. Forty-five-year-old lady with HIV, low-grade fever, altered mental status, nonfocal neuro exam. CD4 count 41, lumbar puncture with just a little bit of nonspecific action. Awaiting final word regarding microorganisms, so I doubt Cryptococcus. Still waiting for Neuro consult. So—no diagnosis yet. We’re looking for Toxo, lymphoma, HSV encephalitis, or other, weirder stuff.”
The attending wheeled her chair forward and pressed the foot pedal to reverse the carousel, the motor loudly reverberating as it flipped backward through the images.
“Right. We just looked at her scans. This is gonna be one of the weirder things. Take a look.”
The nine images in front of me showed cross-sectional slices of her brain starting from the top of her scalp down to the top of her neck. The brain tissue appeared swollen, the grooves and folds less pronounced. I recognized the black fluid-filled ventricles of her brain. They were a bit larger than what I was used to. I saw the clear delineation between the gray matter and the white matter. I didn’t see the grayish, ring-enhanced golf balls scattered throughout the brain that could mean toxoplasmosis, nor did I see the more geographic shape of a lymphoma. I kept scanning as I descended down her brain. Then I was hit with a bright light, a linear strip of white located above her olfactory nerves, with a contiguous white oval mass extending into her right frontal lobe. The temporal lobes looked normal to me. Feeling the powerlessness of my ignorance, I simply pointed to the blinding white region.
“Here?”
“Nicely done, Doctor,” the attending quipped.
“Okay, so I can find the bright white abnormality. Hurray for me. But what is it?”
“Some sort of meningoencephalitis affecting the lining of the brain and then extending into it. The location suggests basilar meningitis. We often see that with TB and syphilis. I’d start there with your treatment, and see what the spinal fluid shows and what it grows. Then you can whittle it down. You might want to throw in some high-dose dexamethasone to get that brain swelling to go down. If you get in a bind, I’d suggest you ask the neurosurgeons to biopsy that frontal lobe. It seems accessible. And lemme know what you find out. I don’t care if it’s on autopsy. I need to know. Don’t forget.”
I rushed back up to 5A to tell Massey and Edmunds that we needed to get TB meds on board, but they were not there. I asked one of the nurses where they were, and he told me that they had to transfer my patient to the ICU because it looked like her brain might be herniating, a neurosurgical emergency.
As I ran over to the ICU, my pager went off: x8172, the micro lab. These guys were good. It was the Filipina lab tech, the woman whom I had gotten to know well in only two weeks on the wards here.
“Hi again, Doctor. Sorry for the delay. We think we have an answer. We needed to run it by our lab director. I first thought it was Cryptococcus, but I wasn’t quite sure. It turns out it’s an amoeba. Naegleria. Naegleria fowleri.”
Naegleria, Naegleria. I knew that name. I reached back to my medical school microbiology class. Yes. That strange amoeba that can crawl up your nose and through your olfactory nerves to infect the base of the front of your brain. You get it from diving into or swimming in contaminated fresh water, usually in warm countries with warm water sources. Super rare, super fatal. Not something I would ever imagine seeing in temperate San Francisco.
“You sure?”
“One hundred percent, Doctor.”
I found Massey in 5R. He was at the nurses’ station writing orders in her chart.
“It’s Naegleria meningoencephalitis,” I told him. He looked up at me, puzzled.
“CT scan and micro lab say so, so that’s what I’m telling you,” I declared. “And like I always say, in HIV, it’s gonna either be a common problem presenting uncommonly, or an uncommon problem presenting commonly.”
Massey rolled his eyes at me.
Dr. Edmunds was helping the nurse transfer my patient from the gurney to her new bed in the ICU. The morning light from over the hills above the highway shined on him, illuminating him like a saint in an El Greco painting. What was he doing? He’s an attending physician. He didn’t even need to be here, since once a patient from the wards was transferred to the ICU, a different attending specialist should take over the care. He certainly didn’t need to be moving a patient. I rushed in to help, getting on the far side of the bed to receive the sheet that the patient was swaddled in.
Massey called out to me, “I have no idea what Naegleria is or how to treat it!”
Dr. Edmunds looked up. “Naegleria? Amphotericin B, 1.5 mg/kg in two divided doses. Follow kidney function closely. Plus, rifampin 10 mg/kg once daily. Check for drug interactions.”
Massey looked at me in disbelief. I ordered the medications.
Neurosurgery arrived and took her down to the OR to place a bolt in her skull and relieve the pressure causing her brain to get squeezed, with no real exit. They left in a pressure monitor to allow us to make sure it was working. Over the next few days, I religiously administered the amphotericin and rifampin. But her cognitive function never returned. She remained in a coma.
Dr. Edmunds visited her twice daily, a familiar guest in the ICU. Or maybe he was visiting me.
“How are you doing with all this?” he asked me in her room on ICU day number four. I am quite sure he had forgotten my name.
“I’m good, Dr. Edmunds, thanks.”
“You’re good?”
“Actually, no, not entirely. This is awful. I mean, we made a quick diagnosis—kind of a superhuman diagnosis—and we started her on the right meds, and she got the bolt right away, just in time. And yet, nothing. I’m not seeing an end to this. I feel pretty powerless.”
I wanted to ask him how long we should continue trying, whether it was even worth it, but I thought better of it.
“I know, I know,” he said quietly. He turned, looking at me with his radiant blue eyes, eyes that seemed to emanate pure light.
“Make sure her teeth get brushed twice a day. And that she gets a sponge bath every few days. And that her hair is brushed. In fact, brush her hair yourself sometimes. With care. Don’t think you’re too highly trained to do that. It can be part of the job. I know I’m not your attending on this case anymore, but that’s my final order. It will help her. And it will make you feel better. I promise.”
Dr. Edmunds never returned to work on the wards at San Francisco General. He died of complications of AIDS-related lymphoma the next month.
A BLINDING NIGHTMARE
Dr. Edmunds’s moment of commitment and mentorship began to open my eyes to the dozens of alternative responses that were emerging around this epidemic—and around me. Witnessing these acts—acts of kindness, curiosity, ingenuity, industriousness, advocacy, resilience, and love—gradually began to change me, allowing me to see and to behave differently. And, in aggregate, these acts changed the culture of the institution in which I was working, slowly converting it from an epicenter of suffering, cynicism, and sorrow to a hub for compassionate models of care, innovative science, community engagement, and broader social change. Over time, I too was transformed, becoming part of this movement, taking in some of these lessons, adapting them, and then applying them to my future work.
Many years have passed since I was a young doctor in training, caring for a thousand or so patients at the peak of the AIDS epidemic. Despite the intensity of this experience, or perhaps because of its unremitting intensity, I recall only a few faces and a few stories as conveyed here. At the time, the highly regarded Journal of the American Medical Association would publish a special annual issue on AIDS. While the cover of the weekly JAMA was traditionally adorned by a beautiful work of art, for this special issue, the editors would adorn the cover with an empty void: pure and white, with no image and no art. It was largely a blank page, an overwhelmingly bright, white page. It is only now that I recognize the statement that they were making. While I have always prided myself in my ability to never forget a face and to always remember a good story, as a formerly overworked and underprepared doctor in training, I admit that my memory from that time is mostly devoid of patients’ faces and patients’ stories. Many of my colleagues report similar difficulties evoking specific names and faces from that time. It was as if we all were suffering from a unique form of vicarious trauma. The kind that blinds.
