A Big Heart
I tried a 4:1 strategy during clinic hours, taking the intern into the room every fourth patient. In between, I found worthless things for him to do like waxing the blood pressure cuffs.
Occasionally I pointed out interesting physical findings.
“This patient suffers from a chronic form of leukemia,” I said, “but it’s quite stable. Notice how large the spleen is,” and we tapped the man’s belly to feel the bulge.
The intern smiled, “Damn. Forgot about that organ—totally blanked that there was a spleen. I feel really foolish.”
“It’s okay, a lot of people forget about the spleen--unless it ruptures.”
“That’s the whole point,” Dr. V,” he said condescendingly. “I think we should think about it.”
But after the intern slid back on his Focus Forum, I had to wonder if he really thought much about anything.
The next few patients were quite routine until Spokansky.
Oscar Spokansky was a stocky sixty-four-year-old retired corrections officer, waiting for a connecting flight with his grandson when he began to experience indigestion.
“You know,” I said to the intern, “not all symptoms of indigestion come from the stomach.”
He flipped up the visor of his Focus Forum like a catcher waiting for a foul pop “Gallbladder?”
Spokansky displayed his boarding passes to Honolulu. “When the Rolaids finally kick in,” he forced a smile, “I promised Todd I’d show him Pearl Harbor.”
The man was so jovial and gentle, I tried to imagine him prodding menacing criminals back into their cells.
A previous chest X-ray showed an enlarged heart.
Grandson Todd paced around the waiting room like a faithful, slightly agitated service dog. “It’s good to have a grandfather with a big heart,” I joked, but service dogs are keen enough to sense upcoming danger.
We barely had time to hook up Spokansky for a cardiogram when he bolted upright with a cold sweat, suddenly severely short of breath.
“I can’t breathe,” he gasped, his words increasingly wet as if he was slipping into the sea.
“Help me, please!” He ripped open his shirt and began pounding on his own chest. “Please help. I can’t breathe!”
“Call the Emergency Department and call a code,” I yelled, grabbing the crash cart and some oxygen.
The intern froze. “What’s going on?”
“Flash pulmonary edema,” I said hooking him up to oxygen.
I quickly inserted an IV.
“Two mg of IV morphine,” I yelled, “and some nitroglycerine, stat.”
The intern began purposeless pacing. “But he was fine a few minutes ago.”
Spokansky was still wide-eyed, tiring from his gurgling. “Can’t breathe!”
“Welcome, doctor” I said, “to the world of acute coronary syndromes.”
Spokansky attempted a few more ineffectual breaths, the next minute flopping flaccid.
“Where’s the code team?” I yelled. “You see, doctor, it’s not always the best thing to have a big heart.”
They ushered away the inconsolable Todd. I bagged the oxygen and the intern compressed Spokansky’s heart to see if we could keep his life spirit from seeping outward, no less futile than trying to patch up a faulty bicycle tire.
As if on cue, the code team charged in, blue scrubs like cavalry followed by the EMTs with their high-powered resuscitation equipment.
They charged the paddles, cut his clothing with trauma scissors and intubated with a plastic tube, clinic patients gawking on the other side of the room.
We shocked Spokansky perhaps a dozen times until it seemed cruel and a waste of electricity.
“That’s it,” I said finally. “Everyone, thank you very much,” and I felt like an umpire calling off a game during a rainout. There was a palpable sense of grief and disappointment but people were anxious to get on with their day.
I told the intern to sign the death certificate. From the corner of the room he swallowed his sobs like a preschooler after a badly skimmed knee, the Gortex liner from the Focus Forum wicking away the moisture of his tears.
In the bereavement room, I tried my best to look Spokansky’s dazed grandson in the eye.
“Todd,” I said, clasping his gummy hand, “I’m so sorry. Your grandfather really did have a big heart.”
That night, Sarah and I were supposed to attend my fifteenth high school reunion.
“I have no desire to go,” I yelled over the roar of her blow dryer. The added heat in our bedroom next to the steaming bathroom in late summer already exacerbated my impatience.
“Who’s the idiot that decided to schedule a class reunion in the summer? People are on vacation. No one’s going to be there.”
Sarah powered off yelling back from the bathroom. “Apparently, in this town, people don’t go away.”
That wasn’t entirely true. I knew there would be old friends at the reunion, ambitious people from childhood who made the escape, actually scratched their way out of the valley for a higher standard of living. They settled in hubs far from our provincial airport where travelers routinely needed connecting flights. And some of those who stayed—call them the more successful of our graduating class--owned small commuter planes, nothing stopping them from taking off on a whim to glorious cities, where etched glass scraped into ozone; where business meeting vistas showcased the curvature of the earth.
It’s not that I dreaded seeing these classmates. I was proud of my profession and accomplishments. But for some reason, the Spokansky death was particularly disturbing. Reminders of mortality tinged with guilt made any doctor feel more vulnerable than usual, especially those like me, unable to dislodge themselves from a small-town existence.
Sarah looked amazing in a creamy linen dress and matching sandals, her outfit complementing the fragrant heaviness of the summer humidity, sticky pollen and willow, a seminal scent that sifted surreptitiously through cracks in the car windows.
River Valley High School was on the western side of the river, close to the airport and my father’s house in what some called the less desirable part of town.
The car clicked over the rusting bridge connecting the two sides of our bisected town. Often the river surged in spring, but now in the midst of drought, boulders protruded and boating was way too hazardous.
Close to the high school I had second thoughts about seeing old classmates and being forced to indulge in shallow conversations. It seemed preferable in this state of mind to visit my own dead, so at the last minute, I veered to the right, in the direction of the cemetery.
Sarah exhaled sharply.
“What are you doing Vick? Come on. Not again.”
The cemetery gate was eerily large and rusted. The tires crunched over gravel.
“Only a minute, I promise.”
Three quarters of a laughing moon peaked from behind a solitary summer cloud tinted lavender by the fading sun. Residual August heat permeated the onion smell you always notice around cemeteries, a reminder of the high nitrate content in human fertilizer.
The crickets already sang. Gnats buzzed past and I wiped one away after it dive-bombed into my eye. To Sarah’s luck, the gate was locked, so I scanned across, squinting in the twilight at the nearest headstones clustered in family groupings.
Mine were a few rows up, just out of the line of sight.
There was Tom from San Francisco whose stroke shortened his Mediterranean cruise and Mrs. Geronimo who fell and kept on falling and the unknown soldier I sent to an incompetent anesthesiologist, whose routine hernia repair ended in a brain damaged fog.
Soon to join them would be Spokansky. He died in front of me and I had to wonder if I could have done more—what if I sent him right to the cath lab?
They all had their stories. It didn’t matter what happened in life, only what did them in. I tried to slow things down but their golden years accelerated into increasingly frequent doctor visits, higher co-pays, and even more bureaucracy. Then they died.
Sarah shouted through a slit in her window. “You need to get in the car now!”
I knew my wife. Knew she wouldn’t open it any more for fear of mosquitoes.
“Vick, I’m not going to put up with another one of your death tours. If you want to spend the night here, take me home. It’s your high school reunion, not mine.”
My practice of medicine had invariably pushed the two of us apart. It was no fault of Sarah’s, but she would never comprehend the high emotional toll after seeing your patient die.
Fear of fucking up. Maybe that’s why I didn’t want children.
I dropped Sarah off in front of the high school.
In the parking lot, I followed a rotund man, probably a former classmate who, at least from behind, looked exactly like Oscar Spokansky.
This happened frequently after patients died. Even if I didn’t visit the cemetery, I would keep running into reminders: the baggy earlobes of a middle-aged man erased by Multiple Myeloma, the hopelessly sprouting hair of a breast cancer victim. Though they were no longer of this world, those lingering souls would continue to mock me in subtle forms of post-traumatic stress--another occupational hazard at the clinic.
My high school still smelled of paste and sweat; stale lunch and mildewed clothing in lockers. Painful smells have long half-lives, lingering with the radioactive fallout from our past. Beneath those burdensome whiffs, I still recognized the indelible scent of death on my hands; on the palms I used to attempt the resuscitation of Spokansky.
“Is that Dr. Vicky V?”
A once popular cheerleader summoned me as if admiring someone’s puppy. We never spoke a word during six years of school. Now she sagged from chin and torso like a canvas mail bag.
“Woohoo, Doc! Hey, what you say if I told you I got a stethoscope?”
She seemed ready to try a split, totally ignoring Sarah.
I hesitated. “I don’t know what I’d say.”
“Tell me, Doc, can you supply my dreams?”
Sarah intervened. “What you say if I told you he got a wife?”
The gymnasium was transformed: catered with crape paper, surrounded by the aging caricatures of people I barely remembered seeing in my yearbook: Fatter, grayer, pocked, spotted and balding--some, oddly beautiful.
In the rest room I ran into the salutatorian Toni, who now identified as Anthony and then zipping up his fly at the urinal was my economics teacher, Mr. Greenleaf still wearing the same suspenders.
“How are you, Mr. Greenleaf?”
We awkwardly shook our unwashed hands.
“We’re all so impressed by your success. Save any lives lately?”
Sheepishly, I shook my head and excused myself. “Good to see you. Sorry, my wife is waiting for me.”
I knew I was socially inept, but I couldn’t help it. The death of Spokansky was still too raw. More than any other patient death, this was the most troubling.
I pondered by myself for a moment in the ancient hallway, not far from where my dented locker had once been.
Was it the plane tickets to Honolulu? The innocence of his grandson, Todd?
No. It frightened me that the intern cried.
It frightened me that the young, incompetent intern, wearing a Focus Forum, actually cared about people.
And, it frightened me that sometime soon, the intern would replace me.