Twelve Patients: Life and Death at Bellevue Hospital (2 page)

I pause, speechless. “He’s finally going home? I can’t believe it.”

“Don’t believe it till you see it,
jefe
. You know how things are around here.”

Juan Guerra going home—unbelievable.

“I’ll go see Guerra before the UN guys come—I’ll be right down. Get them some coffee and donuts if I’m late,
por favorcito
.”

The first thing I ever noticed about Juan Guerra was his neck, which I recognized from twenty-five yards away.

I was making rounds with Budd, the lead physician on the nineteenth floor. Rail-thin, six foot six, Dr. Budd Heyman was an internist with a long history of working in correctional medicine from the Tombs, Manhattan’s prison adjacent to Chinatown. An indefatigable advocate for the disadvantaged, he knew that the game of life could change quickly for anyone and the only difference between the rich and his patients was that the rich had options. We usually began at one end and walked our way around. Even if the patients weren’t in their cells at the start of our rounds, they would magically appear by the time we got there. There was too little going on in prison to miss the opportunity to talk to someone new. There were twenty-five men, between the ages of seventeen and seventy-three, who had been there for as little as a few hours or for as long as five months plus. The corrections officers at their posts were a reminder that they were still prisoners, even though they wore hospital gowns. The gates were solid metal and locked; there was no decor and no color. Mesh screens covered all the windows.

With the guards, the gates, the IDs, more gates, it’s hard to “drop in” on that unit, and I am a drop-in kind of doctor and medical director who prefers to be on the floor rather than behind my desk. You get a feel for a unit. People in the know can actually size up a hospital in a few hours just by walking around it, talking to people, asking questions. You get a clear sense of what’s going on. You don’t need ten inspectors spending two weeks crawling through policies and procedures. A few sentinel scenarios tell you if the hospital is a Potemkin village or the real deal.

Guerra was a slight man under five foot eight, thin, with hospital-issued pajamas and slippers, short-cut pepper-gray hair, and a short goatee. And a neck I would know a mile away. The swelling told the full story immediately. I could anticipate every question, issue, side effect, treatment option, and alternative. I had no idea what his personal story was, where he was from, where he had been, or what his life trajectory had looked like so far. But I certainly had a fair sense of what his future possibilities might be. The left side had four golf ball–size tumor-filled lymph nodes that stuck out and left the skin over them stretched taut. They weren’t giving him any pain or interfering with his swallowing. He was thin but not gaunt and had a glass of water in his hand. His disease was advanced, and his chances of making it very slim. I wondered in what way I, as a physician, could have a positive impact on Guerra’s dwindling life.

Many physicians do not get into the boat at all and stay on the shore. Many become obsessed with lab values and the rituals of the white coat and stethoscope, the computer now safely between them and the patient so that hardly a glance is necessary before they can be off to the next. For this type of doctor, the loss of a patient is a narcissistic blow. It activates a primal fear of loss. It represents a deep professional failure. It makes a sham of what medicine is supposed to do. Regardless of the regimens, treatments, expenses—regardless of other specialists brought in, the surgeries, secondary options, drug trials, and rescue chemotherapies, the futile treatments themselves are a symptom of the physician’s inability to accept an ending. The doctor becomes frozen, protecting the illusion of power. But the illusion is untenable—it goes against the laws of physics. Everything dies. Nothing touches the inescapable outcome that is entropy itself. The Second Law will prevail, it always does, the house never loses.

I hesitated before approaching Guerra. Something else held me back: I was recovering from the same exact disease. My own treatment for SCC, or squamous cell carcinoma, from a peanut-size lesion near my right tonsil, had started on a Monday in mid-October a year earlier and finished with a final dose of radiation therapy and chemo in early December. The complications and recovery were still fresh. I had had a
neck node that wouldn’t quit, that sat out the radiation and the chemo nearly to the end and then finally collapsed in a couple of days. Would his collapse? Would mine stay collapsed? Would his fate foreshadow mine? Seeing his neck created an anxiety in me I didn’t like to admit to myself and certainly couldn’t share. It’s painful to see your own worst fears made real and immediate in the person in front of you. It’s not simply a matter of the empathetic
This could be me
. It’s more like
This could very well be me sometime soon
. I pushed the thoughts as far back as they would go. I understood what lay ahead of him in a way no healthy physician could.

I walked over to him, holding out my hand:
“Buenos días, soy médico, parte de tu equipo de médicos en el hospital. ¿Tienes un ratito para platicar?”

Patty is ushering the two Secret Service men into my office through the front door as I enter through the back. I intended to see Guerra first thing this morning, but was stopped in the hall by one of the chiefs telling me there was a problem in an operating room. Figuring out a solution has taken the best part of an hour, and I need to get back. I ask Patty to find out what’s happening with Guerra ASAP, and then greet the two men.

They are standard government issue. Beefy, short haircuts recently clipped, cheap gray suits off the rack, plastic white earpieces with a cord disappearing down their necks, and the omnipresent clipboards. The president and other heads of state are due to meet at the UN next week, so these men are here to check the hospital security and trauma and cardiology readiness, as Bellevue is the receiving hospital for heads of state. They are here for a walk-through, very hands-on. As part of the emergency-management system, we rehearse a variety of different activations such as biological attacks, mass trauma, and dirty bombs. I make them coffee with my new espresso machine that Diana gave me. A box of Dunkin’ Donuts has miraculously materialized on the polished wooden conference table. This is not the quiche-and-Perrier
crowd. Even though they come every year, we always go down the same checklist.

Randy, the senior Secret Service officer, says, “You have 24/7 in-house trauma attendings?”

Check.

“Dedicated trauma operating room?”

Check.

“Examples of current emergency escalations?”

“We had a gunfight two weeks ago with three cases in the trauma slot and in the OR in a few minutes,” I responded. “Rival gangs involved in narcotics turf warfare. Fifty units of blood and product for the cases. We can access an enormous quantity from the blood bank and sister hospitals quickly.”

Randy looks up and smiles: “Like Maryland. Except their business is car crashes, not the knife and gun club. Do you have helicopter access?”

Check.

Jim, the junior guy, texts on his BlackBerry throughout the meeting. We schmooze comfortably and eat donuts as they complete their paperwork.

We then take the walk around the central administrative hub of the intensive care unit (ICU), where a safe space is secured in the event a high-profile politician or diplomat comes in with trauma or another life-threatening condition. I stop to introduce them to Maria, the secretary to the surgical intensive care unit, and the chief resident on neurosurgery. I look in on the fifteen members of the trauma team that surrounds the bed of a young woman who lies in a coma after her motorcycle was hit by a distracted octogenarian behind the wheel. She was launched into a low orbit that caused multiple cranial fractures, internal bleeding, and swelling that killed all tissue above her brain stem. The doctors are carrying out some of the tests we relied on completely before the age of CT scans. Do the pupils react to light? Are they equal in size? Do you see doll’s eyes moving together when you rotate the head to one side and the other? She has fine features and
long dark hair. For an instant she reminds me of my daughter, and I look away. They are around the same age. Too painful to think about.

My cell phone goes off, and I check it as I walk the Secret Service men to the elevators. It’s Patty—the Mexican minister of health has been delayed at the mayor’s office. We have a meeting to discuss the partnership that Bellevue has developed with the Mexican consulate to provide health care for the influx of documented and undocumented Mexican immigrants—more than five hundred thousand of whom live in the greater metropolitan area alone, and twelve million in the United States. I ask her to call me when he arrives.

She assures me she’s on the Guerra case. “
Jefe
, thought you’d like to know that Dr. Faruz is waiting here to see you. I told him you’re busy upstairs but he says he’ll wait. He wants to complain to you about…” I pray for patience and hang up.

“A happening place,” says one of the Secret Service men.

Juan Guerra is going home—unbelievable. After half a life in prison, his throat cancer might actually save his life. Maybe. I think back on my earliest discussions with him, a fifty-nine-year-old man born in New York of Dominican parents.

As a child in the Bronx, Juan Guerra had made several lengthy trips to the Dominican Republic, first living on a ranch, riding horses near the Haitian border, and later in the capital city, Santo Domingo. Timing was everything, Guerra had told me. And his timing had always been terrible. Coming of age when Vietnam was exploding like a grenade with the pin pulled, his lottery number had been 11 and he went to war with the neighborhood. This was not a Crawford, Texas, neighborhood with street names like Harvard and Princeton Place. There was no question of a deferment for an injury or conscientious objection or a family that could stash him safely in the National Guard to ride out the waves of Hue that would bring the nightly death counts onto living room televisions across the country. Guerra and his family knew he was the one who would always be caught. A black cat had walked across his mother’s path when she was pregnant, he said.

Guerra had served in Vietnam in a combat unit, though in fact he was in Cambodia ferrying U.S. troops illegally into the border areas to find and destroy Vietcong storage tunnels. What he didn’t know was that not all the risks in the army were booby traps in the jungle or black-pajama-clad locals who might be soldiers, sympathizers, or just villagers trying to survive one side or the other depending on the time of the day. What he didn’t know was that a pure white powder would claim his future and, in many ways, remake him into another person before he was twenty-one years old.

He came back, like many in his unit, addicted to heroin, and for the next thirty years tried dozens of times to kick the habit, relapsing regularly. He was caught in possession of drugs, sent to Rikers and occasionally upstate for longer sentences of over a year, and put on parole again and again. The last time he was sentenced to prison was for being fifteen minutes late for a meeting with his parole officer. His adult life post-Vietnam had been one extended coda with the Department of Corrections of New York State. It was like his second family—maybe even his first at this point. He had a wife and a son whom he missed terribly and who’d supported him unconditionally through thick and thin over decades, an aging mother and father, and an extended family in the Dominican Republic. In fact, a lot more than many non-felons could claim.

Guerra and I had talked about this often over a hospital meal at his bedside. I asked him why he would make such bad decisions knowing the consequences—and how the police needed to make their arrest quotas. These were minor drug offenses, possession or selling tiny amounts of methadone. How could he take the risks?

He said that he was an addict and had been one for thirty-five years courtesy of the U.S. Army. His entire social network was made up of addicts, dealers, and minor neighborhood drug types who couldn’t get any type of employment.

“I made a lot of bad decisions and pay the piper every time. After a certain point it doesn’t matter. You will get picked up and charged with someone else’s crimes since they know you cannot say no and you plead down so you don’t have to go upstate.”

“So can’t you play it extra safe, knowing that?”

“I need methadone. Once the clinic shut me out, paperwork they forgot to file. They told me to come back in five days. I had to choose between withdrawal and getting some drugs to tide me over. There is no slack. You do anything not to withdraw.”

Guerra paused, then continued. “A year ago I was arrested for walking Tiger off a leash. He weighs four pounds. He is my grandkid’s Chihuahua. It was the end of the month and the rookie needed to fill his quota. The senior cops all laughed at the rookie for such a stupid arrest. I went to prison and they laughed at him.

“Doc, try living in the stop-and-frisk world of the NYPD. Just for a week.”

“How does your family take it?”

“
Es una locura
. And why my wife has stayed with me for over thirty-five years. Who knows! She knows hard time with her brother for the real bad stuff. Mine is petty stuff and I am faithful and I love her and our kids. Our world includes prison time and probation and the likelihood you will be back again.”

After his latest incarceration, Guerra’s disease was diagnosed, and he began his treatment with radiation therapy. Every morning at ten thirty the guards would escort him per protocol in handcuffs and leg shackles through the metal gates to the elevator bank for supplies. They would go down to the ground floor and walk out to the Blue Room. He would wait there until a prison van arrived to take him three blocks north to the basement of the university hospital. Two officers would escort him to the radiation therapy area. He would be unshackled and assisted onto the table, where he would lie back on the thin metal gantry covered by a sheet.