Twelve Patients: Life and Death at Bellevue Hospital (47 page)

I could see my car coming out from the back lot driven by a guy in an iridescent yellow slicker. Juaquin, the Colombian-born
jefe
of the parking lot, leaned out the open window as he pulled up. “
Hola
, Doc, my sister’s much better. Thanks for the
ayuda
, the help.” He shook my hand and gave me a bear hug slicker than the London fog.

“
De nada
, nothing, Juaquin. She is a sweetheart. Glad to help out.”

I turned to Julian as I threw my bag and papers into the passenger
seat. I always loved the feel of rain. “No illusions, Julian, it can get pretty ugly.” Many of the country’s finest public hospitals had been gutted or were in the process of evisceration. I was not prepared to preside over auto-amputation or organizational seppuku and had spent practically every waking hour since I had joined the system avoiding death by a thousand cuts. There were ways out of the tunnel. They were all politically difficult and, given Albany’s monumental dysfunctionality, perhaps not realistic. In a test case former mayor Rudy Giuliani had backed privatization of the public hospital system, putting Coney Island Hospital on the block. The plan failed a court test, and he beat a quick retreat. The easiest way to close a hospital now was to let it go bankrupt. The market forces at work in a non-level playing field. The private hospitals would pick up the paying customers and high-end specialists from the leftover detritus. We would do the rest. Hardly an invisible hand in action. What was different in the post-Giuliani era was the post–Lehman Brothers collapse syndrome. When 40 percent of the economy is the financial industry, it controls everything. Even the cop at the corner is protecting Wall Street, though the threat is coming from inside. Not only were the poorest sitting in their communities without transportation, decent schools, quality food to eat, and safe parks, but the middle class was slipping and sliding into the same morass.

I got behind the wheel of my eleven-year-old Volvo—the doc car, my family calls it—and entered the converging lines to the automated gate. Forget NPR or music tonight. The rhythmic swoosh of the wipers kept me company as I tried to collect my thoughts and emotions and weaved my way home through Manhattan traffic.

The fractured U.S. health care system was like the universe in expansion, flying apart. The acceleration came with a vengeance after the market crash of 2008. The crisis was not an ordinary banking bubble with John Q. Public picking up the socialized losses and the system going on as usual. The financial crisis represented a much deeper speculative bubble that had penetrated deeply into the structure of the global economy over decades. So many factors, including the cost of wars in Iraq and Afghanistan, were taking their toll. Among these,
the “waste” in the health care system—what the insurance companies and pharmaceuticals call “administrative overhead”—was bankrupting the system.

Phone calls interrupted us that night. The hospital was full, and there was no place to put the patients streaming in. Transfers were coming in from other city hospitals, a man frothing white spittle in a Midtown restaurant went into acute pulmonary edema, a young woman fell unconscious in an elevator with a heart attack, and a man with a table saw amputated his wrist. A cab had killed a woman visiting New York. A young man had committed suicide. The crammed intensive care unit forced us to use the surgical recovery room for overflow. Reluctantly, I called the fire department dispatcher for four hours of ambulance diversion. Emergency cases would be taken elsewhere during a time-out we used only with hesitation. Twenty-five patients were lined up for admission on stretchers in the emergency room like planes on the tarmac waiting their turn at LaGuardia Airport. Little red lights went off on the dashboard of my prefrontal lobe that said we were at the upper speed limit for safety. The state legislature was locked in debate and the “cuts” committee was deadlocked in an Albany hotel room with pepperoni pizza and Diet Pepsi. The lobbyists were out in full force from their two-martini lunches. The medical industry might take a symbolic cut for the front pages but I doubted anything substantial would make it into the final recommendations. The big print would suggest a fair distribution of suffering. The small print would make them whole. Pepperoni pizza and Pepsi versus martinis and medallions of tenderloin smothered in truffle sauce—not much of a contest.

The office floor was completely empty when I unlocked my office early the next day. The vote had been postponed to allow “fuller discussion of the complex competing issues.” Administrative-ese for Mach 4 pressure from the private insurance companies, the hospital industry, and physician lobbyists. Patty had left me some fruit on my desk and a chocolate bobka from Todaro’s on Second Avenue. I must have been
withdrawn and grouchy. She could read me with ease.
You look like you needed a treat!! Hope we still have a job!!!!
read a note Scotch-taped to the plastic wrapper. I laughed when I saw it, cut myself a generous piece of the mouthwatering high-calorie cake, and made myself a triple espresso. The coffee-and-cake euphoria did not last long. I needed to go see the cases that had kept me up all night. The walk to the emergency room is two minutes from my office. I dreaded the trip and had to force myself to go down the stairs past some detectives emptying their weapons outside the adult psychiatric emergency room.

The small family room only partially contained the tears and anguish of a woman hysterical with grief, restrained by uniformed police and nurses. Her lamentation washed out over the hallways. Family members sat mute in a hyper-adrenalized stupor intensified by the lack of food, endless cups of coffee, bright fluorescent lights, hard chairs, and continuous interruptions fed by the automatic metal doors that swung open and shut. A parade of nurses, aides, doctors, policemen, attendants, cleaning staff, administrators, supervisors, wheelchairs, and stretchers went back and forth. But the family didn’t seem to notice. They were lost to their grief. Even the DOC prisoners in orange jumpsuits wearing leg irons and handcuffs and the psychotic men and women escorted by physicians and security to the psychiatric treatment warren did not get through to them.

Usually heads would look up expectantly with every swing of the door, hoping a messenger would bring the status of their wife, husband, child, mother, father, sister, or neighbor. Family members would have cell phones glued to their heads. Some huddled in one another’s arms for respite from the antiseptic air, the institutional colors, the white coats and rumpled scrubs and fragile anticipation, whiffs of hope mixed with the fibrillations of death’s foreshadowings. Lives changed here with time suspended in midstream or in a couple of seconds. Forever.

The door to the trauma slot was open. The room was filled with the detritus of an abortive resuscitation code. Papers, cellophane, plastic wrappers, IV tubing, bandages soaked in blood lay everywhere. A nurse was huddled over an inert body of indeterminate age and sex.
She was attempting to wrap a white sheet-shroud around the corpse. Her eyes caught mine. They locked for a second. The color was drained from her face. Her black stringy hair hung down over her shoulders and touched the jeans and T-shirt. Black shiny cowboy boots poked out from the bottom of the stretcher. Two cops were completing paperwork in one corner; a clump of doctors stood silently to one side. The light blue-ish walls were covered with plastic signs, notices, equipment; huge focused operating room lights like the necks of giant cranes arced at odd angles over the stretcher. Half a dozen pieces of equipment on wheels looked like zoo animals congregating at mealtime. Marion, the head nurse, caught my arm and pulled my attention from the scene.

“Gunshot wound to the head. Self-inflicted. High school kid.
Mother
.” As she spoke, she motioned with her head toward the waiting room. She telegraphed cryptically the key elements as the staff silently and automatically continued its routine to prepare for the next case.

The sounds of the mother keening through the metal doors merged with the sounds of other mothers whose sobbing and tears interrupted my sleep decades later. Deschapelles, Haiti, was where I had heard my Ur lamentation years earlier.

The work was strenuous and satisfying in central Haiti: babies with neonatal tetanus and a new disease bringing otherwise healthy young people to the hospital with combinations of rare skin cancers, rampant tuberculosis, and a new undiagnosable lung infection. We learned later to call this HIV/AIDS. Our number one diagnosis back then was kwashiorkor or marasmus, the formal lexicon of starvation. Flour, sugar, and protein supplements were dispensed from the hospital pharmacy window to patients waving their white papers with our scribbled prescriptions for food. The days were long, blistering hot, and thrilling in the way that only a physician in the early days of falling in love with his profession can appreciate. We were witness to the natural history of a disease voracious and practically unstoppable. There was no treatment. Untouched by medication or surgery and out of reach of shamans and voodoo priests, the hospital was the last stop before internment in the tear-soaked hardpack.

A young woman presented in the late afternoon with her mother
and sisters with abdominal pain. Vague, indistinct, poorly characterized. We went through the history of periods, pregnancies, bowel function, urinary symptoms, fever, sweats, sexual activity. Her exam was remarkable for some tenderness on the right side, and we thought she might have appendicitis or an infection in her tubes. The blood count was normal, and there was a slight elevation of her white cells. I asked surgery to see her. She arrived sweaty with dark rings for eyes. She examined the patient and recommended antibiotics for salpingitis or a tubal infection. That night the young woman’s ectopic pregnancy ruptured, and while the OR was being prepared, she hemorrhaged to death.

The next morning I was in the gloaming clinic. We started early in the cool morning before the sun baked the earth. From the shadows of the courtyard I heard keening. Everything froze. It gradually grew louder, becoming intense and focused like a Greek chorus. Then it diminished as the mother and her daughter carried the body on their shoulders, retracing their steps up rock-strewn dirt paths into the clear-cut mountainsides. The primal sound still echoes in my ears and my nightmares when the world is still and the night sits heavy in the darkness. There is no statute of limitations on what invades consciousness when the thrum of daily routine is drowned out by your own tachycardia and fears.

CJ, the overnight social worker, brought me out of my momentary flight from reality. She had pieced together fragments of the story of Benjamin, the young man who had shot himself, now lying in the slot. We walked to an empty conference room.

“I have been talking to some family members. Benny, who was nineteen, had a tough time for over a decade, but really took a hit when his parents separated and divorced six years ago.”

“Carol, what kind of care was he getting and where—I mean a shrink, professional care?” I asked directly.

“School counselors first and later referrals to private therapists. After a drawn-out nasty divorce, health insurance became unaffordable,
fifteen hundred bucks a month for a family of four with double-digit increases every year. The husband works out of his apartment in marketing if I have it right, after being downsized or right-sized, I forget what they call it this year. Marriage gone, job gone, and finances down the tubes. Mental health coverage is like a Brazilian bikini, it doesn’t cover much. They went to public mental health programs. First come, first served. Long lines and high staff turnover. Pretty much prescription mills.” She shrugged.

“It’s a travesty. We should just Abilify the water supply and get it over with.” I declared the obvious. Fluoride plus Abilify equals public health care.

Carol continued, “Look, there aren’t enough trained child psychiatrists or social workers in their district. This family is rapidly going down the middle-class ladder to a not-very-genteel poverty unless there is some millionaire crazy aunt they haven’t discovered. A ten-minute follow-up visit and a psycho-pharm prescription is standard now. The family makes too much money to be on Medicaid. They make more than twenty thousand dollars a year. So they are part of the increasing horde of ‘uninsured’ and end up in our system for the basics. I forget how much we lose with each visit but they get virtually no treatment except pills.” Talk about a donut hole. You could drive through this one with a Hummer. And California had just received a waiver to pay doctors eleven dollars for a Medicaid visit. The system was being taken apart. I could sense the exasperation in her voice. She was tired from the relentless overnight shift, and I knew she had a kid the same age as Benjamin. We weren’t that different from the patients we took care of, and we all knew it. Death crossed the line with impunity.

“The kid acting out his own demons as his family falls apart,” I said out loud to nobody in particular.

“These kids need multiple and complicated levels of care. They’re just not getting it.” We both knew the system was shredded with holes and gaps. There are times nothing can be done to prevent a suicide. But it was especially painful to lose people who possibly could have been helped. The hope is to get kids through their crisis moment. I touched
her shoulder; she gave a thin smile and went out to finish her paperwork and catch the long train ride home to Long Island.

My phone rang. “Eric, hi, Levanah here. Look, you know the Ramirez family? Right.” Levanah was from the Colombian Consulate. We did a lot of work together over a dozen-plus years on health issues, family problems, and patients who had complex needs. Her birth name was Xiomara Vargas. A long spiritual journey had brought her from Catholicism to quasi-Orthodox Judaism with many stops and side journeys in between. Twice a week for years she’d attended discussion groups that parsed the Torah and Kabbalistic texts with a master teacher trained in Cordoba, Spain, and Jerusalem. She wore a gold Star of David around her neck.