Twelve Patients: Life and Death at Bellevue Hospital (48 page)

“Sure, hi, Levanah. Long time no see. Let’s have lunch soon, you have left me behind in my spiritual development. Remember, I was way behind before you started your rescue program.
¿Por favor?
Of course I know Ramirez. What’s up?”

“He’s been in your emergency room now for two days. No beds and the family is getting antsy. And I promise to catch you up on your ‘development,’ as you call it. Though you are pretty hopeless, Eric.” She laughed. She had steered Señor Abraham Ramirez and his family to me years earlier and I’d followed them through a long medical thrash from symptoms to diagnosis, diagnosis to treatment, treatment to side effects, the inevitable hospitalizations, and terminal slides.

“Listen, I’m in the craziness right now. Let me go find the Ramirez clan and see what’s blocking traffic.” She thanked me and we agreed to have lunch together. The lessons in Halakha and the Midrash over french fries and spanakopita reminded me of a dear old friend, another Diana, twice exiled from Argentina, who had run a Kabbalah group for years during the 1990s in her apartment overlooking the zoo in Buenos Aires. We discussed the Garden of Eden and the nature of desire as the elephants trumpeted in the eerie darkness of the troubled city. The ghosts of the disappeared were everywhere.

Every conceivable space in the emergency room had been turned into a treatment or parking area for stretchers. I weaved my way to the panopticon nursing station and checked the whiteboard for the initials
AR
. There he was “AR, Abraham Ramirez, Medical Record Number and Team 2, east side.” It gave me a place to start. There were half a dozen prisoners handcuffed to stretchers with DOC officers crammed into any available square feet on the east side, but I found one curtain pulled and figured that two days in captivity here had created a mini ecological niche of privacy and family care. Another week like this and we would have a shantytown on our hands. Occupy Bellevue!

“
¿Doctor, como ha estado?
How are you?” I peered around the curtain. There was a daughter and wife, identical in so many ways and exhausted. Abraham was covered by a sheet and multiple blankets, skeletonized, his face waxy and drawn, the skin stretched tight outlining the anatomy of his facial bones, like a cadaver the first day in a gross anatomy lab. A unit of blood was dripping into his left arm. He attempted a smile.

“
Hola
. I am so sorry you folks have been stuck here. Bring me up to date, and I will get a room for Abraham.” I wasn’t so sure I could right away, but something would be done. The hospital was way over census, full to overflowing.
Hospital-paresis
. We were frozen—couldn’t take patients in, couldn’t get patients out. So many of our patients had limited options. Few places take them without insurance. Our own nursing homes were at capacity. That wasn’t counting the homeless, the undocumented, and the countless patients with severe disabilities, mental health issues too numerous to count. Society in mega distress.

The youngest daughter, Claudia, a social worker, spoke to me in English. “Papa has been so weak. The transfusions only last a week now. Even less. He gets a small boost for a few days, a little energy, and can make it to the bathroom and to his favorite chair where he sleeps most of the time. But now we cannot leave him for even a moment. He fell two
days ago.” She was the family’s point person to the medical profession and always accompanied her mother, who never left her husband.

“Claudia, I can see you’re tired. But there’s something else?” She was tense and strung out. Not her usual efficient machine-like self.

“My parents moved in with my sister six months ago,” she said.

“I thought they had the house you guys grew up in, Cortelyou Road, right?” Tree-lined streets with large Victorian homes in central Brooklyn.

“They had the house, but Papa’s illness put them over the top in expenses. They had to mortgage the house and finally sell it. The bills from hospitalizations, nursing care, medications, co-pays, co-insurance were followed by relentless bill collectors. He is not Medicare-eligible yet. So they declared bankruptcy.” She was anguished, and I could see the effect on the entire family. The financial stress was bitter on top of the emotional loss inevitably coming down the tracks.

His illness began three years earlier with easy bruising. A small bump and a large black-and-blue spot appeared. Even holding him by the arm produced a thumbprint. When he came to our clinic, his platelet count was near ten thousand, twenty times less than normal. Steroids worked like magic, and in a few days he was back to normal. The family was delighted and we felt like small-town heroes. There were relapses and a switch to a stronger medication a year later. After another six months of weakness and tiredness, a relentless anemia was detected. The bone marrow biopsy showed a progressive loss of progenitor or mother cells. It was drying up. Bone marrow failure. We knew this was progressive and would continue relentlessly or burst into a leukemic flame that was hiding in plain sight. The clock was ticking faster.

The family had been so together, it functioned as one single unit. A husband and wife like Siamese twins after forty-five years of marriage, affectionate and considerate with a tenderness that left everyone around them in awe. Three children with their own full lives but still revolving around their parents, perpetually full moons. The financial calamity was attenuated by a caring family that would do anything
necessary to protect one another. The house had been their savings, their life insurance, their inheritance to the children and grandchildren. Medical bankruptcy for underinsurance and no insurance was a new epidemic we were seeing more and more. I had wondered for years why the middle class or corporate America was not in open revolt.

We were at the end of the road now with what we as physicians could do for Abraham Ramirez. How many pints of blood had he received? One hundred? More? When was enough enough? How do you decide? Who decides? Home care with his family around him had been the last decision, and no more transfusions. Then panic when he was in distress urinating or defecating and the inevitable 911 call. It was too much for the family. Hospice care near their apartment in Sunset Park, Brooklyn, or we would keep him here for the last days. That is, if they hadn’t changed their minds, watching the unit of blood, drip, drip, drip.

I had almost made it to the sliding doors and a momentary respite in the late-summer air. “Eric,” called a voice, and I stopped in my tracks. The organ donor team leader, Yolanda, gave me a hug and asked if we could go over a case that was “hung up.” The emergency ward break room was just inside its metal doors across from the trauma slot, only a few feet away. I dutifully followed her and turned a sharp right into the rectangular room. Several nurses were sitting around the rectangular table, chopsticks in hand, eating Thai food from half a dozen white paper cartons filled with brown rice, noodles, shrimp, and pineapple chicken. They nodded at me and offered me my own plate with sign language as they chewed and swallowed in silence. The air was somber; the only sound was the clock ticking on the wall.

I emptied a chair piled with paper supplies, and Yolanda sat on a table next to me. “We can’t get OR time for this case, Eric. We will lose all of the organs if we don’t have something by seven o’clock today, that is it. The Kaiser family has been gracious and very under-standing. But they are deep in grief, and the grandparents insist unconditionally that the organs are harvested tonight. They need this
to be over. Can you help me?” She looked at me and shrugged. The nurses looked up at me as one. They were caring for this patient next door. Brain death had been confirmed on two separate occasions and it was becoming unbearable to witness the family’s suffering.

Of course I could and I would. The organ donor team spent a lot of time at Bellevue. Since our trauma center was the largest in the city, the knife and gun clubs and slaloming taxi drivers trained future generations of the best and the brightest surgeons. As Frank Spencer, the former chairman of Bellevue’s department of surgery, reminded me on more than one occasion in his thick, intoxicating East Texas drawl, “Anyone knows, Eric, if you want to train good surgeons, you go to train in an inner city. Near where the action is. The shootings and the stabbings that is. Pick a great city hospital. I came to New York to work at Bellevue.” He smiled his slightly off-center smile, pushed his metal-rimmed glasses back, and adjusted his hearing aids.

After talking to Yolanda, I made phone calls to clear the operating rooms for Miriam Kaiser. There were too many lives hanging in the balance. People on the organ waiting list, sitting with their beepers and cell phones, hoping, many in vain, for a chance to live. To empty an OR I canceled half a dozen elective cases. The cancellations were both painful and annoying to our patients but necessary.

Karina, one of the crime victims social workers, joined the group mid-discussion. She was tall, thin, ex–Peace Corps in Thailand, and had a perpetual engaged attitude regardless of the bone-chilling circumstance that paid her city salary. She’d left a banking career five years ago to become a social worker. The back-office tedium of sitting in front of a computer screen in cartoon-like cubicles to collateralize fiction into make-believe, holding sovereign states and their citizens hostage, became increasingly enervating, depressing, and void of meaning. Buying stuff, the inevitable BMW and exotic travel, had staved off career ennui for a time. But she was calm and composed when it came to rapes, assaults, homicides, and vehicular manslaughter. When I asked her how she did it, she answered, “Resilience really. Most of our patients are amazingly resilient no matter what happens to them. It isn’t me at all, it is our patients.” One definition of maturity
in this business is when the humanity of the people that walk through our doors becomes part of your own.

“Look, I just finished talked to the 13th Precinct guys. They finished their interviews with the cabby and the husband, Marc Kaiser, and half a dozen witnesses outside Dunkin’ Donuts on Second Avenue,” Karina started. I wasn’t sure I had the stomach, but I let her tell me of the final moments in the life of Miriam Kaiser.

Miriam had been visiting Manhattan with her husband, Marc. They had been married for a few years and were planning on having children soon. The trip was to a specialist to check for any indications they had an infertility problem. It was early in the process and they weren’t too concerned at this point given their ages and excellent general health. Marc crossed the street with his wife after parking the car when she remembered she had left her cell phone on the floor of the passenger side. She squeezed his arm, turned around briskly, and crossed the street. The day was warm with a gentle breeze. A perfect New York kind of day after a period of sweltering heat and humidity that had broken with sheet lightning and a biblical downpour. Miriam beeped the doors open, reached into the passenger side, and rummaged around for her phone. Her husband stood on the far curb and watched his wife, checking his watch.

Miriam held the phone in her hand, slammed the door, and beeped it shut. The lights blinked on momentarily. She looked up at her husband and began to cross the street. A yellow cab was heading south on Second Avenue doing sixty miles an hour. The taxi’s top lights indicated he wasn’t picking up any more passengers; he was heading downtown to gas up his cab and switch with his Punjabi brother-in-law, who had the overnight shift. He was running a few minutes late and tried to make up time weaving in and out down the wide avenue while accelerating through yellow traffic lights.

Miriam had made it about ten feet from the curb when the slaloming yellow taxi reached her left side. The sharp crack and screeching brakes ricocheted off the walls of the buildings.

I was saved from drowning as I listened to Karina with a spirited reminder from Patty that I needed to head for my off-campus lunch
meeting. I walked through the emergency room doors and reflexively tuned out the surroundings, retreating to a parallel zone to eliminate the pain, the engine noise, and the insistent whine of an exhaust fan. A helicopter was coming in low for a landing at the waterside mini terminal when I switched mental channels. I hadn’t processed the day and things were hanging loose and unresolved from too many angles. How much heartache could I absorb and not turn into a robot or a madman?

My lunch was with Javie, Juan Guerra’s son. We had kept in touch after his father died. He and his mother had remained close after I coordinated Juan Guerra’s complex medical care over the years. This patient and I had shared the same exact cancer. He wasn’t here, and I was meeting his son. Javie enlisted in the military, following his father’s fateful steps decades earlier in Vietnam. I remembered overhearing the father-son conversation on the prison unit, a mini flashback, a career choice between the local gangs and IEDs—improvised explosive devices.

He stood up at a corner table when I walked into Curry in a Hurry, a few blocks west of the hospital. The military uniform gave him away. I wasn’t sure I would have recognized him. Sidewise baseball cap, studied slouch, low-rider pants, perpetual music plugged in and on full volume, he had fully morphed from a street-smart kid honing domestic survival skills into a young man. We traded brief updates. He was in an intensive language program in Arabic and Persian. Military entrance aptitude tests had put him at the top of his group. In his Latino
pandilla
, gang, there were Latinos who spoke Spanish and Arabic from Caribbean nations. It had become a secret code. I had heard of prison gangs in California using Nahuatl, the Aztec language. Moorish had been around since Columbus and the expulsion of the Jews from Spain, so why not Arabic?

“Tell me about yourself. Your mom said you were tough, difficult, wild, and on the verge of some bad decisions until you went into the military.”

He grabbed a bit of everything, like tapas, blended it all with a mound of basmati rice, and sipped a large mango lassi from a sweating clear plastic cup. “Doc, I was a young kid whose father spent half his
life in prison. What did I know? His military experience… well, you know.” Heroin, addiction, incarceration period. He paused and took a large mouthful of the curry. A group of Pakistani taxi drivers came in white shalwar kameezes, henna-dyed orange beards, and white skullcaps, talking rapidly in Urdu and Arabic and ignoring us completely. Salafi ultra-fundamentalist Muslims. You never knew who was from where and who spoke what language. Javie said they were complaining about the rise in gas prices and also discussing which Internet porn sites were the best, in that order.