Terrence Holt: Internal Medicine: A Doctor's Stories

“Do you know what it was?”

She looked at the basin, in which a thin yellow fluid was swirling. “Not yet.”

“Mr. Scatliff?” Joe called.

“Doc, you know he can’t hear you.”

“He can hear.”

“Yeah, but he don’t know what you’re saying.”

“Mr. Scatliff?”

The face turned upward. A few beads of sweat hung in the thin eyebrows. He seemed to look straight through us, then he rose abruptly from the bench. The nurse caught the basin as it slid from his lap. Without a backward glance Scatliff started shuffling down the hallway, stopping every ten feet or so to gaze right or left before setting off again.

We waited until he reached the next bench, halfway down the long hall, before catching up with him.

“Come on, Mr. Scatliff,” Joe murmured as we steered him toward the bench. “Let’s sit down.”

Scatliff stood by the bench, showing no inclination to sit.

“Please sit, Mr. Scatliff.”

He started off down the hall again. This time we pursued, and he picked up speed. Down at the far end of the hallway stood a trash can. We followed him as he homed in on it, his hospital-issue slippers scuffling faster as he approached his goal, his hands beginning to work at his sides. He let out a low, almost melodic moan.

He reached the garbage can and sank, painfully, to his knees.

“That’s enough, Mr. Scatliff,” Joe said, reaching to stop him as he groped within the can.

Scatliff glanced angrily at Joe’s hand, slapped at it. He seemed to think Joe was competing with him. The moaning became a series of staccato grunts.

Joe had managed to get a hold on both wrists and was turning him, trying to be gentle but increasingly struggling as Scatliff’s cries grew louder. Two aides appeared and began to lift him bodily off the floor. He milled his legs beneath him, crying out as the aides carried him to a nearby chair. When they deposited him in it he sprang up again, his eyes still on the can.

“We’ll need to restrain him,” Joe said. “That’s fifteen minutes of paperwork. Sorry.”

I watched as the aides levered him into a geri-chair. Scatliff looked hungrily past them toward the object of his desire, his head swiveling around as they turned the chair away. His mouth hung open, the tongue working over the toothless gums. In his eyes was a clear blue intensity that shone out for a moment, then was gone. He slumped back in the chair and let them wheel him toward his room.

In his room, held in bed by a Posey vest, he made no objection as we examined him. His mouth was empty, his breath foul, and from his abdomen we heard a series of booming gurgles. No response to deep palpation; no rebound, guarding, or mass. Benign.

Joe looked up at me. “Do you think we need to do something?”

I couldn’t imagine anything medical that might help Mr. Scatliff. I shook myself, and made an effort to think of him as a human being who had accidentally ingested a foreign body.

“Start with a KUB,” I suggested, naming a standard X-ray view that would encompass most of his digestive system.

Joe noted this down, nodding to himself as he did. He looked up from his clipboard. “Anything else?”

I looked past him at Scatliff. He was looking back in my direction, trying to see past us. His tongue swept over his sunken lips and he writhed a little against his restraints.

“Could we try feeding him?” I asked.

“You think he’s hungry?”

“Worth a try, isn’t it?”

Joe looked back at me. “I don’t think it’s that kind of hunger.”

“We could try.”

I realized there was something a little off in my tone: I was pleading. With what or whom, I wasn’t sure. But I thought that if I could see Mr. Scatliff eating something besides garbage I would feel better.

“Never mind,” I said, and stood to go. I walked out into the hallway, embarrassed. I had been thinking of Joe as someone who naively misconceived the world we live in. I didn’t like revealing to him some need in me I didn’t understand. It made me walk a little faster toward the exit.

IT WAS MY PAGER that went off as we were leaving Gero. I recognized the number as 1 North, Acute Women’s. I traded my earlier embarrassment for pique. They shouldn’t be paging me. Pages go to the intern. I showed him the numbers on the little screen. “I think this is for you.”

It wasn’t. They had called me because Carrie B was complaining. Shortness of breath. Tingling hands. Dizziness. Her respiratory rate was thirty-two.

“How does she look?”

This is usually a good question to ask of an experienced medical nurse, but here I could never be sure if the person I was talking to was more trained in restraint holds. I asked anyway.

The reply was clearly skeptical. “She looks okay. I mean, her color’s good and all. I think she’s just hyperventilating.”

It seemed a good call. Of course, she could also be harboring a massive blood clot in her lungs. I tried to thrust that thought aside, even though I knew we were doomed to go through the full workup. Unless.

“Have you got a paper bag there?” I said into the phone. “Like a lunch sack?”

A long pause. “There’s the one I brought my lunch in.”

“Could you let her breathe into it? Just hold it over her mouth and nose for a minute.”

Something not quite voiced that I couldn’t hear. Then, “Yeah. I can do that.”

“Thanks.” I was pleading again. “Let her do that for a couple of minutes and see what her respiratory rate does.”

Joe was looking at me, one dark eyebrow cocked.

“It might work,” I said, the defensiveness tumbling out before I was aware. I caught myself. “New admit I worked up earlier. Carrie something or other. Did you hear about her?”

He rifled his sheaf of papers. “Uh-uh.”

“Internal stimuli,” I said. Joe just nodded.

“She’s hyperventilating. Let’s go down to X-ray. I ordered chest films.”

Joe followed me silently toward a stairwell.

“Any idea what I’m worrying about?” I asked him, remembering that part of my role here was his instruction.

“PE?”

“Yeah,” I said dolefully. Pulmonary embolism is something that happens to people after sustained inactivity, to women who are pregnant or taking birth control pills, and to people with cancer or some kind of inborn clotting disorder. It’s a common cause of in-hospital deaths, and because its presentation is often subtle any suspicion usually requires a full workup. And the workup is famously mined with false results. I was not happy to be thinking about PE in the context of strange little Carrie B and her internal stimuli. There was enough I didn’t understand already.

The radiology reading room was (as they often are) in the basement, where we found an empty, darkened room, with darkened view boxes lining the walls.

“Who’s there?” a voice came from beyond the far end of the room. Light leaked around a corner. Reggie, the X-ray tech, appeared, and suddenly the room was flooded with light. “Hey, Doc,” he said, hastily putting down a magazine. His other hand held an overloaded sandwich, which shed shreds of lettuce as he waved it in our direction. “I was just about to page you. Those films you ordered? Carrie B? You gotta see this.”

An uneasiness was gathering in my chest.

Reggie whipped a set of dark transparencies from a cubby below the counter and slapped them onto the view boxes, which flickered. Light and shadows snapped into shape.

The pair of films revealed the thoracic skeleton of an individual, young by the density of the bones, evidently female. Automatically I began to scan, following the protocol: name and date first, then bones, then—

We all involuntarily drew breath.