She asked me if I was from New York. I told her I wasn’t. I was from California, actually, but enjoying myself in New York City while I was here. I asked her where she grew up. She said Brooklyn. She asked to see my referral card. I asked her to clarify. She said she wanted to see my referral card. For coming here. And did the super know I was here? Where was my card?
I was on a home visit as part of my internal medicine clerkship. We were visiting five home-bound patients today, and Mrs. B, who was the second of our visits, was less than delighted that we had made our way to her living room.
“You know, it is rude to show up unannounced,” she explains. I told her that her husband and health aide had known we were coming. I thought about adding that she had also probably known, for a brief time.
Mrs. B is wearing a tropical muumuu. Her short gray hair had been wetted and combed backwards. She has three remaining teeth, which all neighbor one another. Her lips cave around her gums, mostly, except where the last few hang on.
We inspect Mrs. B’s swollen ankles and then examine a dry patch of skin on her right elbow. I take her blood pressure, which is normal, and her pulse, which bounds along as even as ever. The attending steps out to call Mrs. B’s husband.
Mrs. B starts to pick at her elbow. Her aide tells her to let it be and moves toward her. Mrs. B grabs the aide’s forearm with her bulbous, arthritic hands and, with a growl, tries to bite, her three teeth looking like a cartoon baby’s against the black of her open, agape mouth. The aide patiently pulls her arm lower, Mrs. B’s atrophied muscles long from offering reasonable competition in this match. Mrs. B growls and tries to bite again.
“That is not very nice, Mrs. B,” her aide says, pulling her arm entirely away. I ask if Mrs. B had ever actually bit her, to which Mrs. B interjects that SHE DOES NOT BITE!
I do not want to linger here. I am scared of this woman. I imagine her lunging at me, leading with a few-toothed snarl. I find her a terrifying exemplar of what age does to a mind. I imagine what Mr. B looks like, what his temperament must be like. What it is like coming home to your lifelong partner, now warped by dementia, a washed and combed version of whoever she once was.
“Where is your card?” Mrs. B asks me. “I am going to the police. I will call them!” I explain that her doctor visits every two months. I am a student visiting just this time. “I will call the police,” she threatens again. Had I not heard her? I repeat what I have just told her. She repeats what she has just threatened.
“Help! HELP! HELP! HEEEEEELLLLPPPPPP! Someone help me!” Her fear has spilled over into action. She wails over my continued explanations, so I sit in silence as she pleas with anyone passing by to help. To the neighbors, I suppose. Or to the god she believes in, perhaps. When she finally stops, she looks about to cry.
I am ill-prepared for her punishing, unremitting perception of reality. I cannot calm her, or right her mind. Unable to convince the other, we sit in silence, until a giant, towering grandfather clock standing across the room goes off. It is twelve o’clock, so we are lucky enough to witness its full, timely concerto.
“What an amazing sound,” I say.
“You are such a phony. Do you know that?” this elderly Holden Caulfield asks. After all, how can one bear the small talk of a burglar? She dives back into another round of threats and screams.
Finally, the attending returns, and we ready to leave, for which I am relieved. I wonder how Mr. B deals with the daily howls.
Or, perhaps this only happens once every two months, when strangers barge inward and demand to squeeze her arms, pinch her ankles and prod her belly. For however scared I was, I was able to appreciate the relationship and roles of each person in the tableau of her living room. She is the one left to fend off the intruders, to first politely inform them of their indiscretions, and then, when that doesn’t work, scream for help. Is everyone else mad? There are intruders and phonies in every direction!
We head down the hall. Her muffled wails drift towards us as the elevator climbs upwards. My fear and unease and distress at our meeting thaw into a sadness, for a life and personality distorted by dementia. And that sadness soon ebbs into a compassion for a last stage of life filled with constant and profound fearfulness. Mrs. B had gifted me a deep appreciation of something I had never considered — a gratitude for knowing why I am in the room.
Author’s note: The name of the patient has been changed, as well as specific details about the encounter, to protect patient privacy.
Pleural Space looks at the experiential curriculum of medical school, the many things that are taught and learned that aren’t listed in a syllabus.