Part One
This was not what the manager had in mind for her evening.
An eccentric clientele was par for the course in her occupation. Low cost motels like hers tended to attract all sorts, and she took little interest in involving herself. Late-night traveler en route to some final destination — tenant. Thin, itchy man with wiry veins, eyes sucked back into bony skull, track-marks — tenant. Homeless or otherwise down on his luck — tenant. Each was provided a key to a seedy room with a vibrating, quarter-operated bed, a tube television complete with eight channels but no remote, a tattered Gideon Bible next to an even more tattered phonebook, moth-eaten lampshades and mothballed linens. Vagrants, petty criminals, nomads, the unlucky — all tenants at this godforsaken place on the godforsaken outskirts of this godforsaken small town.
The manager didn’t much know or care which category the godforsaken tenant at the end of the building belonged to. Maybe one. Maybe all four. Anyhow, it didn’t much matter. She was involved now, and that required timely eviction of the old woman at the end of the building. If she was still alive, anyway.
The old woman checked into the cabin a couple of weeks ago, making her stay a couple of weeks longer than most. She arrived with bad teeth and a duffel bag and a younger man with a Rolex. The man identified himself as her son — or was it her nephew? Anyhow, it didn’t matter, the manager never got involved — paid in full for the next few nights, the manager escorted the woman and her bad teeth and duffel to the cabin, and drove off in a sedan that accounted for two years of salary.
That was the last time she saw the man or the old woman, and now the rent was overdue and a blood-curdling stench thrashed the scent of mothballs and contemptuously spat its fumes through the gaps in the door-frame.
No, this was not at all what the manager had in mind for her evening.
She had already found the coroner’s number in anticipation of the inevitable but the old woman, as it happened, was not dead. She was merely ill — violently, graphically ill, at the expense of the motel room’s already dilapidated décor. An ambulance plucked her from the squalor of her cabin and deposited her at a hospital where, dazed and disoriented, she was admitted to the internal medicine teaching service.
At least that’s how I imagine things went before I had the chance to meet her.
Part Two
Delirium is a bread-and-butter presentation. The differential writes itself — stroke, infection, intoxication, electrolyte imbalances, shock, organ failure. The intellectual exercise this invites was practically invented for medical students, even if the final diagnosis (dehydration secondary to gastroenteritis) and its treatment (fluids) were relatively mundane. So it made sense that a medical student just starting an internal medicine rotation would be assigned to such a classic presentation. “Plus, I think she has some kind of unusual social situation,” said the supervising resident as she rifled through her list. It would be the understatement of the year.
I’ve made passing references to my Messiah complex before, so it will come as no surprise that the phrase “unusual social situation” was music to my ears.
The tenant really did have bad teeth — crooked, yellowed and gray, with black empty spaces where the missing ones were (or weren’t). Her duffel, impossibly overstuffed, was slumped over dejectedly in a chair. Scattered across the table were orange pill bottles, each of them empty, each of them stamped with a different pharmacy logo — the only clues the overnight team had to guess at her medical history, which included bipolar disorder.
The tenant appeared to have made a miraculous recovery in the twelve hours since her admission. Fully oriented now, she set her sights on mockery. She made short work of my short white coat and grinned toothlessly as she cracked wise about the “humorless” doctors who she met in the emergency room. “‘They’re all mad here,’” she said, quoting Lewis Carroll.
“Mad” seemed an apt word, I thought, as I perched on a stool at her bedside. The tenant was a riot. She spoke ceaselessly, breathlessly, eloquently, lengthily, tangentially. Each attempted probing of her “unusual social situation” was rewarded with short non-answer answers and then she began her magic trick. It goes something like this: first, she locks her gaze on you, and it is altogether unsettling because she is not looking at you, but through you, past you, beyond you and beyond now. And her black eyes are like shark eyes — wide, dark and lifeless, and the room shrinks around you, and those black eyes grow and swallow you up until you are falling into them, through them, down into the rabbit hole of her mind. You plummet endlessly and her voice tells you about her life in Brooklyn, her life in Europe, her life as an accomplished academic, her life with a few different husbands, her life with a man named Wayne and her life with her cats.
Just as you realize that you are through the looking-glass, that this rabbit hole has no destination, she releases you, and the hospital room materializes again: it is the present again and her pine-colored hair is matted across her forehead again, her eyes are brown and twinkling again and she smiles yellow and gray and cracks a joke at your expense. Again.
As you might imagine, this made communication challenging. We still didn’t know who the tenant really was, where she came from, who was responsible for her or why she was living out of a cheap motel. We were at the tenant’s mercy, and answers to our questions came drip-by-drip in incremental disclosures. The drips filled a basin near to overflowing, and in its reflection her dull black eyes shimmered and swam and uncovered a sinister reality about the man called Wayne.
First, Wayne was her son who was looking after her for the last year (or so). It was he who had dropped her at the motel, apparently just the latest in a string of hotel stays that he arranged. Then, Wayne was her nephew, who, incidentally, had full control of her finances. Finally, Wayne was revealed to be a stranger she met in a restaurant who became her lover. These, and other revelations, raised serious concerns for the possibility of elder abuse and our team made appropriate reports.
Our collective guard was up now. Strong as our suspicious were, we had no proof of their veracity. Not that this mattered any — we weren’t the police, and it wasn’t our job to investigate. Plus, there was no way to separate truth from fiction, or at least fictionalized truth, in the tenant’s meandering stories. She didn’t seem all too worried herself. Once, after resurfacing from one of her rabbit holes, I pointedly suggested to her that Wayne was taking advantage of her for her money, and she narrowed her crinkled eyes into slits and shifted in bed and stared silently at me (or through me) for an hour of a minute and I was sure I crossed a line. Then she shrugged and mussed her matted hair and twinkled her eyes and grinned that ashen grin. “Maybe he is, maybe he isn’t; so what if he is, so what if he isn’t?”
Part Three
We rarely got a hold of Wayne and we stopped trying so hard once we found out about their relationship. The tenant talked to him every day on her cell phone and each day he promised her he would visit tomorrow. As reliable as the morning sunrise, Wayne was inevitably sorry he didn’t come yesterday but his back was acting up, and he was sorry he couldn’t come today because of an awful migraine. The next day, he would surprisingly not show up again, they would talk on the phone and he would apologize again that he didn’t visit yesterday but he had that awful migraine, and he was sorry he didn’t visit today but his back was acting up again. Or perhaps it was some other physical complaint. I chose not to remember.
Reality didn’t much care about Wayne’s ailments or our misgivings — it cared about discharge planning. The tenant’s presenting diagnosis had been satisfactorily treated, and she was medically fit to vacate her hospital accommodations, which charged a nightly rate approaching $2,500. Wayne was still her emergency contact, though not a particularly good one given how reliably our calls went to voicemail. Finally, we got in touch with Wayne; in a brief conversation that was equal parts terse and tense, he acknowledged he did not have the requisite documentation of his alleged POA status before leaving us with an obscenity, a click and a dial tone.
I counted this as a victory. The tenant wanted to be discharged into Wayne’s care, but she had been stripped of her medical decision-making capacity after not one, but two, consultations with the hospital’s psychiatry service. She would not get her wish; instead, we, the system, the medical elite, the protectors, the paternalists, would assert our wisdom and our will because, after all, we knew “best.” We won, and she lost.
So we tried again for family. After some initial reluctance, the tenant shared with us the phone number of an estranged son, which did not really belong to her son but to another person who knew him, and after some initial reluctance he shone a flashlight into the rabbit holes of his mother’s life. Yes, he knew all about Wayne. Yes, Wayne had control of her assets. No, this wasn’t remotely the first time she had been in a situation like this. I still remember how quickly the disbelief in his voice evaporated into weariness and exhaustion. Despite the years of trauma and the thousands of miles and an ocean between them, his mother was back in his life. He shared with us that it had been a turbulent childhood that continued as a turbulent adulthood, always in the churning wake of his mother’s poorly controlled mania and its consequences. Now those consequences had chased him across the globe through a telephone set, and he was falling into the rabbit hole of his own past, because no matter how hard you try, you can never really leave home. His mother was back in his life, and we had put her there. Resigned, he agreed to help make arrangements for discharge. It was another victory; we won, and he lost.
Part Four
We began the discharge planning in earnest and the tenant would outlast every other patient on the ward. I would care for patients with cellulitis, gastritis, pancreatitis, vasculitis and various other –itises, and each of them were diagnosed, treated and released while the old woman played Sudoku and poked at green Jell-O trembling on her lunch tray. She quickly fell out of the formal rounding ritual: she was no longer a patient, but a tenant. The hospital had become an extension of the motel, just another place where she spent her days alone and abandoned in the depths of her rabbit holes.
I kept going back to see her, stealing away during those lulls in the afternoon, when the day’s work has largely been completed but it’s too early to go home. Each day when I arrived at her room for one of our chats, she would greet me with a “Finally, there you are!” before picking up wherever we left off. We talked about everything from her career in academia to the Syrian conflict. We talked about life in her New York apartment building, where she would share anti-depressants with neighbors — “just like lending a cup of sugar.” We talked about how Donald Trump would never, ever, ever become president. We talked about humorless doctors, and she made me promise never to become one. We talked about the kindness of strangers upon which she had always depended. Then her eyes would open up into rabbit holes.
She was captivating, whip-smart, with a wit that cleaved clean to bone. I fought to stifle laughter as I witnessed her expertly eviscerate a consultant with jokes that flew up over his head and out into the sky. We spent hours talking over her three-week hospital stay, she became more of a mystery to me. The lines between mental illness, eccentricities and performance art had not been merely blurred — they had been beaten into submission, and I got the feeling she liked it that way.
I was preparing to leave one evening around 6:30 when I remembered I promised the old woman to stop by before I left, to continue our afternoon conversation. Coat and bag in hand, I walked to her room at the end of the ward, acknowledging a well-dressed bald man who nodded hello in the hall and wore a sweater-vest and a Rolex, promising myself I wouldn’t stay too long. I nearly collided with the tenant’s nurse as I entered the room; “That’s Wayne,” she said.
“Really?” I stepped back into the doorway and looked at the shrinking figure heading away from us to the elevators. I thought for a moment. Then I walked after him.
I was not (and am not) the police. Whatever crimes he may have committed, visiting someone in a hospital was not one of them. Whatever crimes he may have committed were also immaterial, because, as I said, I was not and am not the police. So, I had no delusions of grandeur about meeting Wayne: I was motivated more by curiosity, a desperate sense that if I didn’t talk to him, my mind would have conjured up some imagined confrontation that would have paled in comparison to the real thing. I’m not sure which motivation is worse.
I caught up with Wayne by the elevators, just before he pressed “Down” to go down, and out. He smiled, I smiled, I extended my hand, he clasped it with both of his, I regarded the Rolex on his wrist, the beads behind his spectacles peered forth, he thanked me for taking care of his “aunt.” I asked if he had any questions, he said no but thank you, that he had to be going, he smiled, I smiled, he let go of my hand and got on the elevator and went down, and out.
Part Five
In the end, the tenant’s son came through. He arranged for her to stay with extended family. Her last day in the hospital was also my last day on service, which conferred a sense of poignancy that I still struggle to put into words. The forces of Nature, the Universe or Chaos itself directed our paths to intersect, and I am certain my life has been better for it.
So I perched on a stool across from the woman with the twinkling eyes and the matted hair and the bad teeth and the duffel bag, just as I had three weeks earlier when we first met, and I commented on our diverging paths and how this was goodbye.
She just stared at me quizzically, blankly. Then her gray toothless smile flashed and she extended a hand and I took it. “It’s been a pleasure,” she said. “I think we’ve made tremendous progress.”
“Progress?” I asked, standing.
“On you, of course!” she cackled. “Now sit down, and let’s talk.”
And her eyes opened up.
Author’s note: Part One is partially fictionalized for creative purposes. All names have been changed or omitted in the interests of privacy, and certain facts have been excluded owing to the sensitivity of the subject matter.
Numerous studies have documented that medical students lose empathy during clinical years, becoming jaded and pessimistic. This has been linked not only to diminished enjoyment of our work, but also to worse patient outcomes. My goal is to sustain the humanistic values that drive so many of us to medicine, so that, instead of being quelled by cynicism, our idealism can be refined by wisdom.
Columnist and in-Training Staff Member
Morsani College of Medicine at the University of South Florida
Ajay is a pediatric resident and a Class of 2017 graduate of the SELECT MD program at the University of South Florida. He is passionate about delivering primary care to underserved populations—specifically, low-income and homeless patients in urban centers. Ajay will be specializing in pediatrics, with a particular interest in child maltreatment.
M.D. or Bust
Numerous studies have documented that medical students lose empathy during clinical years, becoming jaded and pessimistic. This has been linked not only to diminished enjoyment of our work, but also to worse patient outcomes. My goal is to sustain the humanistic values that drive so many of us to medicine, so that, instead of being quelled by cynicism, our idealism can be refined by wisdom.
