Twelve Patients: Life and Death at Bellevue Hospital (28 page)

The medical industry had been breached by corporate interests, from drugmakers, to orthopedic implants, to cardiac stents, among a host of others. The relentless focus on the individual patient ignored the social determinants of health that brought patients into the hospitals and offices to begin with. The social gradient of obesity was superimposable on a zip code map of the United States by income. The poorer the zip code zone, the higher the rates of obesity and the darker the color. At ten-year intervals, the rates were rising astronomically. The Southern United States lit up as the epicenter. A Rand McNally of a public health epidemic playing out daily in hospitals near you. “I used to go with my parents to Puerto Rico when I was a child,”
Marta said. “Their parents still lived there in the 1970s. We would go deep into the rain forests, way away from any town. And there’d be a Coke stand. A rutted road four hours from nowhere and the red Coke truck would be tipping its way along the godforsaken path to drop off the bottles and pick up the empties. This poison is sold everywhere. Everywhere.”

She took a sip of her coffee. “I finally feel that it’s not my fault,” she said, looking up at me. I was confused. “I mean my fault that Irene died.”

I was stunned. “How could that be your fault?”

“I keep hearing it. My fault that I smoked. My fault that I ate too much junk food. My fault that Irene ate too much junk food. My fat, my fault. It’s not my fault,” she concluded, softly.

“I know, Marta,” I said. “Look at the patients in this hospital. It’s an epidemic. An epidemic is not one person’s fault.”

“I’m not going to let my babies grow up like this,” she promised, though the words seemed directed more toward herself than to me.

The debate of debates over obesity in our society, like many others, has boiled down to personal responsibility. It is as old as American pie and hauled out periodically and dusted off to engender political support for a business-friendly agenda that promotes a citizen’s natural right to buy what she wants when she wants in the quantities she wants.

The key strategy of the food industry has been taken from the legal, legislative, marketing, and risk-adjusted playbook of the tobacco wars. Many of the protagonists are one and the same, RJR Nabisco the most notable. The overarching narrative blames the irresponsibility of individuals as the root cause of obesity. “Why aren’t parents paying more attention to their children?” say the letters to the editors. Consolidated corporate media receives its largest advertising budgets from the industry and gives it a pass. Corporations are providing their markets with choice. Government regulation, the mantra plays out, stifles the great American job machine and its innovation engine. Its most recent iteration has been the self-serving preemptive laws called collectively the
Personal Responsibility in Food Consumption Act. These laws have been adopted by half of the states and ban lawsuits against the fast-food industry. A tactic the tobacco industry wished it had in place before it paid out billions in settlements. Call it second-generation tactical maturation. The strategists from one decades-long engagement are older and a lot wiser when it comes to limiting liability, Congress, the Supreme Court, and the consuming public.

“Tell me about Doña Olimpia,” I said, in part to change the topic.

“She’s good, Doctor.” Marta smiled. “She gets up, bathes, fixes herself up—her clothes, her hair. She can’t see much, but she can feel—and she wants to feel nice. Jaime reads to her; she holds our baby. It’s good for all of us. She’ll be seventy next week.”

It was remarkable the skill and teamwork that we could put into taking care of a septuagenarian diabetic with advanced vascular disease on dialysis and blind, with a 99 percent blocked left main artery to her heart, and bring her to the point where she could function modestly back home. We did the best we could with each patient in our hands. And yet I wondered what we could do to prevent our patients from getting these preventable diseases. We always said our job was not to solve world hunger, just take care of the patient in front of us. Where exactly did our responsibility start and where did it end?

Marta got up to go back to work. She promised to stay in touch.

The tachycardia of the hospital never seemed to slow down. In fact we all remarked that modern life was characterized by the loss of the ebb and flow or the sine wave of events. Everything now was about efficiency. Multitasking had become malignant, and all of the social media had an intrusive quality despite having a rationale for every “convenience” they offered.

I saw Marta’s invitation to the “Runway” party one evening as I was finally getting to my mail. The flyer announced that the surgery department and Bellevue were sponsoring an event for bariatric patients a year after their surgeries. It was coming up in two weeks. She had scrawled on the bottom: “I have something to tell you.”

I could feel the music pulsating and hear the shouts and laughter
coming from inside the huge rectangular conference room on the top floor of the old TB building, with views to die for. The annual Runway was well under way.

I stood in the back row against the western windows with the late-afternoon sun streaming in and heating my back. Dr. Manish Parikh came over and shook hands. We smiled. He was soon engulfed by his patients and their families. A familiar face flashed on the screen. Marta had chosen a picture after she had gotten married and Irene was five years old. In a corner, an elderly woman sat in a wheelchair. She wore wraparound dark sunglasses and a pristine white linen blouse. Her hair was tightly coiled and her nails were painted. Doña Olimpia had made it out of Brooklyn to her daughter’s celebratory walk. Jaime sat holding Isabela, who was now an active tot. It had been two years since her daughter’s death. They had survived.

Marta came up beside me—I hadn’t seen her. “So guess what,” she said, excited.

“Your family is all here,” I guessed, cheating.

“Yes, but not that.”

“You’ve lost all the weight. Your diabetes is gone.”

“Yes,” she agreed quickly, “but not that.”

“I can’t guess. Tell me.”

“I was voted onto the board of Healthy New York City. The local organization that fights the fast-food industry. I’m going to work there.”

“Wow.” I congratulated her. “That’s fabulous!”

“They’re going to pay to fight the
cabrones
, the bastards!”

“Wow.” I really was speechless. “You’re leaving Bellevue?”

“Yes. I mean no. I’ll be back. But not as a patient. I’ll be tormenting you till you get those Pepsi machines out of here!”

“Fair enough! Torment away.”

Just then her name was called. “Now we have M A R T A, folks…” The emcee went into her medication regime before and after. “Only one pill now, folks, only one pill, do you hear that: one pill!” Marta had started to walk down the runway in her wedding dress in high heels with a confident swagger that had her audience whistling and
chortling with enjoyment and good humor for her and for themselves. She reached the end, a few feet from where I was standing, looked me in the face, and blew me a kiss. Then she turned on her heel and walked slowly away as pictures flashed on the screen of the new Marta Sahagún. The crowd erupted in applause.

Jeffrey had been brought in by the Port Authority police, found at the bus station in central Manhattan curled up in a fetal position under a makeshift cardboard roof between garbage cans. The cul-de-sac where he had been found was used by some of the city’s hard-core homeless in bad weather when an icy wind spiraled up the avenues from Battery Park at the southern tip of Manhattan. The cops were pretty tolerant of the regulars in desperate times, regardless of the broken-window theory that related crime reduction to the arrest of squeegee men, jaywalkers, and unlicensed street vendors. Jeffrey had been a regular in our emergency room for a few years now. I’d known him since his schizophrenic break fourteen years ago, although I had not seen him for at least two. His delusion was that he was a Jain, a practicing member of an Indian religious sect. Mahendra, the physician in charge of our psychiatric emergency room, called my office and left his name and extension.

After attacking the metastasizing cloud of phone calls, emails, voice mails, text messages, tweets, beeps, and teetering piles of snail mail plus a show of force by the trauma surgeons about operating room delays for acutely inflamed gallbladders, gaping colostomies overdue for closure, and knife and gun club wounds that needed second-look surgery, I dropped downstairs and headed toward the adult psychiatric emergency room (CPEP) one long corridor due east of the main emergency room. Finally some midafternoon peace and quiet.

I nodded to the middle-aged black hospital guard. She wore her long hair Rasta-style, tied up in a single long ropy tail. She sat behind her ancient brown Formica-and-metal desk and was alert to everyone in the room. As I walked into the waiting room, full
of policemen and patients to be evaluated, I found myself looking through the Plexiglas walls directly into the coed CPEP holding area. The staff were in civilian gear, pants and sneakers, and had their IDs clipped to their shirts. They were idling around the room, heads swiveling like compact radar units on destroyers, except for one stocky red-haired woman on bathroom check. Every patient wore tissue-thin pajamas washed ten thousand times. Many were lying on stretchers, their feet poking out from the sheets and white blankets, heads covered with pillowcase turbans or limp forearms to block out the intense fluorescent lights. The constant din of people moving about, talking, and shouting added to the hyperventilating atmosphere. Several patients were lined up in front of the single bathroom, shifting from one foot to the other, tapping on the door, their paper slippers half off their feet. Another passel of patients sprawled out, using a long row of blue plastic recliner chairs as small beds, like on the deck of the
Queen Elizabeth 2
during another era through the lens of Fellini.

There he was—Jeffrey. He looked fifty years old, though I knew he was really about thirty-five. He wore our standard faded hospital-issue pajamas with a thin white blanket over his back like a Haredi prayer shawl. He rocked gently back and forth as he spoke to the talking heads on the flat-screen television secured behind a Plexiglas protective box. His beard had turned gray since I had last seen him. His hair was biblical in length and gnarled in tangles. He looked like an Old Testament prophet. Yellow cigarette-stained fingers with long curved filthy fingernails jabbed at the carefully groomed and perpetually smiling faces on the TV. His teeth, where there were any left, were yellowish brown rounded stumps. His eyes were sunken and had dark, deep circles like makeup. He had a pale white paunch streaked with dirt or shit visible through his half-unbuttoned pajama top. He looked in my direction and scanned me for a moment, apparently without recognition. His eyes fixed on mine for a few seconds before he turned back to the screen and continued lecturing the two mannequin-like newscasters. They were twin sexless plastic Barbie dolls trapped in their flat-screen world unable to respond to Jeffrey’s jabbering on about Christ, Muhammad, Yahweh, and the benefits of Jainism.

A middle-aged man in a crisp white attending physician’s coat, stethoscope in the right pocket, without a wrinkle or hair out of place, opened the door to the interview room and welcomed me into his domain, Bellevue CPEP. Amartya Mahendra was a Pakistani psychiatrist who had a distinguished career in surgery and pathology before switching to the study and treatment of serious mental illness.

“It is more interesting than surgery and pathology put together, Eric. I couldn’t resist it. Like an unseen seduction I got drawn into it after doing hundreds of autopsies and brain dissections. My first love. I know it sounds strange. Once the physical part of medicine was revealed, I became interested in the invisible part. The emotional life of man, the strangest, most unknowable, and most fascinating parts. Psychiatry, or whatever it is called, is pure mystery in an infinite regression of permutations no matter how many diagnostic labels are put on it. Medicine is my wife and family. Please don’t tell Wendy!”

I had met his “real” American wife and gorgeous seven-year-old daughter, the true loves of his life. Over hamburger specials slathered with ketchup and mustard in the hospital coffee shop, he had told me about his training in London and later in the Bronx. We had also talked about his homeland, where I had spent some time in 1986 as a guest of the Karachi-based Aga Khan Medical Center. While in Pakistan, I had worked in the tribal areas in the Northwest Frontier Province, now the sanctuaries of the Taliban and Pashtun resistance to another empire’s incursion into what became the Soviet Union’s graveyard. Because I had once sat under tables when Russian helicopter gunships strafed the Pashtun refugee camps, I had some street cred with Mahendra and some primitive idea of where he was coming from.

“Mahendra, how is business today?” I asked him, knowing he enjoyed telling me the stories behind the stories of his patients’ medical problems, as well as the fault lines of the intricate politically connected systems we relied on when it was time to send them out into the “real” world. Mahendra particularly loved to talk about what was real and what wasn’t. He claimed it was his goal to figure it out by the time he was done. He figured one of his patients who appeared to have a delusion was really an all-knowing one with the truth embedded in
the riddle of his delusion. “You never know, Eric. I have learned more from my patients than they have learned from me. I have been doing this for over twenty years—don’t forget—and that is after two other medical careers. Plus both of my parents and my sister are physicians.” He smiled. He clearly enjoyed keeping me alert and thinking.

“We are over census by fifteen patients, definitely in the red zone.” He felt that getting over census by twenty-five patients created a hostile environment where an individual patient’s personal space evaporated into thin air. Violent incidents were conjured into existence from an inadvertent touch, the wait for food, disrespect from a medication nurse, a gaze that lingered half a second too long. Pushing and shoving could escalate into a vicious assault. De-escalating acrimony and heading off tensions were mental martial arts. It meant accurately reading emotional language, decoding it in the moment, and having the tools to bring the tension down… with humor, a favorite sport, a candy bar, or a game of checkers. Mahendra and his team were all black belts. I loved to watch them in action.