Twelve Patients: Life and Death at Bellevue Hospital (39 page)

A soulless rectangular reflecting glass DNA lab had gone up on our property post-9/11, a gift from an ex-mayor to the chief medical examiner. “And by the way, he has been treated now for over two weeks so you guys don’t have to worry about catching any red snappers from him.” I was alluding to the appearance of TB under a microscope.

I saw they were still jumpy when the door opened. A doll-like Chinese nurse came out wearing blue latex gloves, with the tight-fitting mask sealing her nose and mouth. She peeled off the mask and threw a big smile in our direction. “Good morning, Officers and Dr. Eric. Anything I can do for you?” Her diminutive size, youth, and creamy complexion made the cops’ fear more than a little ludicrous. They mumbled and relaxed a few notches. The square air filtration box hanging off the wall near the door with its buttons and dials and lights didn’t reassure them, but this was the key to controlling contagion. All the rooms had negative air pressure that recirculated the air and sucked, vented, and diluted it into the atmosphere. Plus people wore special fitted masks to keep them from inhaling the germs. The city invested in rebuilding public health TB infrastructure in the early 1990s.

“You’re okay,” I repeated to them. “We will look after you. You look after this guy.” I jerked my head in the direction of the room. Beltrán—the details were coming back to me—was a very bad actor. I left it at that. I wasn’t sure what they all knew.

While the cops’ fears of catching TB were irrational, they were understandable. The germs were aerosolized with a cough, dispersed and inhaled by whoever was in the room. Infection wasn’t limited to junkies shooting up in dank abandoned Bronx tenements littered with stained mattresses and broken glass. Worldwide, TB remained and has remained an enormous challenge, with millions of new cases a year. The development of several “miracle” anti-TB drugs in the 1940s and early 1950s gave hope that it could be eradicated with medications. Tuberculosis hospitals, sanatoriums, and the public health infrastructure built around the comprehensive management and isolation of the disease were gradually downsized and shuttered. By the 1970s there
were only a few centers specializing in TB diagnosis, treatment, and control nationally. My personal training at Kings County Hospital between Bedford Stuyvesant and Crown Heights had included regular rotations in a six-hundred-bed TB hospital that closed a few years after I finished my residency.

Since its triumphant return, my colleagues and I had seen every kind of TB. From TB of the skin to TB meningitis, TB of the ureters with renal failure, and Pott’s disease or spinal bone TB. Cavitary TB or TB of the lungs was highly infectious since millions of the organisms sat in the liquefied destroyed lung tissue or cavities and with each cough were aerosolized in a fine mist. But as TB “died out,” so did the specialists who knew it so well. The protean nature of the disease created a subtle, confusing masquerade of other ailments. Patients’ presenting symptoms mimicked cancers, blood clots, common infections, and masses in ingenious ways. Fevers of unknown origin. Night sweats without any focal symptoms. A solitary lesion in the brain. A swollen abdomen filled with fluid in an alcoholic with too many lymphocytes. The pericardial sack around the heart swollen with infected fluid and no bacterial growth.

I marveled at the disease’s variety, its trickiness. It would hide encapsulated by an auto-fortified rind for many years. Decades of normal healthy life would pass by as the bacilli created a shell and liquefied the tissues within so they could not be engulfed or attacked by the host’s immune system. Throw in aging, an innocuous viral infection, treatment with steroids or immuno-suppressants, however, and the long-dormant bacilli would become active. The TB bugs began to multiply and spread beyond their redoubt, usually in the lungs. HIV’s explosive entry on the international scene in the early 1980s brought many infectious diseases that were medical textbook curiosities, like a two-headed circus snake, into front-row seats. The HIV virus crippled a class of immune cells of its host. TB erupted on main street in a society that had temporarily banished it to the margins in areas of destitution, drug addiction and alcoholism, clandestine immigration, malnutrition, and economic vulnerability. The democratic HIV virus knew no such restrictions.

“Hey, Doc, TB, but also HIV?” added Officer Jones to make sure I understood the risks they had undertaken sitting ten feet from the hermetically sealed door of his room behind a small desk covered with the
Daily News
and the
New York Post
, thumbed beyond recognition. A fat green-lined notebook in which they recorded the comings and goings of life on the unit lay open. The medical issues were complicated but parsed out by our specialists into options A, B, and C as the gang member’s responses to the treatments and their interactions evolved.

“They travel together a lot. Wherever you have TB, you find HIV,” I said. “South Africa and prisons around the world—like Russia, for example. If you have the HIV virus, your immune system isn’t working fully, making you more susceptible to the TB germ. Most people who have TB don’t know it. They got it as a kid and it hides inside them until something damages their immune system and then it takes off.” Short course on TB for the guys in blue.

Swann interrupted one of the officers about to continue the commentary on TB and HIV infection. “Doc, he needs to be treated here for the entire time until he is cured, right? I mean the TB. You can’t cure HIV yet, right?”

“We hold the D-5s here until their TB is totally cured. Remember, D-5 was created for that tiny group of patients who don’t or can’t take their medications for the full course. Taking the medications intermittently also makes it likely the bugs will become resistant to the usual treatments, which by the way are not easy to tolerate. It’s a lot of pills to take. How many times do you guys finish a course of penicillin from your local family doc?”

No one answered.

“Like I said, if it’s the usual kind—sensitive to the tried-and-true pills—that would be a six-month to nine-month course. The HIV infection makes it a little more problematic since Beltrán’s own defense system is partially down. We will have our AIDS group come around and help with that decision.” They were doing some mental arithmetic trying to figure out his remaining days at Bellevue.

By this time everyone was more relaxed. The infections were scary to
the cops whatever their grade. Their Glocks and the weapons strapped to their calves wouldn’t help, and they knew it, so everyone’s fears were operational here. Wearing black rubber gloves was one thing, part of their modern culture post-HIV. With an invisible respiratory pathogen and a virus like HIV, all bets were off from their point of view. They were counting on us to keep them safe. The air filtration, the tight masks, the antibiotics in combination, the tests and X-rays were what was going to protect them and their families.

The officers did their shift switch as I put on a mask to enter Room 36 on 7 West. I looked like a cartoon version of a
Star Wars
Imperial stormtrooper.

The mask fit snugly over my lower face as I pushed open the door to the negative-pressure room. I wasn’t worried about the TB. The little I knew about the patient I was going to meet made me queasy. Gangs, narco-trafficking, hit for hire, Central American military to the United States? Like a puzzle turned over on a table, the pieces scattered everywhere. The air circulated multiple times a minute then was vented out of the building and diluted in the New York City air. There were ultraviolet lights in each room delivering lethal frequencies to the DNA of any errant airborne bacilli.

Beltrán looked up from
El Diario
as I came in with a whish of the door. He was midforties, fleshy, full-faced with a mustache and thinning black hair slicked back with pomade on his large head. He wore pale blue pajama bottoms and hospital-issue slippers. His upper body was swaddled in white bandages. He had an empty can of Pepsi and some take-out Chinese food containers on his bedside sliding table. Chopsticks stuck out of a white take-out carton of partially eaten brown rice that was already turning black at the edges. It attracted a fly that had miraculously made it into the air-filtered room.

“Beltrán,” I said, and then introduced myself. “How are you feeling? Any pain, fever better, breathing, cough, sputum color, moving around okay?”

“Señor Doctor, I could use some more pain medicine. It is hard to cough with the stab wound in my side and my ribs cracked by the surgery. I can barely move.” His accent was not Mexican, that was clear.

“I will talk to the nurses and see when you are due for your next medication dose. You got a narco tablet just an hour ago. It should be fine now. You are two weeks post surgery,
verdad
?” He smiled and realized I had gone over his records in some detail, so we could skip the games like conning me for extra pain pills.

“Where are you from? Your accent is not Mexican,” I stated matter-of-factly. “Guatemala?”

“You have a good ear,
jefe
,” he answered, looking at me carefully, as if I hadn’t had a blue mask covering half my face. “I was born in Alta Verapaz near Copán.”

I knew a little about his hometown—a place where many Germans had settled in Guatemala in the nineteenth century looking for business opportunities in the flourishing international coffee business. A couple of hours north from where my patient Soraya had grown up and ultimately fled in horror. A friend of mine, Father Ricardo Alemán, had spent nearly twenty-five years in that area until the day he was notified by the Vatican that he was on a death list. He was in Guatemala City on some personal business when an albino man in dark glasses came to his hotel, handed him an airline ticket to Newark, and drove him directly to the airport. There were two Uzi-armed bodyguards in the backseat. His infraction was being a liberation theology Catholic priest suspected of “supportive attitudes” toward the “communist insurgency.”

The military was after him. Copán had been and continued to be a very dangerous area. Alta Verapaz bordered Chiapas, Mexico. It was
Ganglandia
, infiltrated by narco-trafficking and immigrant kidnappings, and in a permanent state of low-grade civil war against its own population of Mayan and Ladino or mixed-race Highlanders.

The room was spare and reminded me of the bare prison cell of a hotel I had stayed in near Rabinal in Guatemala south of Copán. Diana and I had gone to the festival of Rabinal Achi that occurs every January, and there were no hotel rooms to be had. In the pre-Columbian drama, a warrior from an invading Mayan tribe is captured by the Achi Mayans and offered his life in return for marrying one of their princesses and becoming an Achi. He is given a year to travel on his
honor and think over their conditions. He returns a year later and refuses the offer of life with forced/voluntary conversion. He is sacrificed according to the terms of the agreement. He was respected as an honorable warrior. And he knew he would die when he was captured. A little different from the post-modern narco-violence that percolated into the U.S. newspapers, offering scenes of tortured policemen and heads stitched up as soccer balls.

“So, Beltrán, tell me how you ended up in Manhattan getting Chinese takeout? A guy from the boonies of Guatemala?” I teased him from underneath my mask. My wife and I had been obsessed with this part of the world for decades. Diana spent months every rainy summer in San Cristobal, Chiapas, working with Tzetzal-speaking Mayan women. We had a deep history here.

“It’s a long story,” he said, debating whether to put down the newspaper.

I didn’t have to tell him he would be our guest for a long time.

Over the next few weeks we talked many times, and I pieced together a story that may or may not have been the total truth—in fact, I was sure it wasn’t, but the truth for this guy may never be known. He had lived a life of disguises, of hidden lives inside of hidden lives. He had molted identities so many times, he might not actually know which one was which at any one time. The identities were adaptable and served as survival tools depending on the circumstances.

My familiarity with his childhood haunts and even some of the characters in his community, including Father Alemán, whom he regarded as a wonderful human being however misguided he must have been—“Perhaps naive, Doctor?” was the way he put it—gradually made it easier for him to talk to me. The hours on the unit went by slowly for him. He was not a difficult or complaining patient. In fact, because he was a “special” guest of the city or federal government, he had cable television, a cell phone that received incoming calls only, and access to unlimited take-out food that he bartered to other patients for favors, cigarettes, candy, music, and other things, as I would later
find out. He had a loose-leaf binder next to his bed, filled with menus coded by country and cuisine. We were in Manhattan, after all, the take-out capital of the free world.

One night Beltrán developed a raging fever of 106 with drenching sweats. He had been a model patient clinically, improving on schedule. Adhering to the textbook version of what was supposed to happen. His TB was being treated with a standard four-drug regimen. You always began treatment with multiple drugs to avoid the emergence of resistance, and then modified the combination under the careful eye of our HIV specialists so the medications would not interfere with one another’s pharmaco-metabolism. His T cells, HIV virus–infected, or CD4 count was coming up to normal. He looked so good that I had thought his lead doctors were overly cautious when they talked of a shoe about to drop. When I came in that morning, I had an email from our diagnostic prestidigitator warning that
B has a rash, looks like Pox to me!!! IRIS syndrome!!
The subtext was obviously
I told you so
. Chickenpox.

Chickenpox in an adult is no small thing. He was covered with a papular itchy red bumpy rash on his back and chest and was clearly miserable from muscle aches, nausea, a headache, and a temperature close to 107. The team had started him right away on intravenous acyclovir, an anti-viral medicine that was safe and effective in preventing complications not uncommon in adult men (with HIV and TB), and towels soaked in cool water. He was convinced he was going to die from chickenpox. Not the tuberculosis saturating every millimeter of his body. Not the HIV virus hog-tying his immune system. Chicken-pox!