Twelve Patients: Life and Death at Bellevue Hospital (49 page)

I smiled and said, “Just what Osama was doing when his uninvited guests landed in his compound. Complaining about low oil prices to bankrupt the decadent capitalist West while downloading porn to his hard drive.” Javier smiled and nodded in agreement as he dipped into the slurry of curries, tandooris, and raitas with a mound of hot garlic parathas.

We went back in time. Javier knew he only had a short interval in New York before he would be shipped out again for at least six months off the grid. “I was making some really stupid mistakes as a teenager,” he said seriously. “The easy money was drug-related. You started as a runner or a lookout and then graduated to selling stuff. Everyone did it. Remember, there was no other employment in our neighborhood. The hood, remember.” I looked at him and listened. “I went to six funerals during middle school and high school before I bailed out and enlisted. Six. All shot to death, guys my age within a year or two. Very simple stuff. Drug-related killings, revenge killings, innocent-bystander killings, stray bullet killings. Does it really matter? What they call ‘collateral.’ In my current line of work that is what they call people killed who are not supposed to be shot. Collateral.”

“You know, Javie, you made me just wonder how much of what we see here, I mean at the hospital, is what you call collateral damage. Policies gone amok, unintended consequences, good programs highjacked, incentives distorted beyond recognition?”

He continued: “The U.S. government apologizes, sends cash to the families, pays off the sheik in charge with more boatloads of cash and an SUV. Not that much difference between the South Bronx and South
Waziristan, Doc. I have helicopter gunships and drones directed from Nevada by video game–trained pilots in case things get too hot. Would have been handy on the Grand Concourse on summer nights when I was fifteen. Drone to Pelham Parkway, drone to Willis Avenue Bridge. Come in, drone.” He took a breather and looked around the restaurant filling up with taxi drivers. The delivery guys were all young Mexicans loading up their bicycles chained outside to a “No Parking” sign.

“So the only way out of the hole and not be in a body bag is to enlist in the military. You still get a body bag, but your mother gets a folded flag, you get a burial site in Washington, and a little cash flows to your ‘contingent beneficiary.’ ”

He looked at me as he was mopping up his plate. The horde of cabdrivers had left with their takeout to say their prayers on the sidewalks on small colorful rugs they kept rolled up in their trunks.

“It is all about respect, Doc. One hundred percent respect and its polar opposite, disrespect. If the guys feel disrespected, then it is warfare. You carry your attitude with you at all times and show no feelings and no weakness, none whatsoever at any time. The price is too high and you learn it when you are in
pañales
, diapers. Excuse my language, Doc, pre-military training for illustrative purposes only, you fuck up and that is it for real. It is school on the streets. That is why the military is not that hard. If you survived and graduated from the University of the South Bronx, then what exactly is so tough to learn about advanced weaponry and survival skills? Especially when you have billions of dollars of backup, equipment, gyms, McDonald’s and Cinnabon shops, bowling, plus air-conditioned tents in 117-degree desert and everything else you want and don’t need. Turkey and gravy for Thanksgiving. Stuff you never had and never thought you would have unless you were a drug entrepreneur. The workforce handing out your burgers and fries, ironing your socks and underwear, are conscripted from all over Southeast Asia. They jump on board to work in a combat zone to make some ready cash to send back to Bangladesh or the Philippines. They spoke better English than the guys in my battalion.”

He slowed down and finished his lunch. Rain clouds had moved in and big fat drops were hitting the metal overhang, pinging hard. Then
a torrential downpour hit. We had the window open and were splattered from the backsplash but enjoyed the gusts of fresh air through the window, the smell of the rain, folks hustling to find corners to hide in and overhangs filling up. The cabdrivers had rolled up their rugs, opened their trunks in unison, shut them, and were slowly pushing off in their yellow cabs one by one, knowing a guaranteed time to get customers was during a downpour in NYC.

The rain eased off to a steady drizzle. We did not talk for some time—just listened to the drops, the clatter from the kitchen, and the Urdu, Hindi, Punjabi, and Arabic that filtered from the other room.

Javie continued. “For me it is about knowing when to get out. I just need to learn my languages and get out alive. Being a black op is not a marketable skill if you want an ordinary life. It’s about risking your life for skills without getting killed or addicted along the way. I learned that much from my dad. Not in lectures, but his life and the decisions he made. And how he got trapped and played by the system.”

“Javie,” I interrupted. “Your dad, why didn’t he finish his treatments?”

He looked at me and took a moment to answer. “Doc, when we finally drove him home, I carried him through the apartment door and put him into his own bed. We had made it up with his favorite
bachata
CDs within reach and pictures of family and friends from his lifetime. My dad made it clear he was not leaving again. There was no discussion about it, he made up his mind.

“Mom and I knew he hadn’t completed the treatments. I think between radiation, the chemo, the plastic stomach tube, and being locked up he had finally come to a decision about his life. He was in another zone and we only tried a couple of times to get him back to the hospital. My mom and I knew. He wanted to die in his own home. He ground up a handful of pain meds, put them in his feeding tube one night, and went to sleep.”

I understood. I’d had the same illness, the same radiation and chemo. As the weeks passed I was less convinced that I could complete the regimen. And if I did complete it and the tumor came back, there
were no other treatment options. It was morphine and palliative care. Like Juan Guerra, I had silently designed my escape route—I would end my life myself—if the treatment was not successful. Which gave me some satisfaction and a measure of relief.

When at one point I refused further treatment, only my wife’s tenacity could override my choice. Still, I understood why Juan Guerra’s family did not feel they could or should do that.

We said good-bye on the sidewalk and headed in different directions back to our own lives.

The swirl of people at the Bellevue shift change had the feel of Grand Central Station when I pushed through the revolving doors into the glass atrium. I nodded and waved my way through the crowds and headed toward the emergency area. I went out the ambulance bay doors with some physician colleagues to catch up. Things changed so fast, even an hour made a difference. The depth of the cuts and layoffs was on everyone’s mind. We finally fell silent as the last cumulus clouds fled the city riding the rainstorm’s easterlies.

The glinting early-evening light sliced in from the west, riding small particles and exhaust fumes in the narrow crosstown gap, like a clean scalpel cut that ran from the Hudson River to the East River onto the emergency room ambulance bay. We stood outside, our backs against a warm white concrete wall, looking east across the tight fresh asphalted zigzag to the metal-and-plastic overhang and automatic sliding doors that led into a small sea of stretchers. Then more sliding doors and the pantomime bustle of inaudible women and men in blue, green, and tan scrubs performing indecipherable rituals with prostrate bodies on stretchers. It was the end of summer minus the asphyxiating heat, humidity, and Con Edison brownout alerts. A few minutes to chill and huff the gasoline.

The ER bay was yet another stage for nonstop activity. Bright orange, yellow, and green hard-plastic trauma backboards were propped against a wall like surfboards outside a café on a California beach. A scrum of boxy FDNY ambulances were backed into the unloading bay, facing outward three abreast in uneven rows, as they unloaded their human cargo, scooting their steel stretchers with their charges wrapped in white sheets. A pair of emergency management technicians navigated
the shoals and chutes with dexterity like double kayaks around parked ambulances. Pairs of drivers were waiting in the cabs with their engines on, the AC running, for the last to arrive to complete their paperwork and clear an exit lane. Gridlocked into a small space, they chatted, smoked, and flirted in their dark blue uniforms. A tall EMT with a graying ponytail to his shoulders came around the side of the post-9/11 decontamination showers covered in amber-colored glass zipping up his fly and adjusting himself after urinating like a dog against a wall only partially hidden by his cab. He looked around to see who had seen him, was satisfied, and walked into the emergency room.

Clumps of Orthodox Jews with knotted tzitzis poking from white shirts over their black pants chatted in groups scattered around the lot. Some smoked, some gesticulated. A group near me talked animatedly in Yiddish. I could make out the “oh fuck” and “shit” amid the guttural German-Hebrew mixture from one overweight thirty-five-year-old emergency worker from Hatzolah, the Orthodox community ambulances. He danced small circles as he pointed with his right index finger and raised his voice decibel by decibel. Black-bearded senior community members wearing finely tailored long black coats that fell below their knees arrived to the ambulance bay on foot from First Avenue. Their plastic IDs were clipped efficiently to their lapels. They nodded at me and walked through the doors past the huge black guard slouching over his beat-up wooden lectern like an old-time Southern preacher about to raise his audience of mute stretchers like Lazarus from lethargy and slumber and sin. An elderly member of the Hasidic Orthodox community had been hit by a truck near the Williamsburg Bridge in Brooklyn. The Hatzolah ambulance arrived within a couple of minutes and screamed its way across the bridge and uptown. The patient expired on the way, bleeding out from internal injuries, ripped blood vessels, a tear in his liver, and a ruptured spleen. His heart had stopped on Delancey Street. We could see it on our monitors and our BlackBerrys as it went flatline. A modern-day app for a post-modern world. Death is a flat line regardless of the medium.

The community was turned inside out for another reason. Any death was important and resulted in the arrival of rabbis with beepers
and double-barreled smart cell phones. Rabbinical interlocutors interpreted for the closed Orthodox communities and the outside world. These Orthodox communities descended from rabbis who came from the Pale of Settlement of what is now Russia and Poland. These huge reservations had been transplanted to Borough Park, Brooklyn. A young boy had been kidnapped and murdered by a member of the community. The unmentionable and incomprehensible had happened. A Jew had killed a young Jewish child. After smothering him, the alleged murderer cut him into pieces, putting his feet into his freezer and disposing of the rest of the corpse in neighborhood trash bins.

It would be only a matter of two days before the alleged murderer was transported from Rikers Island to Bellevue Hospital’s nineteenth-floor inpatient prison units for a full-bore forensic psychiatric evaluation. Was he competent? Was he hearing voices? Command hallucinations from passersby, buildings, dogs, aliens, the CIA, hidden microphones, women, internal electronic devices, his penis and testicles, a uterus, invisible umbilical cords, tormenting him for years telling him to kill and in a sexual catharsis dismember? Were there other body parts in the backyard? Was he mentally retarded? Had he suffered childhood sexual abuse and now begun recycling the shame and excitement? Did his media habits predispose him to acts of violence and desecration? Had the boy been violated before being sacrificed to a wrathful God? Would his urine tox screen be positive for crystal meth and a cocktail of drugs? We had been through so many varieties of human illness, suffering, and depravity it was startling to realize that there were forms and varieties we had not seen, that could still penetrate the formalistic gaze of the professional forensically trained physician.

Overwhelmingly these patients had been severely abused and deprived as children, humiliated, neglected, and disrespected to the point that they were dead souls. It was part of the script loaded against them that enabled us to see victimizers as part of humanity even though they had lost their own. My first night in charge of the emergency room at Kings County in the mid-1970s, a call came in. A man had bludgeoned his wife and three children to death with a baseball bat and then attempted to disembowel himself with a steak knife. We were scoffing down a pizza
and Cokes between physical exams and suturing cut tendons from an orgiastic Kristallnacht in the hood during a citywide blackout.
Do you walk or run to save that life?
we asked one another.

Back inside, I put on my scrubs and wound my way to the operating rooms on the eleventh floor to talk to the organ teams. Three nurses were hunched over a computer screen, chatting, and they turned around when the door clicked shut. The schedules were being updated for tomorrow’s cases. “She is in Room 14,” Jo said when she saw me. We were short both nurses and anesthesiologists for what would be at least eight hours in the OR if not more to harvest Miriam Kaiser’s liver, her two kidneys, a pancreas, the small intestine, both lungs, and the heart. The liver would be split, one lobe for a child waiting in New Jersey and the larger lobe for an adult in the Bronx. There were eight operating rooms going strong. Two for orthopedics—a pelvic fracture from a fall and a cleanly broken femur in a young Asian guy whose in-line skates were not meant to go off a five-foot stairway when he lost control. An expanding abdominal aortic aneurysm in a middle-aged smoker with hypertension had cut off the circulation to the artery supplying his intestine and he was back in for a “second look” operation to make sure the surgeons had removed all of the dead gut.

The neurosurgery room was wheeling out one patient after treatment for a subdural hematoma he’d suffered from a fall while taking blood thinners for an erratic heartbeat. Anti-coagulants to prevent a blood clot had made him susceptible to a random bleed. The pressure was on to turn the room around quickly for another patient with a blood clot in nearly the same location from head trauma incurred when a drug deal had gone sour. The heart room had an overtime second case. The heart of a young Senegalese woman with undiagnosed mitral valve disease and fluid in her lungs had flipped to chaotic atrial fibrillation from the increased fluid load of a third-trimester pregnancy.