Making Rounds and Oscar (2010) (3 page)

I said one last good-bye to Kathy and realized that our association had come to an end.

"Take care of yourself," I said.

Kathy nodded as I left and returned to her thoughts, and to Oscar.

CHAPTER FOUR

"Cats are connoisseurs of comfort."

JAMES HERRIOT

WHEN I RETURNED TO STEERE HOUSE A FEW DAYS LATER
I found Mary seated at the nurse's desk brushing Oscar. Sprawled out in full glory, he looked like a boxer after a major bout--or, given his mane, one of those big-time wrestlers.

"The last couple of days Oscar's seemed pretty beat from his vigil," Mary said.

"Sure...sitting on a bed sleeping is really hard work."

"You laugh, David, but Oscar's always tired after the fact. It's like he's on the clock when someone is dying and then afterward he's spent."

I rolled my eyes, something that annoys Mary as much as it does my wife.

"Domesticated cats were like dogs, you know," she said, as she continued her ministrations. "They had to earn their keep on the farm. Maybe this is like Oscar's job."

"Well, I need to start doing my job," I said, opening a chart that I had spent the better part of ten minutes looking for. As any nurse or doctor can tell you, the chart you need is invariably the one that is missing. Anyway, I must have made it look awfully inviting because suddenly Oscar left Mary's side and jumped up onto the counter next to me. Then he twirled around twice before sitting down in a clump of fur on my paperwork.

"Will you look at that," I said in anguish.

"It's a cat's world," said Mary. "We just work in it."

I grabbed the chart out from under Oscar, who glared at me.

"You're gonna make me sit somewhere else, aren't you?"

Mary laughed.

"David, you never win an argument with a cat. Don't you know that by now?"

She got up from her seat and motioned for me to sit down.

"Here. I've gotta go down and see Ruth Rubenstein anyway."

"Anything going on with her that I need to know about?"

"I don't know yet, but Mr. Rubenstein wants to see me."

"Do you need reinforcements?" I inquired, drawing a smile.

"No, I think I'll be all right...but you might want to keep your pager handy in case I need you later."

As Mary disappeared down the hall, I thought back to the first time I had met the Rubensteins.

I LOVE MY JOB
, even though it's sometimes less than satisfying. Often I'm the bearer of bad news, the detective with the inconvenient truth. Too often the suspects work in pairs, covering for each other: mother and daughter a lot of the time, or, in the case of the Rubensteins, husband and wife. If they work together to keep me out of their lives--even when they come to me looking for help--it's because I'm the messenger, the one with the bad news. I'm the one who confirms what they often already know deep inside. There's simply no easy way to tell someone they have cancer, heart disease, emphysema, or any other horrible disease that takes so much before it results in death. But it's particularly hard to tell someone they have dementia, even when the person intuitively knows it already.

That's what I had to do with the Rubensteins some three years before. I had to look into the eyes of the eighty-year-old woman I had just examined and ruin her life. I knew from experience that her husband would be sitting with her, a deer-in-the-headlights look on his face. I knew this look and it said that I am their judge, jury, and executioner. To a certain extent, he would be right. I thought of the end of the mouse's tale in
Alice in Wonderland
: "'I'll be judge, I'll be jury,' said cunning old Fury: 'I'll try the whole cause and condemn you to death.'"

Earlier on the day that I first met the Rubensteins I'd been with Mr. Earl, a delightful eighty-five-year-old with few medical problems and a mind that ran at full throttle. During his physical exam he told me in great detail about the book he was reading. Then he regaled me with stories of his recent volunteer work with a local nonprofit and his plans to travel to Florida for the winter. When my exam was finished I sat down with him. Even though I was running a little behind, I wanted to let him go on for a few more minutes before I moved toward the door, the indication that our time was over. He took my gesture with good grace and apologized for taking up more of my time than he intended to.

"Mr. Earl," I said, waving off his apology, "I hope I am as healthy as you are when I get to be your age." I knew I wouldn't be--I already had more health problems in my thirties than he had--but I said it anyway.

He smiled. "I'm a lucky man, Dr. Dosa. The trick is eight hours of sleep, a healthy diet, and lots of lovin'!"

Who can argue with that?

Donna Richards, my office manager, confronted me as soon as I stepped into the hallway. She was looking at her watch and seemed a little frazzled.

"Are you done yet?" she asked.

I nodded.

"You have a new patient in room 3 who is getting restless. Her husband has already been out to ask where the doctor is. I've played interference, but you've got to speed it up."

I told her I was doing the best I could. Of all people, Donna should know how hard it is to appropriately care for older patients and give them the time they deserve. Her own mother was a patient in our clinic.

I grabbed the next chart and took a moment to look over some paperwork from another local doctor before I knocked on the door. The well-dressed couple I found did not look pleased. The man held up his watch and tapped it several times with his finger.

"You know, Dr. Dosa, our appointment was for 2:15 pm. You are twenty minutes late."

"Mr. and Mrs. Rubenstein, I'm so sorry to keep you. Please accept my apology."

Going to the doctor is not like getting your shoes shined and, unfortunately, there are times when other patients need my attention for longer than I anticipated. But I've learned over the years that explanations only make things worse. Simple apologies work better. Not in this case, though.

Frank Rubenstein was insulted, not on his behalf, I soon realized, but on his wife's. He was a gentleman of the old school, and rather old world, at that. I recognized his Eastern European accent as being not so distant from that of my own parents, and I thought I recognized the attitude too.

Concern takes many forms, I've come to learn as a doctor, and it's easier to recognize when it comes as a purr than a growl. Frank was like a papa lion protecting his lioness from predators, real or imagined. I posed no threat to his wife--I was simply there in front of them at the wrong time. What was really stalking her came from within.

Ruth Rubenstein, who was sitting across from him, seemed mildly embarrassed.

"Oh, Doctor, I'm so sorry for my husband's brutish behavior. I'm sure you have lots of other patients to attend to. Frank just doesn't like coming to the doctor's office."

She flashed me a disarming smile and then turned quickly to glare at her husband. He got the message; they'd been together long enough. As Ruth stared down her husband, I took a moment to look her over. She was neatly dressed in a long skirt and white blouse. She was strikingly attractive with blue-green eyes that radiated warmth. Her long silver hair was arresting, pulled back behind her ears with what looked to be an expensive pearl hairpin. Her skin still had a youthful vigor, and my first thought was that this woman still had it together.

I offered her my hand. She grasped it firmly and I was overpowered by her perfume.

My heart sank.

I moved in closer and confirmed my initial suspicion. Beneath the scent of her cologne I recognized the unmistakable musty odor of urine, a sign of incontinence.

I introduced myself again and asked how I could help them. Mr. Rubenstein launched into an explanation.

"Doctor, as you've probably figured, neither of us particularly want to be here, but I'm concerned about my wife's health."

He looked down at the floor, collecting his thoughts.

"I'm concerned..." His voice trailed off as if he was searching for a delicate way of telling me about his wife's problem.

"Go on," I said, nodding. He looked back at me, having found his voice.

"My wife has started to do some strange things. She loses things. The other day, she couldn't find her keys. She blamed me. Eventually I found them in the refrigerator with the groceries she had just brought home. She's also gotten lost a couple of times coming back from the grocery store. One time she called me and she was halfway across town."

He looked over at Mrs. Rubenstein, who acted as if we were talking about someone else. She just stared at the cover of the magazine in her lap.

Frank continued. He was likely the same age as his wife, although he appeared significantly older. He was dressed in a vintage suit, circa 1970. No doubt he was the original owner. His hairline had receded and whatever hair remained was uncombed. As he told me more stories about Ruth's memory lapses--the day she forgot to meet him for coffee or the morning she put the milk in the cupboard--I looked back over at Ruth. Now she was attending to his words, and if looks could kill, he was the one who would have needed medical attention.

When Frank finished speaking, I asked Ruth conversational questions geared at assessing her memory. She skillfully deflected many of them, often deferring to her husband. There's an almost symbiotic relationship between couples that have been married a long time; the Rubensteins were no different. When I asked Ruth to tell me about her favorite restaurant she responded by playfully asking her husband to answer the question.

"Darling, what was the name of that restaurant we ate at the other night?"

"The Golden Palace, Ruth."

"Yes, Doctor, have you eaten there?" she asked.

I shook my head no.

"You really must try it. We really love that restaurant. They have the best meals."

"What do you like to eat there?" I asked her, doing my Columbo routine.

"Oh, I like everything."

"What did you eat last time you were there?"

Ruth stared at me blankly. I imagined her flipping through her mental calendar and finding every page blank. Eventually she looked to her husband for assistance.

"We had the Peking duck, Doctor."

"That's right, the Peking duck." Ruth seemed pleased with herself, as if she was the one who had recovered the memory. "It was so good. You really have to try it."

I smiled and said I would. The conversation, however, was troubling. Despite her preserved social graces, it was becoming increasingly apparent that Ruth had some issues with her shortterm memory at the very least. Though she skillfully hid it by deferring to her husband, the more I continued to isolate her from his coaching, the more apparent it became. The simple memory tests I gave her next only confirmed my suspicions.

I gave Ruth a piece of paper and a pen.

"I'm going to ask you to draw me a large circle and pretend it is a clock. Please put the numbers on the clock."

It's a simple task that any grade school student should be able to perform, but Ruth struggled with it. Robbed of her husband's assistance, she painstakingly placed the numbers on the clock, pausing to consider the position of each one as if her very life depended on it. Perhaps, in a way, it did. After a minute, she looked up at me with a sense of accomplishment. Like a student proudly giving an aced test to a parent, she handed me the piece of paper. I looked down at her work and noted that the numbers one through twelve had been placed correctly on the clock. Then I handed the paper back to her.

"Now I want you to draw the hands on there at 2:45."

My request was met with a concerned smile. Ruth's eyes drifted up toward the clock above the doorway. She studied it momentarily before speaking.

"Doctor, I don't know how any of this has anything to do with me. I'm fine, really. I don't know what my husband is going on about."

"Mrs. Rubenstein, I know it seems silly, but the test can really be helpful to me in figuring out what is going on. Could you just place the hands of the clock at 2:45, please?"

Ruth sized me up.

I refused to back down.

She looked back at her drawing and shook her head, as if frustrated by the inconsequential nature of my request. She considered the numbers on the page.

"What time do you want?"

"2:45."

Over the next minute, the mental strain of the activity became more obvious. She tapped her pen on the paper. Intermittently she broke the silence with nervous laughter.

"I was never really good at math," she announced. I didn't have the heart to tell her that the task had more to do with visual-spatial skills and executive function than math. The clock test is standard for just that reason: If you can do it, the chances are excellent you don't have Alzheimer's. It's also a highly significant indicator of how you will do on the road. I wish the DMV would give this test along with the eye exam.

I waited patiently for Ruth to finish. Finally, after several minutes, she drew the little hand pointing to the 2. Then, like thousands of other patients with memory impairment, Ruth placed the minute hand of the clock between the 4 and 5, rather than at the 9.

Convinced that she had once again aced her exam, Ruth looked up at me with a sense of extreme satisfaction. As I looked over at her husband, it was apparent that he didn't share her enthusiasm. A tear had come to his eyes, which he quickly wiped away before it could find its way down his check.

I then launched immediately into another battery of memory tests without saying a word about her performance. She seemed momentarily disappointed by the lack of feedback, but there is nothing much that I can say in that situation--nothing that the patient wants to hear, anyway.

"All right, Mrs. Rubenstein, I'm going to say three words and ask you to commit them to memory."

I recited three words--
apple
,
book
, and
coat
--and asked her to repeat them back to me. She remembered two out of three. Five minutes later, she would almost certainly remember none.

I asked her to spell a five-letter word,
world,
forward. She did so, quickly and precisely. A smile that said "I told you there is nothing wrong with me" appeared on her face.