Twelve Patients: Life and Death at Bellevue Hospital (38 page)

“Susanne’s father called her. He will be here tonight to see her. She just passed out in the hall. They called a code, for God’s sake. Fortunately Pam from cardiology was there before they put the paddles to her chest. She is almost catatonic.” I headed upstairs to meet with her on the unit.

So he was flying back to see his daughter. What did that mean? This case was operating on multiple levels, and all were increasingly complex. On the one hand we were coming out of a near-lethal trauma and a near-lethal complication. The medical part was starting to look easy, though, as the focus telescoped rapidly onto a family dynamic that was at first blurry and suggestive, confusing and yet increasingly worrisome for another kind of violence.

I wasn’t prepared for the possibility of uncovering a bottomless well of emotional trauma inside a fairly routine Saturday-night-special gunshot case. The fragments and loose ends flying around started to line up like iron filings around a magnetic field. “Can’t she block his visit?” I asked, starting to glimpse the outline. We found a niche to talk privately.

“She won’t block his visit.” Marion was back to her professional demeanor.

“Better to black out? Become catatonic?”

She gave me that look, the one that meant
We see this. It happens. Sometimes there is nothing we can do about it.

Marion had an intimate knowledge of the gravitational pulls of intimate violence and abuse. Years of working with the police department, social work, advocacy in professional organizations, and training the next generation plus thousands of emergency room visits had given her a critical third eye and an extra sense. The attachments could be so deep they completely defied sense, except if you spent your days and months in this world. It was children’s services, inpatient psychiatry, day hospitals, crisis intervention teams, addiction centers, adoption
agencies, family court, juvenile prison, and Rikers Island rolled into one. This was not just the Stockholm syndrome, but a Greek tragedy linked in a death-rattling spiral that contaminated everything around. “I don’t get it, Marion, what is real and what isn’t?” I asked her like an innocent.

“We ask ourselves as well. We go over it again and again. It looks like abuse and acts like abuse. Was there abuse a long time ago that ended? Once you start dissociating or splitting your personhood to survive, how exactly do you stop? It becomes second and third nature. Incest…” She stopped for a few seconds. We looked at each other.

“The ties that bind,” I said to her. “Can last for decades?”

She nodded. “The bonds that tie can last a lifetime if the person is undermined so badly. Real threats or even suggestions of violence and the cycle continues. The most we can hope for is that her husband can help her get out of it. The mother certainly hasn’t helped. Probably made matters a lot worse, in fact.”

Like broken shards from an archaeological dig, the outlines started to emerge over a series of interviews and visits over months after discharge and during Susanne’s physical recovery. The black hole at the heart of the family leaked a little light through its overpowering gravitational field, but never enough to let us know with complete certainty. Only the 99 percent kind of certainty you got from watching the shadow dance of people caught in a slow-motion drama.

The fog of memory sets in almost immediately. Stories change, events once clear become more confusing, time erodes details, time lines, and specificity. The outside world and its codes of conduct and rules of engagement implacably intrude like an unwritten law of physics. Every day squared becomes the distance to travel. It is not linear. Whether it is exploring the details of a bad event in a hospital with a dozen participants or carefully weighing the hints of a family in a four-alarm fire of distress, the window is open for a short time only.

The trail gets cold.

The name was familiar, Hugo Beltrán. Where had I heard it before?

We were in the middle of making patient rounds on 7 West, reviewing all the cases on the unit with the entire team, when his story came up.

“Hugo Beltrán is a forty-seven-year-old Hispanic male with TB and HIV, a D-5 who was transferred from 15 North Surgery one week ago today.” The resident, Don Liu, wearing a rumpled buttondown shirt, had been on service for a few weeks and was well versed in both his patients and the routines of this special locked unit. He had been up all night with a new admission hemoptysizing, coughing up blood, and had a casual way of presenting his cases without any sleep that belied a complete command of all of the facts. He made it look easy.

“Beltrán’s biopsy came back from pathology positive for tuberculosis from a partial lobectomy or lung resection specimen from his trauma surgery. His fever is down to ninety-nine degrees. He has no more night sweats, and his appetite is coming around. Asked me where he could get decent Chinese food when I made rounds this morning.”

“So what are we waiting for?” the chief said to the group. “Let’s get this guy home soon.”

“His home is on an island…,” the social worker Linda looked up from her clipboard and said matter-of-factly. “Rikers Island.”

“Everyone has a home. An apartment, a shelter, a cardboard box, the street, and even Rikers.” The chief did his half-smile thing, undeterred.

“Besides, they won’t take him back until he is not infectious, and for some reason he is a D-5 now, the highest level of detention for
tuberculosis. So he is ours until we say he can go home, whenever that may be.” Liu jumped back into the conversation. He continued.

“We are waiting for the AIDS team to come by and discuss when to begin treatment. His CD4 lymphocyte count is fifty-four, less than one-tenth of normal. Risk factors include unprotected sex with prostitutes, drug use but no needles, cocaine, marijuana, crystal meth, poppers, and alcohol. He was under DOC, Department of Corrections, but has been transferred to D-5 courtesy of the Department of Health and Hospital Police.” He said it again for emphasis. More complicated than the usual HIV-positive, TB-positive, homeless prisoner hallucinating about Jesus and the end of times.

Fragments of the case fell into place when Dr. Liu mentioned the DOC or Department of Corrections. Beltrán had been admitted a couple of weeks earlier, delivered by a screaming fire department ambulance to the Bellevue emergency room. He had been stabbed in the chest at Rikers Island in an “altercation” with another prisoner. From the trauma slot he had gone directly to the operating room. The collapsed right lung was compressed by blood accumulating rapidly in the pleural space that surrounds the lung like a slippery second skin. An emergency thoracotomy or lung operation had cost him a piece of a lobe and left a long clear drain coming from his chest into a bubbling water-filled plastic container hanging from his bed rail. The microscopic review of the specimen revealed rice-size nodules embedded like a hailstorm everywhere the pathologist looked. There wasn’t any untouched normal lung tissue. Mycobacterium tuberculosis or TB was the diagnosis.

I had barely seen him while walking through the surgical intensive care unit and recollected several corrections officers outside his room along with two New York City detectives in dark suits. The nurse mentioned to me that he was under a John Doe alias since the attempted murder had been gang-related. FBI officials came by for a private chat with a couple of us. Beltrán was in that netherworld between prison and a Witness Protection Program. Apparently he was an informant related to national-level gang activity. I hadn’t seen so much police activity since Son of Sam was in G Building, the Gothic psychiatry
monolith at Kings County. The Maras, the deadliest gang in the Americas, attacked him at Rikers. They would find out he wasn’t dead.

So his real name wasn’t Beltrán. He was recovering from the stabbing and the “incidental” biopsy showed widely disseminated tuberculosis, the miliary variety from the millet-size lesions. You could make it out on his chest X-ray as a gray haze where it should have been jet black. The CT scan showed golf ball–size lymph nodes surrounding his trachea and main bronchi along with the rice-size lesions peppering what lung remained after surgery. His drug screen had come back positive, and some astute history taking in the recovery room two days later made it clear he had plenty of risk factors for HIV infection. Consent was obtained, and his blood test came back HIV-positive. TB usually lived a quiet dormant existence for many years or a lifetime after an initial infection. HIV’s targeted destruction of immunologically active T cells brought it to life.

D-5 was reserved for patients who demonstrated that they were not compliant with their treatment through multiple treatment failures. TB treatments last from six months to two years, depending on the relative resistance of the strain. New York City had passed public health laws in the early 1990s when a TB epidemic surged from the confluence of immigration from vulnerable areas of the world with significant TB and the HIV epidemic that was celebrating its tenth anniversary. The public health detention laws were a last resort, implemented to protect John Q. Public from infectious patients who could or would not participate in treatment regimens. The reasons for screwing up on treatment regimens were many: isolation, mental health issues, fears of being deported, hostility to authority, drug or alcohol abuse, and the long-term medication compliance that a TB cure demanded. The bugs were killed by the TB antibiotics during their reproductive cycle, which was very slow compared with those of other germs. The laws were controversial; civil rights advocates butted heads with the power of the state. Even Typhoid Mary had not been incarcerated the first time she infected her customers. Only after she killed again did the authorities finally get wise and quarantine her on an island in the East River.

There were a lot of pieces missing from the unknown patient’s story,
but they would have to wait until after rounds. The team continued to go over the rest of the cases before we started walking and talking.

Chin continued the tour: “Mr. Thierry has paraspinal TB with two large abscesses that are drying up on treatment. He is receiving medications for toxoplasmosis—a germ often complicating AIDS infection, with a propensity for attacking the brain. His CT scan shows persistent lesions. He will be here for another few weeks. Still requesting narcotics for the pain. He’s a fringe guy, a vagabond who bounces around from Jersey to Connecticut to New York City. Has a long history of going from hospital to hospital.” Gratuitous comment for a D-5 patient, I thought. And they weren’t all vagabonds.

“Okay, let’s get the pain people by to see him. At least that will make him happy and get us out of the bad-cop-of-the-day role.” The head nurse usually didn’t say too much during rounds, but when she did the suggestions were on target. Patients on this unit stayed from weeks to years, and she and her staff lived with the patients 24/7. Angry, manipulative, antagonistic patients made the unit impossible to work on or provide decent care. She believed in negotiating and giving the patients what they needed if possible. Her philosophy was simple: If you were reasonable, the patients would be reasonable no matter their social challenges and backgrounds. She was proud that none of the staff on her unit had developed TB in almost twenty years—thanks to meticulous attention to protocols. She wanted to keep it that way.

There were several other patients on D-5 hold. Mr. Castro had an obliterated left lung, a whiteout on a chest X-ray from tuberculosis. It looked like a black-and-white photograph from your grandmother’s collection of a heavy snowstorm in Vermont. You couldn’t see any normal tissue at all. He also had heart disease and the merest suggestion of a lung tumor sitting in a bronchial tube. He was too weak to take care of himself. The main issue with this patient would be making arrangements with a nursing home after he was non-infectious. Patients were non-infectious after several weeks of treatment with three to four antibiotics. Itinerant Department of Health TB caseworkers would bring their medications to them several days a week. Long-term residential facilities were not enthusiastic about having even a treated TB patient
in their midst. We were held hostage to both staff’s and society’s phobias around AIDS, famine, and starvation, Russian prisons, and old novels.

I drifted down the salmon-pink hall with scraped orange bumper wall guards toward the cluster of guards outside Room 36, home to Beltrán. It was change of shift and there were two cops from the local precinct talking to two gentlemen with buzz cuts and off-the-rack suits. I came over and introduced myself.

“Heard about you, Doc,” said the senior police officer in a dark chocolate-brown suit half a size too small. I fished my business cards out of my pocket and handed them around. They scrutinized the rectangular card with minute attention. “Detective Swann, glad to meet you, Doc. Detective Keller.” He pointed to the other detective to his right. We shook hands. “Officer Jones and Officer Peralta here are just switching shifts right now.” We nodded.

“Are you guys all 13th Precinct?” I asked matter-of-factly.

“The two officers are, yes,” Swann said quickly. “We are from Police Plaza, downtown,” he added, to make sure I understood the command order.

Most of the time, we had an amiable relationship with New York’s Finest. We needed each other and never knew when something might happen. In essence, we were doing a lot of the same work for a lot of the same people. Being a first responder for humanity’s less-than-finest moments was challenging. Plus a hurt cop’s place of choice was our emergency room.

“Hey, Doc,” Officer Keller asked, “how long does this guy have to be treated? I mean so he is not infecting anyone around him? I mean so you can’t catch what he has?”

“You mean so you can’t get infected?” I got to his point. “Six months at the minimum if his TB germs are the usual suspects. We test for resistant bugs and will know pretty soon from the lab what antibiotics we are going with for the full treatment. We have seen some recent strange new TB strains in the Garifuna population from Honduras and Nicaragua who now live in the Bronx. With DNA extracted from the bugs, we can type where the strains came from. Just like what
your forensics techs do with DNA at the lab next door,” I answered quickly.