Map of life expectancy at birth from Global Education Project.

Sunday, December 10, 2006

Slacker Sunday, a repost

(I'm not really a slacker, I just did the Today in Iraq post, but this seemed timely. Tanta wondered whether an experience I had in the hospital when I was young prompted my interest in physician-patient communication. No, not really, but an experience I had when I was hospitalized some years later did contribute. For background, I had emergency abdominal surgery for what turned out to be a solitary cecal diverticulum, which the surgeons at first thought was cancer, and they acted accordingly. I first posted this in August, 2005. This is a very long post, sorry.)

People are Strange, When You're a Stranger

My roommate, Mr. Karasik, wandered past my bed a few times on his way in and out of the room, pushing his IV pole. Mr. Karasik would stop and talk to me brightly in Russian, holding the pole with one hand, gesturing expansively with the other. I obliged by replying in English. "Yes, the latest red-shift survey certainly does imply a young age for the universe," I might have said.

Mr. Karasik appeared to be in his fifties. He was rather overweight. He wore the obligatory posteriorless smock, and paraded his naked and excessive buttocks without shame. Some exotic injury or disease had caused his lower extremities to be pitted and darkly mottled. Not surprisingly, since he could communicate with no-one in the hospital, he spent much time on the telephone. He seemed happy and healthy; he had not yet had his surgery. But as we were in a surgical ward I presumed his time would come.

I gathered from overhearing what Mr. Karasik could not that he was not in fact healthy. My doctors did not visit him on their rounds; it was a different gang. The leader said, "This man is a pulmonary cripple." Mr. Karasik had Chronic Obstructive Pulmonary Disease. He also was suspected of having bladder cancer. They brought in a translator at one point to talk to Mr. Karasik about logistics, for example that he could have nothing to eat or drink, but no-one told him anything about his condition or prospects.

The next morning Mr. Karasik had surgery. He came back making a lengthy discourse on what I took to be the subject of physical agony. Occasionally he would yell out in real pain. I could not see him as a curtain separated our beds, but it was enough to hear what went on. Nurses would rush in and grotesque activities would follow. They were somehow "irrigating his bladder", which from the sound of it caused gallons of water to drain into a bucket. The objective was to extract blood clots. It was the "long, ropy ones" that caused the major trouble.

Just after midnight Mr. Karasik had his worst attack. Nurses rushed in, followed in a few minutes by doctors. They shouted orders and vital signs at each other. More nurses rushed in pushing equipment. Doctors would ask Mr. Karasik questions, and when he didn't understand, they would ask again, louder. Then they would yell at him. Gallons, barrels, acre feet of water gushed. Mr. Karasik shouted in pain, discoursed angrily in Russian, then muttered and moaned. They called a translator who yelled at him in Yiddish, until she determined that he spoke only Russian. People cursed the hospital for admitting "these people.” Finally the crisis subsided. The Doctor in charge said, "I think he had pain from a clot and he vagaled. He just vagaled."

He never vagaled again, but he started to piss all over the floor as soon as they took his catheter out. I didn't hear them warning him about this -- in fact, I don't think they brought in a translator all week -- and they certainly didn't do anything about it. I discovered it (the hard way) on one of my hourly trips through his half of the room. (By this time, I had severe, relentless diarrhea – more on that later.) I called the nurse to see if we could get it mopped up, but apparently it was the wrong time of day to expect any mopping. When someone finally did come, they didn't mop the lavatory. "Oh, they won't go in there," said the nurse. I didn't blame them, frankly, but I had to go in there, twenty four times a day.

The next day a nurse (who I had never seen before) wandered over to Mr. Karasik's side of the curtain and started telling him, in English, that he was discharged. "You can go home now," she said. He answered in Russian, uncomprehending.

She spoke more loudly. "You can go home. This is a taxi voucher. The taxi will take you home. Here are your clothes," and so on. As he continued, stubbornly, to refuse to understand English, she just turned up the volume. Finally concluding that deafness was not Mr. Karasik's problem after all, she strode out indignantly.

Thirty minutes later she returned with a translator, an earnest young man. The dialogue which follows is reconstructed – put it in Janet Malcolm quotes. But this faithfully represents its essential substance and spirit, to the best of my ability. As I am ignorant of Russian, all speeches in that language, regardless of length or dramatic subtext, are represented by ellipsis in brackets, thus: [...]. Where not credited to a character, the ellipsis represents dialogue between Mr. K and the Translator.

Nurse: Tell him he's going home now. He can give the cab driver this, he doesn't need to pay for the cab. This is his prescription. He needs to get dressed and we'll take him downstairs.
Trans: He wants to know, will anyone tell him about his surgery, what was the result and what it will mean for him, and so on?
Nurse: Whatever the doctors have told him, I can't tell him more than that.
Trans: He says the doctors haven't told him anything, he really doesn't know what's going on.
Nurse: Oh for chrissake.

Exeunt nurse and translator. Thirty minutes later, they return, accompanied by an intern.

Trans: [...] Dr. Peachcheek [...]

Dr. P: Well, he has bladder cancer. We took out as much as we could through the urethra, but we just can't get it all that way.
Dr. P: Unfortunately, it will continue to grow. We think, in three to five years, it will be fatal.
Dr. P: We can't operate to remove his bladder because he has chronic pulmonary obstructive disease, and he couldn't survive surgery.
Trans: He wants to know, when the tumor grows, can't you scrape it out again as you did this time? They did it before in Italy, if you can just keep doing it...
Dr. P.: (laughs nervously) Well, eventually he will run out of bladder wall.
Trans: You mean, every time you do this you use up some of his bladder?
Dr. P: Yes. I mean we could do it again but it would be futile. He will only live for so many years, and we cannot get rid of the cancer ...
Trans: He says, what about the possibility he has an adenoma? In Italy, they told him it might be cancer and it might be an adenoma, that would be something different...
Dr. P: (surprised) An adenoma? Well, no, no it really doesn't seem to be an adenoma.
Trans: In Italy they told him perhaps it could be treated with radiation or chemotherapy, is there any possibility you could try some of these things they discussed with him in Italy?
Dr. P: Well, I mean those things could be tried, but I mean ... well, it just would be futile, we can't do surgery to remove the bladder...
Trans: He says for two days his right leg above the knee has been numb, he has no feeling here on his thigh ...
Nurse: Oh for chrissake.
Dr. P: Well, let me see. (sounds of bodies repositioning) Okay, now I'm going to touch him with my pen, like this. He just needs to tell me when he can feel it.
Trans: [...]
Dr. P: Hmm, Hmmmm.
Mr. K: Da......... Da.
Dr. P: Okay, I'm going to get a neurological consult on this.
Trans: [...]
Exeunt translator and medical personnel. Enter new Doctor, trailed by new intern, nurse and translator.
Intrn: I've been able to find out a little bit about him. He's a fifty-five year old factory worker, and lives alone. He says his legs have looked like that for twenty years.
Doc2: I understand from Dr. Glomerulus that he is a commercial airline pilot. Alright now, tell him this is sharp and this is dull. He is to tell me what he feels, whether it feels sharp or dull.
Trans: [...]
Mr. K: (We all get a quick lesson in the Russian word for sharp and dull.)
Doc2: Well, this is something we see in patients with circulatory problems. You see it maps very cleanly here, this represents damage to the freeblemeyer nerve. It may have happened from lying on his side for too long. It may improve, in time, but usually it will not. He may feel some tingling or it may feel very cold.
Trans: [...]
Enter Translator and nurse.
Nurse: Alright, he's been discharged, he has to go now.
Trans: He says he can't hold in his urine. What is he to do, he can't get in the cab like this.
Nurse: Oh yeah. Well this is normal after the type of procedure he's had, it will improve in a few weeks. Uhm, we can give him absorbent pads, like diapers.... Excuse me.
[exit nurse]
[enter nurse]
Nurse: Here.
Trans: He wants to know what he's supposed to do with them.
Nurse: They just fit into his underwear, he just puts them in his underwear.
Trans: He is concerned about going out, if he is out of the house for a long time will he be alright like this.
Nurse: Look, my shift is over, I've gotta get out of here. Oh alright. There's another system we can give him, hold on. (exit)
enter nurse, with apparatus.
Nurse: Okay, this goes over the end of his penis like a condom, okay? Does he know what a condom is? Then he has this bag around on the side of his leg, you see, with this garter belt-type arrangement ...
Trans: He want to know, won't there be a bulge, won't it show?
Nurse: Well it's up to him what he wants to do. Anyway, tell him he shouldn't use this when he doesn't have to. He needs to try to control his urine; his control will only come back if he works at it. If he relies on the apparatus he won't improve.
Trans: He says what about his drugs, can't he have his prescription filled here at the hospital before he goes?
Nurse: Oh for Chrissake. Look, we need the bed, there's somebody waiting in the ER for it and I don't have time for this, he was supposed to be discharged this morning. This is really getting ridiculous.
Trans: It's hard for him, he doesn't speak English.
Nurse: Alright, does he have his Medicaid card?
(nurse exits; returns in fifteen minutes with drugs)
Nurse: I had to lean on the pharmacy to get this sent right up. I'm out of here. Goodbye.
(exit nurse. Translator and Mr. Karasik exit a few moments later, conversing in Russian. CURTAIN.)

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