[img_assist|nid=843|title=Mountains of the Sun by Gregory Dolnikowski © 2008|desc=|link=node|align=right|width=150|height=201]I found the two carbonless message slips on my desk after the last patient. The first was the transplant team wanting me back to consult on Carl Lawson’s fevers. The second was an email address for Bobby Schmidt. When keystrokes failed to pull up any Schmidts I’d seen in medical records, I stared at my partner’s wilting bromeliad and reread the message; some things were as simple as water. This wasn’t Bobby Schmidt, patient, this was Robert Schmidt, old boyfriend.
I pulled on my white coat for the trip to the transplant unit and stuck the message in the pocket with my prescription pad. The late afternoon sunlight made the June day feel young; I’d do the consult tonight. Carl was a frequent flyer on the transplant service with two kidneys under his belt already. My job as infectious disease consultant was straightforward: repeat all the abnormal tests the other doctors had thought to order, spot the ones they hadn’t ordered, and make sense out of it all
Rob hadn’t believed I was going to be a doctor until he had seen The Cell on my bookcase. Before I started medical school, he was cloudy and beautiful with messy black hair and a recent drunk driving acquittal. He wondered how there could be an entire book devoted to the cell. After reading different books devoted to biochemistry, physiology, and pathology, I diagnosed alcoholism.
“Hey, doc,” Carl Lawson called from his hospital bed, “how’s it going today?”
“Same old, same old,” I replied scanning the most recent the chart notes. “What’d they put you in for this time?”
Carl shrugged the same shrug he treated me to every admission. If someone asked me how much longer Carl and I would play this game, I would have shrugged too. The fluorescent lighting did nothing for his stringy hair, nicotine-stained fingers, and the yellow-grey cast of kidney failure on his skin. Carl had a genetic disease that slowly destroyed his kidneys, but his bad boy substance abuse had landed him on dialysis before he turned thirty. For two years he managed to clean up his act and pass blood and urine tests for all sorts of illicit drugs while the transplant doctors hunted for the right donor kidney. As soon as Carl felt well enough after the transplant to start raising hell again, his kidney function deteriorated. It was back to dialysis and a second kidney transplant three years ago.
More recently, Carl developed an abscess from a nasty, resistant bacterium. Despite triple antibiotics that were damaging the transplanted kidney, his fever still raged. I was running out of suggestions. If the fevers persisted, we’d get a CT scan and see if there was anything the surgeons could drain.
I wrote a brief note on Carl and moved the message from Rob to my bag before heading home. He’d been the love of my life, but that monumental memory was a place I no longer visited. I hadn’t heard from him in a long time, and the last time he’d practically crowed about an auto accident in which he’d lost consciousness and teeth. By then, I’d known a lot of patients like Rob. Sometimes they just hurt themselves, but I’d handed out enough tissues to weeping spouses, parents, and children to know that wasn’t true. After residency, I retreated to practice a specialty that examined the dark old corners of childhood vaccinations, travel, and sexual activity. I could usually blame a virus, bacteria, or maybe even a parasite. When infectious led back to anther person, no matter how close, the correct term was vector.
[img_assist|nid=147|title=Buttons by B.J. Burton|desc=|link=node|align=right|width=150|height=307]
As contributor to his own demise, Carl should never have been given a second kidney after he burned out the first. But a commitment to a patient was a commitment, and the renal team, like forgiving parents, kept crossing their fingers and betting on Carl.
Rob, with his self-destructive habits, was no better than Carl. When we had dated, he was almost as pale and thin as Carl was now, and I could count on one hand the number of times I remembered seeing him eat. He drank in bars, at clubs, and surreptitiously on the steps of the D.C. monuments that blazed against the night sky. In my medical opinion, Rob should have been burnt out, dead, consumed by sadness, anger, and, I might once have been able to believe, by love.
On the drive home, I remembered Rob’s sweet kisses, the result of alcohol dehydrogenase metabolizing alcohol into the fruity acetaldehyde until my pager silenced the thought. The floor nurse reported that Carl had thrown his low protein/no-added salt dinner across the wall nearly hitting the woman who laid the dinner trays. I reminded the nurse that I was the consultant for Mr. Larson’s infection; she would have to call the renal service about his diet order. While she was at it, I told her she should probably call security and social services.
I ate take-out sushi with my family and checked email once more before heading to bed. Carl’s attending was scheduling a group conference to discuss the possibility of a third kidney transplant—a question of medical futility if anyone asked me. I ticked off the names of patients I knew who had died waiting for a kidney in the last five years and made a note to troll the medical literature for the rate of former addicts staying clean after transplant.
For Rob, I typed a doctor’s open question, “What’s it been, ten years?”
I found a delirious Carl on rounds in the morning. Overnight, his temperature had spiked to one-hundred-and-five. I recommended that the team request FDA permission to use an investigational antibiotic. The CT scan was scheduled for 2 o’clock. The nurse noted that Carl had been too sick to throw his breakfast tray or sneak off to the roof garden and smoke.
I didn’t get to my email until lunch. Nothing from Rob. He’d probably been drunk when he called and that would be the end of that. Carl’s transplant team conference wasn’t for another two days—if he lived that long. By dinnertime, his temperature was a little better controlled. He winked and asked why I wasn’t making quick business of this infection they way I’d cleared up “that first little problem.” I had to smile. If Carl felt well enough to bring up his gonorrhea, so be it. I warned him that even that bug was getting harder to kill with the usual antibiotics. He told me he’d keep that in mind and closed his eyes.
The face of this man with oxygen prongs in his blood-crusted nostrils and a central line in his jugular vein read pain, fatigue, anger, and hard use. The odor from his dressings was hard to ignore. Would this be how it finally ended? I’d given Carl up for gone before to spare myself work and pain. Who would be there to mourn him? I scrolled back to the social work consult in the chart that read:
Carl Lawson is a forty-two year old male well known to the transplant service with a history of polycystic kidneys, substance abuse, renal failure, dialysis and renal transplant times two. This most recent hospitalization is for a perirenal abscess with the same multi-drug resistant organism that infected his dialysis graft. Mr. Lawson lived in an apartment downtown until being readmitted. He receives disability and has limited social supports.
Over the years, I’d fleshed out a little more of the framework of Carl’s life—the long-dead disaffected mother, the two years of vocational school, and the long streak of boosting Hondas to support his drug habit. Carl had a sexual history a mile long, and I remembered a girlfriend floating around the hospital during his previous admission for fevers because we HIV tested them both. I couldn’t remember her name. On any given day, it was difficult to keep track of the medical information, let alone the personal.
What I didn’t know still drew me: why and when did Carl start using? How did he manage to stop for two years before the transplant? Where was the rest of his family?
That afternoon, the transplant surgeon who jealously guarded his patient survival data, took Carl back to the OR to open up the old dialysis graft site in his arm and the transplant site to debride infected tissue. We loaded Carl with IV dilantin to prevent seizures, and instead of talking about his third kidney transplant at the meeting the next day, the renal fellow jumped all over the medical student chosen to present Carl’s last electrolytes.
“Has Mr. Lawson died?” the renal fellow said.
The student, who couldn’t see where this was going, blustered, “No.”
“Then these are not his last labs. They are his most recent labs,” snapped the fellow. “You’d do well to make note of the distinction.”
The student sunk into his chair while we discussed Carl’s code status.
I’d had low student days too. I spent the night I got my acceptance letter for medical school drunk on the kitchen floor with Rob. I had worked so hard for so long that I only felt sadness for the mountain of work and abuse I was finally privileged to face.
Carl went on to have another forty-eight hours of lab results and fevers before there was a reply from Rob. “Sorry to call your work number,” he typed. “That’s the only information I could find for you. I saw your story on the web. Are there more? You had a gift.”
Rob was digging into that ancient time when I’d written about a teen with typhoid fever back before the lives I cared for in the hospital seemed so fictional that all fiction froze. Once I’d been as interested in the patient who had the disease as the disease that had the patient, but the last few years with my patients, the cuts from the hospital, and my family’s move, I was barely surviving from one caffeinated drink to the next.
Before any transplant, patients talked with the team psychiatrist about chronic medications and risk of rejection, but no one talked with me about the night I sat next to Rob at the top of the cold marble steps of the Lincoln Memorial and he said he wouldn’t be seeing me again. I went home and would later read medical texts that offered prognoses for risk-taking males. When the pathology professor slapped a cirrhotic liver from the five-gallon canister of formaldehyde onto the lab tray, I touched the hard-knotted tissue and practiced professional distance.
Carl was one hundred-and-three and sweating and didn’t react to my gentle greeting or more robust examination the next day. The transplant team had asked social work to locate next of kin. I changed the protocol medication dose to accommodate Carl’s dwindling kidney function, and put my hand on his unbandaged one before leaving.
“Whatever chips you’ve got, Carl,” I whispered, “it’s time to call them in.”
I skipped the noon conference, went to the office, and shut the door. Dark clouds framed the hospital across the street. A thunderstorm seemed likely. Sometimes I knew when a patient was going to die. Sometimes I didn’t know, and I would go to the floor to follow up on a consult to find the bed empty and the name removed from the census board. Once I attended a morbidity and mortality conference when the disease and the patient’s initials matched a young kid I had really liked. I had rotated off service, and no one thought to tell me he died.
At the start of my residency, I kept track of the deaths. At the hospital memorial service for patients who had died my first year, I listened for names I remembered. By the second year, I sat there wondering, as the familiar names washed over me, what was more painful: watching them die or mourning their life and our failure.
Outside my window, the lightening and raindrops reminded me that summer was flashing by while I was stuck here in the hospital. It would be easier right now with one less noncompliant chronic patient. I chastised myself for being wrong about Rob, but it wasn’t my fault he hadn’t read the textbook.
I wrote Rob that I didn’t write anymore; I was a doctor.
We finally got Carl on the experimental protocol, which meant I was now responsible for assessing him three times a day. The worksheet with his vital signs and labs spilled over the edges of the table that usually held the meal trays. By the next morning, Carl looked a shade less grey. He was down to one hundred and twenty pounds but his fever had dropped below one-hundred and two.
“I’m not leaving in a box you know,” he said.
“I never said you’d be leaving in a box.”
“But you thought it,” he said.
I scanned the flow sheet. “Looks like your temperature is down, so maybe you’re going to luck out with whatever this new wonder drug is. But overall you’re on your third kidney, and I’d say you’re behind in the count.”
“Yeah, yeah,” he waved his hand. “I’m going to walk out of here and find Jacelyn.”
“Who’s that?” I was thinking girl friend, drug dealer.
Carl rummaged in his bedside drawer before pulling out a banged-up photograph. “That’s me and Jace when she was two,” he said pointing to the little girl with corn silk blonde hair and brown eyes who sat on the grass in a rose pink dress. “We had a party at the park, and Sheila even baked a cake. Those were good times,” he gazed out the sunny window, closed his eyes, and dozed off. It was just as well, he needed the rest.
I studied the photo of Carl, smiling and proud with long brown hair and clear eyes, before turning it over. The photograph had been taken almost twenty years ago, well before the kidney failure. After all these years, who knew Carl had a daughter?
In a box somewhere I had a photograph of Rob looking calmly into the camera and affirming he was young and beautiful once, too. I was glad he hadn’t emailed back. I didn’t want to see his words, scars. He was as foreign to me as Washington D.C. had been when I was back there for a conference on emerging pathogens. In the humid July sun, the monuments blazed white hot, and I didn’t have time to sit on the marble and bear distant witness to the pain.
The hospital days traced the storyline of Carl and Sheila, Jace’s mom, who moved across the country with the baby to get away since he wouldn’t stop using. Sheila vanished, never asked for money, or sent photos. Ten years later, Carl got a letter from Jace, who wanted to visit. Carl wanted to see her too, but before she could come out, Carl had the first round of kidney trouble. He told her she’d have to put off their reunion a little longer. Then Jace wrote back that she was afraid of Sheila’s latest boyfriend.
“There I was high while this kid, my kid, was being bothered by some low grade pervert,” Carl said. “I was just about to go on dialysis, and I took the hospital social worker up on an offer to get subsidized housing and pull myself together. It wasn’t perfect, but with the little bit I got from disability and some car repair work on the side, I had us a little place.
“Jace came out, started school here, and we got acquainted,” he said. “She looked so much like her mother, but older than I expected. She got a job answering the phone at the garage after school. Those were two good years.” His voice trailed. The nurse had him up in a chair next to his bed, and he picked at the blanket covering his lap.
I asked what happened.
“She said I wasn’t letting her grow up,” he laughed, “after I made a place for her.” He shook his head and coughed. “She started acting up and hanging out with the wrong crowd. I didn’t want that for her. She was bringing the stuff home. It was too much. I started using and cheating on my drug testing.”
I thought of all the teens who had gotten high and stupid and into trouble. It was a kid’s job to treat their family the absolute worst, but Jace had gone up on flames and taken her father with her. I nodded my sympathies.
“You guys called me for the transplant right then. I was in the hospital for weeks. She never came to visit. When I got back home, she was gone. I called Sheila; she hadn’t seen her and blamed me for her running off. I was sick, and I tried so hard not to die because I wanted to find her again. I didn’t know what else to do. I blamed myself for being a lousy father, and then I blamed myself for caring. I was on so many medications; I figured a few more didn’t matter.”
“Why didn’t you tell us?”
“You think I wanted you all sitting around talking even more about what a loser I was?” he said. “Besides, Jace was a kid, and I figured someone would take her away.”
Another week went by and Carl was doing much better. I brought a simple wood frame for the picture and wished there was something else we could do. There was buzz from the new set of residents rotating on the service about putting him back on the transplant list. I tried to remember when I had stopped thinking ‘why not?’ with borderline cases.
Labor Day weekend came, and its festivities filled the hospital with trauma patients. I’d changed into scrubs and clogs to stay late for a heart transplant patient in the intensive care unit and logged on to look for the results of a spinal tap. There was another email from Rob.
“I sobered up just enough after the accident to get a construction job,” he wrote. The crew boss handed me a hammer since I looked so good at beating myself up. The lead carpenter gave me a chisel a few weeks later, and I never looked back.
“While I was drying out, I wore out sheets of sandpaper and covered everything in my apartment with this thin layer of dust. At first, they sent me home with bits and pieces: finials, the curled ends of banisters. Then I moved on to fretwork, the odd swag of fruit or roses. It’s better now. I leave the sanding at work. I love wood and want to try marble someday.
“We get hired to do restoration by expert types who can tell if the work is done by hand and not power tools. A lot of it is fire and water damage. Fire damaged the area around the altar at St. Joseph the Worker, and we’re restoring the 1890 woodwork. You can always smell when wood’s been through a fire. I have a wife and two kids. They’ve forced me to be closer to the man I want to be. You always said you were going to be a doctor. I never doubted you.”
I moused to the lab results and logged off to see the patient whose heart had been cut out and placed in a plastic pan before her rib cage was wired shut over the stranger’s heart that beat in her chest. The transplanted heart, severed from its original nerves, now driven by a pacemaker.
I felt enervated. Why tell me now he was alive and not drinking? My clogs clacked along the empty tile corridor. He had walked away from me. I had waited for him to stop. I had lacked faith and energy. I had given him up for dead.
There had been no books to teach hope in medical school, but we were required to attend an AA meeting. I remember a brittle old lady with soda bottle glasses who led me down the steep stairs from her apartment over the dicey market on 13th Street to the smoke-choked meeting room at the church around the corner. She talked about her powerlessness over alcohol, the moral inventory, the admission of flaws, and the desire for amends and improvement.
Did Rob hope to restore our warped past through a 12 step program? I drifted to the other end of the unit and ran my fingers over Carl’s wood frame. Some mind, body, history receptor, long blunted by brutal training, sleep deprivation, and the endless needs of patients, fired again with small hope: someone had made it. Someone I knew. They hadn’t made it with me, but medically, that was of little consequence. As I walked to my car, I felt the warm breeze through my thin scrubs and wondered if a world with Rob could hold Carl and Jacelyn. I would find her and tell her about Carl even if she didn’t care.
It took time to track her down. The phone was disconnected; the house sat in a bombed-out block. The soot from the fire that consumed the building next door still licked its bricks. A street lamp at the end of the block cast the only light. I knocked and explained. A woman pointed toward the basketball court where Jace played with the boys when they’d have her. She shut the door.
I drove. Patients lied, I reminded myself. What if Carl lied? Maybe Jace left because he’d been neglectful or abusive. I wouldn’t know until I heard her story. I parked and watched the local mischief play out on a court surrounded by a carpet of green and amber glass. Shapes flickered in and out of the street lap, I spotted Jace, adolescence burning immortal. With the assembled tough but ready acolytes smoking and drinking, the shadowy beauty from the old photograph wanted for nothing. Eventually she would need to use the ladies.
When she moved for home I called her name. She waved an angry hand. “Jace,” I shouted, “I’m not with the police, or juvenile, I’m one of your dad’s doctors. He’s dying.” I held out a card; she stepped toward the car and took it, her hand and wrist scarred with a homemade design. She ran.
I drove to the diner near home where I often sat to shake off medicine. Once again, I had arrived after closing. I’d done my best by Carl, and other than lying down on the operating table for the transplant surgeon to extract one rose pink kidney from a half moon incision in my flank, I could do no more. I mourned for Carl and the boy and the girl sitting late at night under the back portico of the Lincoln Memorial looking out across the dark Potomac toward the graves of Arlington.
Jace left a message with her number on my voice mail. “He needs another kidney, doesn’t he?” she said.
I called and told her he did.
“I’m too messed up and late to help,” she said.
“Your dad talks about seeing you when he’s well.”
“Could I be a match?”
“I wouldn’t know the answer until we run the tests.”
“Then let’s do them, I want to know.”
Carl’s fever returned along with the odor of his draining wounds. Jace sat at his side and told him she was keeping her kidney warm for him until the doctors took care of the infection.
She and I knew she wasn’t a match.
A few days later, Carl’s blood pressure became unstable and the surgeon took him back to debride the dead tissue, flush away the bacterial putrefaction. He died post-operatively.
I left messages for Jace. She didn’t call. I asked the pathologist to page me when someone came to sign for his remains to be removed after the autopsy.
Jace looked better than I expected. I wanted her to know that the tests showed she’d inherited the gene for her father’s kidney disease but wasn’t showing any signs of kidney failure yet. Get checked regularly, I told her. Carl would have wanted her to. She shrugged.
The colored slip in my department mailbox told me to claim a package in the mailroom. Inside the box I found a block of wood and a pack of sandpaper. Live oak, Rob wrote, was a very hard wood.
L. M. Asta has published fiction in Schuylkill and Lemniscate, and her essays have appeared in the Journal of the American Medical Association and Hippocrates. A native of Bucks County, she trained at Temple University School of Medicine and St. Christopher’s Hospital for Children. She writes and practices in northern California.