Eternal Springs

AUTHOR:
Faith T. Fitzgerald, MD
University of California, Davis

CITATION:
Fitzgerald FT. Eternal springs. Consultant. 2010;50(1):30-31.

Doctors, especially primary care doctors, love stories. We love hearing them from patients and telling them to one another. "Anecdotal learning" it's called by some (somewhat derisively because it's not science). However, science tells only one kind of truth—visible, measurable, reproducible, objective. Scientific truth is vital to medicine, but by itself it is not enough. Many of the major ills of our patients—hopelessness, guilt, fear, pain, fatigue—cannot be seen or measured but are nonetheless very real and very important.

Some of the gratification of medicine, too, may be in the epiphany of scientific discovery, but more often it lies in that other kingdom of human reality, of which hope, love, courage, humor, birth, death, and beauty are denizens. These are the things around which our stories center, and it is these things that we remember when we reflect on our careers long after biochemical pathways are forgotten.

So in an era in which we are besieged, enraged, and confused by the efforts of crass mercantilists to mutate our art into business and to reduce patients to "thru-put" and doctors to dispensers of "services" and "products," telling our stories helps remind us of who and what we really are. Our stories remind us that whatever the conditions under which we are compelled to practice, we have a gift no other possesses: the wonder of entry into the rich lives of our patients and the privilege of witnessing their courageous adaptation to the most portentous hours that men and women ever live.

This is honest value paid for our service to them—and, as things are going, perhaps all we'll get.

This is a tale of presumption, which I tell so the young can hear what older doctors know: that the human spirit will always find a way to astonish. It is, for the most part, a true story.

He was a retired union leader, tough and blunt and charming. She was bright, small, agile. Both were golfers, and when he retired he built his wife her dream home in a golfing community near Sacramento. She was 80 and he was 84 when my story starts.

They'd been married over 60 years and were one person: they moved together with practiced grace, sharing dozens of small physical gestures of endearment. He called her "the Boss." She called him "He," as if there were no other men. I learned early in our 15 years together to see them both at once, no matter who had the appointment, for they answered for each other better than they did for themselves.

"How are you doing?" I'd ask her.

"She's getting clumsy," he'd say.

"Any problems with you?" I'd ask him.

"He's going deaf," she'd reply.

If I called their home, they'd both be on the speakerphone, each telling me their concerns about the other. He'd had a childhood osteomyelitis that left him with a limp; he also had asthma and had had a coronary bypass at age 76. She'd had some arthritis. But they were mostly robust, golfing every day.

Then her game got worse—and worse. Her left hand grew weak, her speech soft and slurred. She began to fall. Her animated face stilled, became masklike—except for her frightened eyes. Within a year of her first symptoms, she was in a wheelchair. Her body stiffened and was racked by cramps, which he would try to massage away through endless painful nights. Swallowing became deranged, and she was repeatedly hospitalized for pneumonias.

Her neurologist was not sure but guessed she had an odd form of Parkinson disease. Multiple therapies gave no pause to her inexorable decline, and we finally resorted to botulinum toxin injections when she ripped her hip from its socket in one great spasmodic contraction of the muscles of her upper leg.

Each time she was admitted, her husband came in with her. He sat and slept in a big chair by her bed, never leaving her side. He fed her, bathed her, turned her, talked to her. The busy nurses loved him for his love of her and nonintrusive helpfulness to them. When I told him how much the staff admired him, he was nonplussed: "Isn't this what husbands are supposed to do?" he asked.

He modified their house for her: ramps, grab bars, stair lift, bed sling. And when even this was not enough, he reluctantly persuaded her to leave the home they had built together ("Just until you're better," he told her—and she, seeing his despair, pretended to believe him). They moved into a single story house near their granddaughter, who checked on them each day. Home nurses visited, did what they could. Yet he still himself would lift her, bathe her, help her to the toilet. Often now they fell together, each taking the other down. His arthritis worsened, and his heart began to fail.

Over his prideful protest that he could take care of his own wife, the family hired a full-time live-in helper, a strong Tongan woman. She was deeply sympathetic, as sometimes is the gift of those themselves oppressed. She was the sole parent of a 6-year-old girl, and finding a job that allowed them to stay together had been hard. However, the old couple welcomed the active child, who brought joy to them both with her radiant vivacity and affection.

Still, the old man continued to lift and turn his wife at night, though the live-in helper slept near them. "The helper needed her sleep," he said. He refused hospice when the nurse told him that he'd have to promise not to rush his wife to the hospital in an emergency, but call the hospice nurse instead. Neither he nor his wife wanted to be in the ICU or to have CPR, but he'd too often seen her pulled back from the brink by intravenous antibiotics and pulmonary toilet in hospital to surrender these options yet.

The call finally came as I knew it must: She looked bad, he said. Should we get the paramedics? "If you want to," I told him, "or you can wait for me; I'll come now."

"It's hard to know what's right," he said.

"Yes, it is. Call your family. I'll be right there."

"It's really bad this time," he said, and hung up. I drove like a fury, but when I arrived, the ambulance, siren screaming, was pulling away. He and his granddaughter were in the driveway.

"She had trouble breathing," he said, "so I called 911. I thought maybe they could just give her some oxygen here, but they said they couldn't do that, that they had to take her to the nearest hospital." He and his granddaughter got into her car to follow the ambulance.

I had no privileges at the hospital to which she'd been taken, but the triage nurse knew me from a lecture I had given and let me into the emergency room to see my patient. She'd had massive aspiration, was febrile, pale, and obtunded. The pulmonologist was an older man who—once he'd heard the story and spoken to the family—readily agreed to palliative care and antibiotics only.

She died 3 days later, her husband holding her hand. Although there were many family with him in that hospital room, at that moment he was truly alone: it was in his face as he stroked her hair. I knew then that he would die soon, and that it would not be his heart but his aloneness that would kill him. Half of him—her—was already dead. For 60 years the other half had been, above all other things, her husband, her protector. It was his role in life, and it lay dead with her. What was left?

A week after the funeral I phoned him.

"How are you?" I asked, and was unexpectedly startled to hear his voice reply—not hers, as had always been the case before.

"Okay," he said.

"Just okay?" I asked.

"Well … my arthritis is better." No surprise. He no longer lifted her.

"Good."

"And the swelling in my ankles is gone."

"Fine."

"My breathing's better, too." His heart was being less stressed by exertion now.

"Doctor?" he said.

"Yes?"

"Do you think I could try that Viagra that everybody's talking about?" I was stunned.

"Viagra?"

"Yeah. Will my heart take it?" I thought perhaps he was confusing Viagra with some new anti-inflammatory. "Viagra—you want it for …?"

"What else? Performance! You know … it's been a long time, what with the Boss so sick and all. Now a lady's asked me out to dinner, and I don't want to embarrass myself."

"Do I know this lady?"

"Don't think you ever met her. She came up to me at the Boss's funeral. The Boss and I used to play golf with her and her husband a long time ago. She told me she'd decided way back then that if her David died—he keeled over last year—and the Boss died, that she'd come after me." He laughed. "Isn't that something?"

"That's something!" I said. Then I just had to ask, "How old is this lady?"

"About my age," he said.

I prescribed the Viagra. A week later, I called again. He answered. "How are you doing?" I asked.

An unfamiliar female voice came loudly over the speakerphone: "Great!" she said. "He's doing great!"