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| PATIENT-DOCTOR RELATIONSHIP |
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| Year : 2008 | Volume
: 9
| Issue : 2 | Page : 91-94 |
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Like a prayer
Rafael Campo
Harvard Medical School and Boston's Beth
| Date of Web Publication | 17-Jun-2010 |
Correspondence Address:
 Source of Support: None, Conflict of Interest: None  | Check |
How to cite this article:
Campo R. Like a prayer. Heart Views 2008;9:91-4 |
Recalling his time as an exhausted intern working through a last, long, in-patient rotation among homeless men with AIDS, physician, poet, and essayist Rafael Campo tells of a harrowing experience on the ward. That experience allows him to realize his capacity for great empathy toward the least among us, while also providing readers with a meditation on the origins of altruism under the most trying of circumstances
As I went about inattentively jotting down his vital signs, and then taking a perfunctory listen to his heart, he entreated me with a voice so raspy from disuse it was almost gentle: "Hey, doc, when you get to church this morning, pray for me." A few soundless moments passed. After I had said nothing in response, he added with the same hoarseness that at higher volume became a surprisingly vicious snarl, "Yeah, you must be a real good f…… Catholic, with a name like that." Now I was annoyed, to have been startled out of my dim reverie, and by such a crass slur. Was he referring to the Latino-voweled surname blazoned on my plastic ID tag, I wondered - or perhaps, I thought with rising contempt, he was familiar with the lesser-known archangel Rafael?
I had simply been trying to get through my tedious daily morning work rounds without a hitch, the hypnotic lines of Madonna's latest hit song, which I had blasted on my car stereo on the way to the county hospital, still pulsing suggestively over and over again in my head: "Just like a prayer/your voice can take me there/just like a muse to me /you are a mystery. . ." For the whole of the twenty-minute drive in to work that day, I had kept my car's front windows rolled all the way down to let the bracing wind and all of frivolously sundrenched San Francisco pour unimpeded into me as I sped down Potrero. But the deepening poverty was too obvious to ignore, the Mission district looking more and more like a destitute Latin American country with each passing block.
I had not even realized that the gorgeous day I wanted so desperately to relish was a Sunday. For me, a dysfunctional intern stumbling through my last in-patient rotation with only randomly and infrequently scheduled days off, each day had grown monotonously more and more indistinguishable from the one before it. Death was inevitable and omnipresent; resurrection was not only impossible but ludicrous. The hushed and somber hospital, whose hermetically sealed neighborhoods of illness and contagion went in house staff parlance by various quasi-celestial nicknames - the busy cancer unit was sarcastically referred to as the Death Star, and the grim and even more crowded AIDS ward was known as the Temple of Doom - had long been my exclusive place of dark worship and forced atonement. If I would have preferred to be in church, it was only because I so despised the hospital.
His nurse entered with a gelatinously floppy bag of IV fluid to hang. According to her, my patient had been babbling incoherently off and on for much of the night, yet I felt how unmistakably and clearly these last few words of his pierced me. Pray for him? This patient was a filthy junkie who had bitten another nurse in a squabble over his regular methadone dose; numerous times, I had been paged in the middle of the night and awakened from a precious hour or two of sleep to respond to his incessant demands for other narcotic drugs to treat his "pain," always to arrive to find him resting in apparent comfort amid half-emptied take-out cartons of Chinese food brought in by his rowdy, ponytailed friends. If I could have hoped or prayed for anything, it would have been that he'd be stone-cold dead when I next returned to the ward.
Instead, to my chagrin, each morning he was still there, very much alive and moaning and urinating in his bed, or hurling the occasional intelligible and angry epithet at me. Though nothing was likely to salvage him at this point in his illness, with his terminally low T-cell count of 2, a long history of violence and intravenous drug use, and widespread aggressive lymphoma involving his central nervous system, I was still leery of trying anything new at all - even a begrudged prayer - that might prolong his misery, and thus my own. He was little more than a disgusting chore to me, something akin to mopping up a stubbornly grimy floor. In my view, each new hospitalization he had required, thickening his chart as if only to make it heavier for me to lug back and forth from medical records, was a waste of already scarce public health dollars. This latest crude remark of his was the last straw. I stormed out of his room without even bothering to finish examining him.
By simply going elsewhere in the hospital, however, I could not escape him. I saw versions of him shadily averting their eyes in the elevator, hungrily consuming free food provided by the methadone clinic in the cafeteria, and wildly quarreling in the outdoors smoking area off one of the hospital's main hallways. Wherever I looked, his blunt plea would flood back to me, only to elicit the same reflexive rage. Though one of my intern's strategies for conserving energy was to minimize thinking whenever possible, I found myself obsessively wondering whether I walked around stooped by the heavy burden of some unresolved religious guilt, so that even my most ostensibly faithless and disoriented patients could tell that I was once a Catholic. My hip Ray-Ban sunglasses, my pumping Madonna CDs, my chilling surliness, even my Gay Pride T-shirts worn secretly underneath my scrubs all failed to secularize me sufficiently in the discerning eyes of others. Even through the thick fog of his delirium, somehow he had alighted upon my name.
My name. I locked myself in a windowless staff bathroom, the only place I could think of where I could be completely alone, if the pungent presence of ammonia were ignored. I wondered: What secrets did a name betray? I regarded it from a distance as if for the first time, quietly pronouncing it over and over to myself; undeniably, "Rafael Campo" was as generically Latino as a colorful street festival for a local miracle-working Virgin, but my actual relationship to the Catholic Church was much cooler than my stereotypically churchgoing family's. I was a hard-core outcast for my supposedly sinful life, and no longer even considered myself a member of any faith. It amazed me that a low-life like this patient, who probably had stolen stereos from cars in the hospital staffs parking lot to pay for the heroin he was known to shoot directly into his IVs, could still consider himself among God's children, worthy of a saving prayer. . . .
When that despicable AIDS patient finally did die, seizing intractably and without my prayers, I was glad, and relished his death over an unappetizing late-night meal with a few of my colleagues in the nearly deserted cafeteria. Still, I knew he would only be succeeded by others.
Sure enough, late one night on call a few days later, I was paged to place an IV in yet another patient with AIDS, one who belonged to an intern for whom I was cross-covering. He was an emaciated young man who had been receiving wide-open fluid resuscitation for dehydration, until he pulled out his first catheter. His veins stood out beneath his yellow skin so clearly that they seemed to beckon me to enter them, so plump that my mouth even watered a little. I prided myself on my ability to obtain intravenous access, so at first I was only mildly annoyed that the nurse had called me to perform what appeared to be so easy a stick. She was probably overworked herself, though when I had arrived an hour or two after her page she seemed to be on a break, and this was one task that could be unquestioningly relegated to a defenseless intern, with the automatic, well-rehearsed apology: "I've tried three times, and I just can't get it."
In a few moments, I had gathered together the necessary supplies in a small heap at the side of his bed: a drape, some sterile gauze, a small syringe filled with saline, a bottle of iodine, a liter bag of normal saline and some clear coiled tubing, a few strips of tape, a rubber tourniquet, the flimsy but requisite pair of latex gloves, and a 16-gauge Angiocath. I had selected such a big needle partly to underscore to his coffee-sipping nurse, without having to say a word, how effortless the job would be for someone competent. The patient remained asleep while I set everything up, the arm I had selected dangling lifelessly off the side of the bed. When I tried to awaken him to explain what I was doing, before I said more than a few words he mumbled, "Just get it over with and get the hell out of my room." Unfazed, I accepted his gruff statement as informed consent and decided by way of retribution not to bother with lidocaine to numb the area. I positioned the gleaming needle at the bifurcation of an especially large vein, which was swollen nicely under the pressure of the tourniquet I had tightened while he still dozed.
As I applied traction with my other gloved hand above the puncture site, I watched intently as the needle pierced the skin delectably, anticipating with confidence the bright flash of red blood in the needle's small reservoir that would indicate that the lumen of the catheter was inside the vein. I marveled at the permission I had to inflict pain, to assault another person with a sharp object under the pretense that I was actually helping him, but knowing that he would be dead soon, just like the rest. I was more surprised than annoyed when no flash occurred, I was perfectly positioned, and the vein was huge. I withdrew and made a second attempt, again with no success. Sweat began to trickle down my brow, and I had to hold his arm down forcefully with the same hand I was using to apply traction to the vein; he was moaning more and more loudly now. A purple hematoma was growing slowly under his skin where I must have nicked the vein, further unpleasant evidence that this was a sentient, living being I was working on, not just the cadaver I foresaw he would become. On the third pass, with my hands visibly trembling, I finally nailed it and, feeling more than a bit relieved, looked away for a moment. I needed to find the syringe I would use to withdraw blood and then flush in a small amount of saline to confirm the patency of my line.
Perhaps it was the strange violation, the unwanted communication of the outside world with so intimate an interior space that aroused him; perhaps it was the pain I knew I caused, but which I so callously, even sadistically, ignored as I focused on my task, that prompted him to react. Before I knew what had happened, he was sitting bolt upright, screaming at the top of his lungs and flailing his arms out in front of him, scattering my neat pile of materials across the floor. I tried to stop him. When the same needle pierced my own skin, my first thought was to deny the literal connection between us, one that emotionally I had been for so long incapable of accepting but that was suddenly as lasting as metal, as pointed as agony. Blood poured out of the hole in his skin so profusely that in seconds the left leg of my scrubs was soaked in it, and I felt the cool slickness against my thigh, perplexed that it did not feel warmer as it was absorbed. I finally came enough to my senses to call out for help and staggered to the door of his room, leaving sticky, bloody sneaker prints behind me, my path in life momentarily made visible by another's suffering.
The look of horror on the nurse's face pulled me across the remaining dimensions through which I had begun to drift, back into the real world. After we had together restrained him enough to apply pressure to the vein and control the bleeding, I went directly to the sink. Both gloves I wore were covered with quickly drying blood, and when I peeled them off, I noticed stonily that the one on my left hand had been pierced through. I washed my hands before looking at them and felt the sting of the antiseptic soap in the middle of the palm of my left hand, the same sinister hand I had used to hold down his arm, the awful hand that had felt the strain of his weakened muscles against me and then the needle's terrible bite. Still afraid to inspect the sore spot, I took my time patting my hands dry and unwillingly noticed flecks of blood on the crumpled white paper as I tossed the used towels in the trash. So I knew. My left hand balled in a fist, I calmly announced to the nurse that I was fine and that I needed to get changed into some clean scrubs, before I exited the room on wobbly legs; she seemed to hover above the dark pool of blood, plump and white and dumb as a dove, and the fact that she said nothing to me made me wonder if she suspected the truth.
The rent in my skin was only two or three millimeters in size, though the small amount of blood that had fanned out in the subcutaneous tissue made a dusky red spot that was alarmingly much bigger, maybe a centimeter or so. I squeezed out whatever blood I could, not knowing whether the drop or two I was able to express was mine or his, or mine mixed with his. I changed my scrub pants in one of the deserted hallways of the labyrinthine OR, the dried blood that had soaked in pulling at the hair on my thigh as I shucked them off, not caring if a stray orderly or scrub nurse happened to spy me undressed: I finally knew how human I was, I was made acutely aware in one terrible moment that all any of us has in the world is the same body. I wanted to pray that I had not been infected. I wanted to believe that a god, any god, had protected me. After I was changed, I found an open utility closet and shut myself in it with the syringes and plastic emesis basins and face masks and blue gauzy hairnets close around me. I stared into the wound in my palm beneath the dim yellow light from a bare bulb, my forsaken faith even more dim; I found that I kept thinking of Christ, with the incongruous and gruesome fact dancing in my mind that in Roman crucifixions the nails were driven not through the palms, as seen in conventional depictions of Christ on the cross, but through the wrists.
I recalled that I had once stuck myself with a needle a few years before, as an inexperienced medical student attempting to draw blood from another patient with AIDS, but that incident had left no mark in my skin, and I had found no hole in the gloves I was wearing. Still, I had been unable to sleep for weeks, and it was several more months before I could even talk about it with anyone. In contrast, what was happening to me in the utility closet felt like an opening, a revelation, a chance for survival; though I certainly would not report to the Needlestick Hotline what had happened to me, perhaps there would be someone else, some higher authority, who would listen to me. Perhaps in the mixing of my blood with another person's, I could learn the true meaning of forgiveness, I could understand human failings, I could begin to fathom how we all share original sin. Perhaps in the possibility of dying of AIDS myself, I could realize finally and fully my capacity for empathy. Perhaps in a prayer, in a poem, in an embrace and a kiss, I could speak again to God.
These days, my version of the physician's "God complex" is to pray secretly at the bedsides of my patients, sometimes thinking myself silly for doing it, but finding it impossible not to do so. Whatever my religion might be - Catholic or Doctor Not of Theology, Queer Sister of Perpetual Indulgence or Undecided - I understand now that one's faith is intensely personal, in the same way each individual has his own hopes and dreams, and that it can be shared not only within the thick walls of churches but also in the open wards of a hospital. In my visions now, the patients who are dying, or who are getting well, all have a place to go; each holds inside and is held by the beating heart and the feverish closeness of his loved ones. Even the most despised and isolated of patients has someone to whom he can turn, one who truly does have the power to heal, a hope that is the source of all poems. The terrifying needle stick is just a reminder, the bearded chaplain on his rounds exudes a kind of comfort, the hideous skin lesion becomes the glorious impact of God's touch. Today I see that the nurse carrying away feces in a bedpan is an angel; the quiet glance we exchange is the meaning of life.
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