A Brush ~ Danielle Ofri

“And how are your kids?” Mr. Corrales was asking me. As one of my long-term patients, Mr. Corrales had been following my life for the past decade, as I had been following his. He was one of the patients who’d known me before I was married, and as it happened, his visit was taking place on my wedding anniversary. He had followed each of my pregnancies, seen pictures on my desk of my three kids, run into me on First Avenue while I was rushing my kids to daycare. And I followed his life over the decade, through his multiple attempts to stop drinking and smoking, the stress of his mother’s death, his intermittent bouts of unemployment, the ups and downs of his blood pressure and lipid levels.

Mr. Corrales had a jovial, “one-of-the-guys” feel about him—backslapping, joking, always ready with a wink and a one-liner. But there was also a genuine sweetness about him—his devotion to his mother, the help he constantly offered to his elderly neighbors, the doggedness with which he assisted a prior roommate with bipolar disorder, the soft chuckles that always came out when he heard of my children learning to walk or starting to talk.

Mr. Corrales wasn’t the type to drink alone, at home. His entanglement with alcohol centered around weekend baseball games and the neighborhood bar with his buddies. Though he was never fully abstinent, there were months and even years in which he was able to limit himself to one or two beers. But then there were other periods of time when his unit of drink was the six-pack.

Cigarettes exerted an even tighter stronghold. Mr. Corrales smoked right through his nicotine patches, right through his counseling sessions. He was fully aware of how he was damaging his body, but he could only shrug with a resigned smile. “I’m trying, Doc,” he’d say, “but nothing ever seems to budge in my life.”

Mr. Corrales was one of my favorite patients. Being a native English speaker—one of the few in my practice—made it easier for us to schmooze. It also made him a prime candidate whenever I had medical students in tow. He cheerfully, and repeatedly, submitted to the earnest and often protracted interviews by the students, never annoyed at being asked to recite, for the umpteenth time, the age at which he had chicken pox or his tonsils removed.

It was a typical busy clinic afternoon that day and I’d long since parted with the fantasy of finishing early and sneaking out to celebrate my anniversary. There were several charts in my box, and—given the confusion of overbooked patients, add-ons, add-ins—I honestly couldn’t figure out which patient I was supposed to see next. Mr. Corrales and another patient—a new patient—appeared to have identical appointment times. I decided to see Mr. Corrales first, figuring that it would be faster because I knew him and his medical history so well. I quickly scanned the computerized record and realized, to my dismay, that he’d been admitted to the hospital a month ago for alcohol withdrawal. Drinking was obviously an “active medical issue” now and that’s what we’d have to focus on during our visit.

I’d called him into my office, and he leaped out of the chair with gusto, striding energetically into my office. Our clinic offices are cramped affairs, with an exam table, desk, my chair, two patient chairs, examining stool, sink, and file cabinet all competing for purchase in the impossibly tiny square of office space. My desk and chair are stationed right by the door, so whenever patients enter, we always engage in a little do-si-do to slide politely by each other without ending up in an unplanned embrace. This becomes trickier in the wintertime with bulky jackets, and nearly impossible when the patient is obese, in a wheelchair, or using a walker. The designers of the building had evidently planned for a community of razor-thin doctors and anorexic patients.

Mr. Corrales squeezed into the room, gave me a quick hug hello, and told me how happy he was to see me. I asked how he was doing and he said he was under a lot of stress lately. Mr. Corrales’s legs were in constant motion as he spoke, and there was a heightened intensity about him, as though he’d had too much coffee that morning. His roommate for the past two years was an older man who was now quite ill. Mr. Corrales was helping to care for him, and told me that he hadn’t slept at all in the past three nights because of this.

We discussed the recent hospital admission and I was blunt about the serious risks that alcohol posed to his health. Mr. Corrales nodded in agreement, his whole body seeming to vibrate with his nods. “I’m ready to quit drinking and smoking. You’ve saved my life before, Dr. Ofri, and I know you can do it again.”

It wasn’t quite true that I’d saved his life, but we did have a brush with mortality together several years prior. Mr. Corrales had shown up in my clinic complaining of belly pain. When I examined him, I felt an ominous lump in his abdomen. An emergent CT scan revealed a mass in the pancreas, “suspicious for malignancy” as the radiology report read. Pancreatic cancer is a virtual death sentence and I did my best to prepare my 45-year old patient for the possibility of this grave diagnosis.

We arranged for urgent surgery for biopsy and possible removal of the mass—if it were even feasible. (Pancreatic tumors are often hopeless entwined within arteries, veins and organs, rendering them inoperable.) Mr. Corrales was overdrive nervous, and also guilt-ridden that his inability to give up drinking and smoking might have contributed to this disease. I was also nervous because I knew that the 5-year survival rate for pancreatic cancer was a dismal 5%.

For both of us, then, it felt almost like an angel’s intercession when the biopsy revealed a non-cancerous pseudo-cyst. This was still a sign of the damage of alcohol (the cyst was from repeated bouts of alcohol-induced pancreatitis) but it wasn’t the automatic death sentence of pancreatic cancer.

I didn’t save his life, as he liked to put it, but that episode forced us both to get serious about his alcohol. Mr. Corrales kept a lid on his drinking for a number of years after that, though cigarettes remained a steady partner. Slowly alcohol began to creep back in, first intermittently, and then more relentlessly.

Now in my clinic office, Mr. Corrales and I were once again getting serious about his two addictions. “I’m ready to quit both,” he said, fingers twittering on his thighs like compact swarms of gnats. “Sign me up for whatever programs you have. I’ll go anywhere; I’ll do anything.”

I didn’t quite believe that Mr. Corrales’s actions would equal the conviction of his words—we’d been down this road numerous times—but if he expressed a willingness to try, I was certainly going to take advantage. Mr. Corrales surveyed the colorful kindergarten artwork taped to my walls while I typed up referrals to the smoking-cessation clinic and to the alcohol-rehab program. I even convinced him to enroll in a clinical trial that was researching new medications to treat alcohol addiction. It was while waiting on hold for the research physician that Mr. Corrales asked about my children.

“They’re doing well,” I said, a bit absent-mindedly because I was now typing in the vital signs that the aide had taken earlier. I was just beginning to process the fact that his pulse was recorded as 100—rather high for him—when I noticed that Mr. Corrales was twisting his head up to his left, away from me, as if trying to see something in the back corner of the office. There were no paintings in that blank corner and I briefly wondered if he might be experiencing alcoholic hallucinosis—when severely intoxicated patients see or feel objects that don’t exist. But before I could even complete the thought that Mr. Corrales didn’t seem particularly intoxicated, certainly not enough to cause hallucinations, Mr. Corrales’s body snapped 180 degrees in the other direction toward me, collapsing onto my desk with a concrete thud.

There was a nanosecond of eye-blinking disorientation as my brain wrenched from “sitting-in-clinic-typing-a-note”-mode to “patient-collapsed-medical-emergency”-mode. As his body began to convulse, I realized the Mr. Corrales was having a grand-mal seizure and jumped out of my chair to help him. I shouted to an aide in the hallway for help and we eased him off the desk onto the floor where we could turn his shuddering body the left side to allow the foam emanating from his mouth to spill out rather than pool in his throat. There was barely room for the two of us on the floor with Mr. Corrales, so when the scores of non-anorexic people began arriving for the “Rapid Response Alert,” all they could do was to crowd in the doorway. Even a regular-sized stretcher could not fit in; only a fold-up recliner could be squeezed in. Two senior residents and a nurse hoisted themselves up over the stretcher into my office.

While I listened to Mr. Corrales’s heart and lungs with my stethoscope, one resident started an intravenous line and the other injected a sedative to prevent further seizures. We struggled to worm an oxygen tank and pulse-oximeter into the cramped space as the hordes of people in the doorway called out suggestions and advice, trying to help but really just adding to the chaos. The seizure finally abated and Mr. Corrales lurched groggily into partial consciousness. I imagined how frightening it must be to wake up into a pandemonium of medical equipment and unfamiliar faces, so I tried to focus Mr. Corrales’s fragmentary awareness on me. I held his face in my hands and turned it toward mine. “Mr. Corrales, it’s Dr. Ofri,” I said firmly, over and over, hoping something familiar would click and ease his transition back to the real world.

Slowly he came to, and we maneuvered the whole group out of my office—stretcher first, staff second, since we all couldn’t exit together. I wheeled the stretcher through the waiting room, past rows of waiting patients who couldn’t help but gawk, down the elevators, over to the hospital building, through the waiting room of the emergency room with its waiting, gawking, patients, into the triage area of the emergency room, then finally into the ER itself. All the while Mr. Corrales was straining to figure out what was happening through the fogginess of his post-seizure state, and struggling to physically extricate himself from the stretcher. Each time, I gently but firmly pushed him back against the stretcher, reminding him that he’d just had a seizure, and that we were admitting him to the hospital.

In the ER, we hooked up the cardiac monitors while I compressed his medical history of the past decade and the past 20 minutes into a concise report for my ER colleagues. I gave Mr. Corrales one last squeeze of the hand for reassurance and then dashed back to clinic. I briefly entertained the irrational thought that a medical crisis would somehow offer dispensation from the ongoing workday schedule, but no, I was now even more behind on my schedule. There were four more charts were in my box, including the new patient whom I’d chosen to defer until after Mr. Corrales, the new patient who’d apparently been sitting outside my office the entire time, witnessing the drama and chaos. “You’re cool under fire, Doc,” he said when I called him in, apparently unflummoxed by the events.

And although I had indeed been calm and unflummoxed during the entire event, it was later that it began to catch up with me. I found myself needing to relate the whole chronical of events to a close friend by phone while walking home from work, and then again to my husband, but when it came out of my mouth—“a patient of mine had a seizure in my office”—it didn’t sound like much. The retelling didn’t provide any release of the vague tautness in my stomach. I was distracted with the kids that evening, only halfway engaged during the din of feeding, bathing and bedtime.

We hadn’t been able to score a babysitter to go out for our anniversary, but my husband and I uncorked a bottle of wine for a few minutes of relaxation in the peaceful wake of three children finally sleeping. But I found that I couldn’t focus. I couldn’t be fully present. My mind kept retracing the events of the day, dissecting and redissecting the details until they began to break apart and reappear in random order.

I tossed and turned in bed that night, my mind flooded with tenebrous fragments of recollections. It was only a seizure, I kept telling myself, but somehow it wouldn’t leave me. I began to realize that the events of the day were reorganizing themselves not by temporal sequence, but in a hierarchy of emotional resonance. The detail that recurred most frequently, and with most cinematic detail, was the thud with which Mr. Corrales’s head and torso landed on my desk. Although I’d diagnosed the seizure fairly quickly, there was that brief of moment of murkiness, of being caught off guard.

As I lay awake that night, it dawned on me that during that disorienting nanosecond before my cortex confidently delivered the diagnosis of seizure, some deeper part of me—perhaps it was my soul—was convinced that my patient had just died in my lap.

The fear of death doesn’t disappear when you become a doctor. For sure it is heartily sublimated, as doctors witness death more frequently than most people, but it never goes away. I’ve witnessed innumerable seizures, cardiac arrests and assorted medical calamites in my medical career, but as I looked back at them, I realized that I was almost always prepared in some way—by being called to the event after it started, or seeing a seizure in someone with known seizure disorder, or witnessing cardiac failure in patient already critically ill, or at the very least being in the acute care hospital where such events were part and parcel of everyday life.

Though Mr. Corrales was certainly at risk for seizures by drinking, he’d never had one in the decade I’d known him. He wasn’t a hospitalized patient, or even a patient coming for a urgent-care visit because he was feeling ill that day. Mr. Corrales had simply showed up for his scheduled doctor’s appointment, ready to talk about flu shots, colonoscopies and how my children were progressing with their letters and numbers.

The shift of events had been so rapid and so unexpected. My brain had moved along commendably quickly, but the emotional processing was several beats behind. Although I knew—clinically, confidently—that I was witnessing a seizure that I was well-trained to handle, a part of me was convinced that I had just witnessed death.

As I twisted irritably in my bed that night, I realized that a brush with death is a brush with death, no matter how brief. In fact, the brevity was irrelevant; facing the void seems to be an all-or-none phenomenon. Even though it was only a nanosecond of lag before I was out of my chair initiating the resuscitation protocols, the briefness of that brush with death did nothing to diminish its potency.

That was why I could not sleep. I had seen death up close, felt its hostile breath pucker my skin, winced at its corroding presence in my lap, recoiled from its imperious barreling into my private space …and it scared the pants off of me.

In our daily medical lives, death is camouflaged in a variety of ways. It’s not just the euphemisms that we use, or the subtle distancing of the dying that mark this camouflage, it is also the psychological hunkering-down that we do. In manners large and small, we prepare ourselves so that we are not caught by surprise. Terminally ill patients are downshifted to a separate category in our minds, critically ill patients to another—realms that are incrementally removed from the here and now, the immediacy of the alive, the defiant denial that is our ability to proceed forward in the existential muck of our own existence. It’s not that our emotional investments are necessarily decreased toward the dying, but they are subtly altered so that the eventual toll is lessened and we can protect our friable sense of self. When the cut of death does finally come, it is not as  close to our crucial vessels, so we bleed less. The camouflage surrounding our own terror of death thus remains steadfastly intact.

In that fleeting second before diagnosing Mr. Corrales’s seizure, I was alone and completely unprepared for death—his or mine. My guard was down, my psychological bunkers unreinforced, my camouflage patently absent. When death muscled in, it cut right to the bone with the rapidity and splintering crack of a whip to its target.

It had only been a second, but it would take days to process, weeks, perhaps, to fully settle, if it ever would. Perhaps I would never return exactly to my baseline. Perhaps my defenses would be permanently ratcheted down a notch, however subtle.

I visited Mr. Corrales the next morning in the hospital. He had fully recovered, and thanked me profusely, for once again “saving his life.” The CT scan of his head thankfully showed no tumors or bleeds that might have been responsible a new-onset seizure. In consultation with the neurologists, we concluded that Mr. Corrales’s fluctuating alcohol levels in combination with his recent sleep deprivation was the most likely cause. “I’m quitting, Doc,” he said to me. “Quitting everything. You set me up with every rehab that’s out there, Dr. Ofri, and I’ll be the first one on line. I just want to know that I’ll be okay.”

I told him that he would be okay.

I did not tell him that I wasn’t sure if I would be okay. I did not tell him that I hadn’t been able to focus on my children or celebrate my anniversary after his seizure. I did not tell him how sleep eluded me while I obsessed about what happened to him. I did not tell him that about the fright of my confrontation of death. Eighteen hours after Mr. Corrales collapsed, my defenses were still visibly weakened. But it was my job to keep his fortified. His healing would be a partnership; mine would have to be private.