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Narrative and Healing

Home  >  Narrative and Healing  >  Perspectives
Narrative in Medicine  -  Cold Bones
By Patricia Kullberg, MD, MPH « Prev   Page 2 of 2  

A short story.

The moment she saw him, Fran knew she had no help for the man. With some patients she could just tell. A dark, jagged scar angled from above his left brow down to his left ear. But the old gash didn't demoralize her, it was the way his eyes pulled in the light and never let it go, the indelible lines of sadness etched into his face, the stoop in his shoulders, as if he expected a beating, but knew how to take it.

When she'd entered the exam room, both Mr. Truong and the young woman interpreter had stood and inclined forward from the waist toward her. "Good morning, Doctor," the interpreter murmured.

Mr. Truong dipped his head without speaking. His smile, called up to honor Fran, looked stuck on, as if she could have lifted a corner of it with her fingernail and peeled it off. As soon as she sat down, his face caved in.

Mr. Truong and the interpreter took their seats and folded their hands into their laps. They leaned forward, rigid and attentive, as if to aim themselves at her. Their backs did not touch their chairs. The diminutive interpreter wore a white blouse fastened at the neck, a dark colored skirt of modest length, and low heeled pumps. She'd pulled her glossy, black hair into a clip at the back of her neck. Mr. Truong was dressed in slacks and sport coat over a knit vest and white shirt with a stiff collar. His hair was combed back off his forehead in oily grooves. The shine of his shoes caught the overhead light.

He was shorter and thinner than Fran and looked to be older as well, though he was born the same year she was, in 1947. Later she would write in his chart: appears older than stated age. It wasn't fair to say it that way, to suggest he might be older than he admitted. But what would she say otherwise? Trauma and deprivation have aged him prematurely. It was too bald a judgment for a medical record, too much a taking of sides.

At the top of a blank page Benny had written Mr. Truong's chief complaint, feels bad, by which he meant the patient had too many complaints to list. The new patient questionnaire was a chronicle of negatives: no chronic illness, no medicines, never had surgery, never hospitalized, non-smoker, non-drinker. Fran smoothed her rumpled slacks over her lap. When she looked up she noticed the rip in the Naugahyde covering of the exam table. It didn't look fresh. Odd that she hadn't seen it before; had it been there the entire year she'd worked here? Now the whole room looked shabbier than ever.

She smiled at Mr. Truong and the interpreter. "What brings Mr. Truong to the clinic?"

The interpreter posed Fran's question to the man, then replied back in English. "He feels tired inside and his bones are cold."

Cold bones - impossible. But how miserable it must be to suffer a chill from such a deep and inescapable place.

Mr. Truong interjected a few more sentences. "He feels dizzy behind his eyes. There is a buzzing in his chest and the left side of his body is swollen. His left arm especially is hurting and doesn't work right." Mr. Truong ran his hand from his neck down to the fingers of his left hand, which he grasped and wiggled back and forth.

"Anything else?"

"He is tired and his sleep is no good."

The pain in his arm seemed the most promising. She wouldn't wring a diagnosis out of cold bones.

"Has he ever injured his arm or neck?" she asked.

"He had a bad fall back in his country many years ago," the interpreter said.

"Did he hurt his neck or shoulder?"

Mr. Truong and the interpreter talked back and forth several times. "His neck is all better now."

"What else did he say?"

She cast her eyes down. "He was just explaining to me."

Such a proper young woman with such a tricky job. "Okay. Maybe you could just sort of tell me everything he says. Would that be okay?"

"Yes. I'm sorry, Doctor."

"No problem." Fran smiled. "Does his arm feel weak?"

The young woman nodded. "The whole left side of his body feels numb and swollen. His eyes feel numb." Mr. Truong placed the palm of his hand on his brow as she spoke. "It hurts his forehead, there, where he is showing you."

"What seems to bring the arm pain on?"

"The arm hurts when he goes outside."

"Does it bother him when he uses it, like lifting a bag of groceries?"

"He doesn't carry the groceries. His daughter does the shopping."

"But does it hurt more when he tries to lift something heavy?"

"He says the pain is very deep."

"The scar on his face, how did he get that?"

"He was injured."

"How did it happen?"

"He was cut."

So much for the history. Fran rose. "Could he have a seat on the table, please?" The tear in the Naugahyde gaped when Mr. Truong sat down. He removed his coat, vest, and shirt. He was so thin his skin barely creased where he bent at the waist. He had no deformity, no wasting.

He winced when she touched certain spots around the shoulder, but they didn't correspond to the anatomical structures that interested her. Fran raised her arm, touched the back of her head, then the middle of her back and watched as he repeated her movements. No problem there. With her thumb she depressed the taut strand of the biceps tendon at his elbow and tapped her nail with the reflex hammer. His forearm jumped. Same with his other two reflexes. Normal. She poked him with a tiny, rigid length of plastic, which he couldn't seem to feel at all, anywhere. No one had a neurological hook-up like that.

It used to bother Fran how she tossed out little bits of a patient's story — the cold bones, the anatomically incorrect sensations — as if they were trivial or meaningless details of an over-elaborated plot. But it was her job to pare down the patient's complaints into a story that made sense to her. In Mr. Truong's case, she could already see that the remains would amount to no more than a few pages torn from a book from which she needed to divine the entire narrative. Her narrative.

"My dad," she said to Benny after Mr. Truong left, "always told me if you didn't know what was wrong with the patient by the time you finished with your history, ordering a bunch of tests wasn't going to help."

Benny peeled the backing off a label and smoothed it around a culture tube. "Sounds like he was a smart guy."

"He was quite astute about some things, but he lived with his head in the clouds, drove my mom crazy." She laughed. "He had this enduring vision of how wonderful life in America was and then when something ugly happened he'd be shocked." She stopped.

Had something just passed across Benny's face. He looked down at the tube in his hand. She waited until he looked up again; his expression was decidedly neutral. "But he was right about some things," she said. "I'm going to order a whole bunch of tests on Mr. Truong and they're all going to come back normal."

"Why bother?"

"So I won't be plagued with uncertainty. But my take is when you can't figure out what's wrong with a patient after talking to him, it's because he's depressed."

***

Benny laid his chart on the counter at the nurse's station and turned to Fran. "You want an exam table without a tear in the upholstery? What makes you so special?"

"Not special enough, apparently. Did you ask?"

"There's no money," he said.

"It's so...undignified."

"Now it's dignity you want?"

"Exam tables couldn't cost that much."

"They said they'd send over some duct tape."

But the tear looked even larger when Mr. Truong arrived with the same young woman interpreter for his fourth visit. Each visit had been the same. A litany of bizarre complaints, detailed questions, repeated exams, blood tests, Xrays, scans, with nothing to show for it all.

Every visit added to her premonition that he was beyond help, as if she had begun with the core of the onion and layered the flesh back over it. At each visit more of his despair rubbed off onto her, though she was not entitled to the feeling; it cheapened his suffering.

She sat sideways at a small desk pushed into a corner. Mr. Truong's chair stood at the side of the desk while the interpreter sat off to Fran's right, facing them both at an angle. "How is his mood?" Fran asked.

"He is tired."

"How does he spend his days?"

"He lives with his daughter and her husband. They have two children who are not yet going to school. He takes care of the children during the day."

"Does he enjoy his grandchildren?"

"He is tired during the day."

A black smudge dropped off the counter to Mr. Truong's side and momentarily distracted Fran. She hoped the cockroach would scuttle off away from them and was relieved when it disappeared under the exam table. Neither Mr. Truong nor the interpreter seemed to notice.

"Does he get out to do things that he enjoys?" She asked.

"The children like to go to the park. His arm hurts when he goes outside and his chest swells."

His malaise was too physical for him to grasp her questions. But anyone with a stuck-on smile and cold bones had to be depressed.

Fran spoke directly to the interpreter. "I understand that depression is not easily accepted in Vietnamese culture."

"We know about mental illness, but it is a thing of disgrace." The young woman darted her eyes to Mr. Truong.

"Tell him that sadness can make the body feel bad. Maybe you can just call it sadness."

The young woman looked too small and fragile to serve as the fulcrum on which the weight of this dialog would tip. She hesitated, then spoke to Mr. Truong with her eyes averted. "He says his body feels bad because he is sick."

"Sadness can be a type of sickness."

As the interpreter spoke to him, he rubbed his arm. "He says there is something wrong with his arm."

"There's medicine I could give him that would help him feel better and help him with his sleep."

"He wants to know is it medicine for his arm?"

"I think it will help his arm."

"What kind of medicine is this?"

Fran looked down, laced her fingers together, and lined up her thumbs side by side. Somehow she had not clipped the left thumbnail as short as the right. She brought her intertwined hands up to her chest. "It's medicine I use to help with sadness." Fran looked at Mr. Truong, who kept his eyes fastened on the interpreter.

"He does not want this medicine," the interpreter said. "He wants medicine for his arm."

He didn't buy her story any more than she bought his. Now what? Fran pursed her lips and began to leaf through the pages of his chart. She stopped at the notes Sylvia had made. "When did he come over from Viet Nam?"

"He came from a refugee camp in Thailand."

"How long ago?"

"In 1981."

Twelve years already. "How did he come to the refugee camp?"

A lengthy exchange ensued between him and the interpreter. The expression on his face didn't change. He must have lapsed into the telling of more complaints. Fran twiddled her pen between her fingers.

The interpreter finally spoke. "He says they lived in a fishing village in Viet Nam. His wife stepped on a land mine. She was holding their baby. They were blown up."

Fran laid her pen on the desk.

"After the helicopters came his home was gone, his boat was gone. They all burned up. He could not fish. There was no food. He left in a boat with his son and daughter. It was very crowded. They were on the sea for many days. His son was too small for this travel. He was too sick and died on the boat. They forced him to push the boy over into the sea. He and his daughter got to the camp and stayed there many years."

Fran thought about how her own kids as toddlers had grabbed at her with dimpled hands and pressed their hot, squirmy flesh against hers. She had to breathe away the clutch at her throat before she could speak. "I'm so sorry for your loss, Mr. Truong."

He sat with his eyes fixed on the empty space in the room.

All that focus on his swelling and buzzing and chilling and numbing and she'd missed the pieces of his story that really mattered.

***

Fran lifted her eyes from the blur on the page of her paperback to the streams of water trailing backwards across the smudged window of the bus. She followed the jerky progress of a single drop to the point where it flattened out into a thin, wet film. Indistinct and grayed-out forms flashed across the film. Some things were better seen through a smear. Details just confused the matter.

Mr. Truong's daughter was scheduled to come to the clinic this morning. Fran hoped to enlist the daughter in treating her father's depression. The maneuver was disrespectful. And necessary. The bus swayed around a curve, dragging Fran's stomach along with it.

She never should have met Mr. Truong, not like this. He didn't even belong at Davis, but where they lived, none of the doctors accepted Medicaid patients. He should have been at home on the other side of the world. She pictured him fleeing into the jungle as a young man, one wailing child slung under each arm, pursued by screams, waves of superheated air, and the pop of gunfire. Only once in her life had she run from danger, away from the sting of tear-gas and the thud of nightsticks on flesh. The antiwar protest had gotten out of hand when she and her fellow students, pissed off and full of themselves, refused to vacate the steps of the federal courthouse. She'd run so hard she hadn't dared to look back out of fear she would stumble and be crushed under the boots and swinging sticks of the helmeted men.

It was never her war, but Mr. Truong was her patient.

Fran had expected to see the daughter alone, but she'd brought her father along. There was no interpreter. Fran guessed the daughter to be in her mid twenties. Her hair was styled in a short, boyish cut. She wore a crimson turtleneck sweater over blue jeans with a crease pressed into them and black, opened-toed shoes with spiky heels. The color of her toenails matched her sweater.

"Coming to a new country is difficult for many people, Ms. Bui."

"Yes, Doctor." She replied in English and tilted her head forward.

Mr. Truong sat like a blown-up photo of himself propped up in the chair.

"When people have to leave friends and family behind and adjust to new customs, they often don't feel well, physically or emotionally." Fran paused. "Your father looks sad to me."

"My father's very happy. He's glad to be in America." Her English was impeccable.

"Does your father ever complain of homesickness?"

"No. He's here with us and we have a good home. He doesn't have any family left in Viet Nam."

"How about all the physical problems he's been having? Does he ever seem depressed about that?"

The daughter tightened her smile. "He comes to you for help with that, Doctor."

"Does your father ever have nightmares?"

"No. Was there anything else you wanted to know?" The young woman rested her hands on the clasp of her purse. She hadn't interpreted a word for her father.

"What does he enjoy doing at home?"

Ms. Bui cocked her head slightly. "What do you mean?"

"Does he have friends to visit, does he have hobbies? Does he go out at all?"

"He comes to church with us."

"Does he ever talk about what happened in Viet Nam?"

"We are American now. My children are American. They are happy and healthy. Do you understand, Dr. Besser? Viet Nam is not a part of our life."

Fran gazed at the young woman, her face bright and hard. "Yes, I understand. Thank you for coming, Ms. Bui."

At noon Fran took a seat in an overstuffed booth in the far corner of the bar down the street and ordered a bowl of chili. The smell of stale booze and cigarette smoke lingered from the evening before. Aside from a thin, flat-faced man at the bar, Fran was alone, with no cheerful lunchtime chatter to grate on her melancholy. The silent flicker of the TV above the bar caught her eye. On the screen American troops stood sentinel over a dry and rocky terrain. Two ragged, skinny, young boys squatted in the foreground. The picture cut to a dark-suited and gesticulating man, Senator Somebody. Fran rose to sit on the opposite side of the booth with her back to the TV.

"US imperialism?!" Her dad had smacked the folded up newspaper he'd been reading onto the table and glowered at Fran. "What's that? Protecting our interests, that's what it is. What do you know? You think the Viet Cong are so great?"

His fury had startled Fran. He hadn't said a word when her mom caught her smoking weed in the upstairs bathroom, thinking it wouldn't smell if she blew the smoke out the window. Later she and a friend were arrested for trespassing into the zoo at 2:00 am - a genuine scientific interest, she swore, in the habits of nocturnal animals. He solemnly bailed her out, then stifled a smile in the car where her mother sat tight-lipped with her arms folded across her chest. But when she skipped class to protest an immoral war, she provoked a temper she never imagined he was capable of.

His face went red with the effort not to yell. "Those young men over there are fighting to preserve your rights, even your right to be duped by the communists!"

"Rights? What rights did those kids at Kent State have? The right to get shot and killed?"

"You know nothing!" He stood up and yelled at her. "Nothing about the sacrifices that have to be made!"

"Like sacrificing innocent Vietnamese women and children?!"

He glared at her, then abruptly turned and left the room.

Her mom later took her aside. "Honey, don't rile your father up. He saw things during the war you can't even imagine. He has his feelings and they aren't going to change."

"This isn't Hitler. This is a small, impoverished third world country fighting —"

"Fran, please."

Two decades later the war her dad so passionately believed in, the conflict she found so vicious and wrong-headed, dumped Mr. Truong and his profound grief onto her to manage, to tidy up and sweep away.

Mr. Truong baffled her. What kind of faith would compel a man to come over and over again to a doctor who had no answers for his questions, no remedies for his ailments, a doctor who could not even bring herself to tell him that she had no help for him? She was a fraud. She pushed away her half-eaten lunch and signaled for the check.

Outside, the wind gusted through the streets, pushing litter along the sidewalk. The sky was dun colored and distant and looked as if it would stay that way forever. A couple of blocks from the clinic, she met Benny on his way back from lunch.

"You ever get to know any of the Vietnamese when you were over there?" Fran looked sideways at him.

"No," he answered after a pause. He stared straight ahead. "We didn't fraternize much. It was discouraged."

"I was wondering if you'd know what they thought about mental illness."

"Wasn't the thing to do, learn about the natives."

"You remember Mr. Truong. He lost everything in the war, including his wife and two of his kids. He's depressed, any fool could see. Not his own daughter, though."

"What's in it for her to have a mentally ill father?"

"He lives with her and it can't be very happy at home."

"Happiness is relative."

"But not all suffering is necessary. If I could get him to take antidepressants, he'd—"

"Some depression can't be treated." He pushed the clinic door open and held it for her. The wind drove dead leaves into the waiting room and he stooped to pick them up.

***

A month later the same young woman interpreter sat with Fran and Mr. Truong. He'd cycled around to an old complaint of chest pain. Sometimes Fran imagined he came for no other reason than to torment her with his grief.

"His heart feels swollen and painful, " the interpreter said. "It feels too big for his chest."

"Why does he think he has all these problems?" Fran asked.

"He says he doesn't know. He comes to the doctor to find out."

"What does he think will happen with his sickness?"

"He doesn't know."

"What is he afraid might happen?"

"You will help him with it."

What was that? The truth? A muddled interpretation? She nodded.

"He thinks there is something wrong with his heart," the interpreter said.

Fran had tracked the possibility of heart disease to a dead end a few times already. But maybe she hadn't taken his complaints seriously enough. Maybe the metaphors of the body he employed were so alien to her way of thinking they could not be interpreted. She would be forgiven if she missed the diagnosis of depression, but not if she overlooked heart disease.

"I don't think you have a heart problem, Mr. Truong. However, since your chest continues to bother you, I could have the heart specialist see you."

The interpreter spoke to Mr. Truong and he nodded.

All right. It couldn't hurt to send him to a cardiologist.

***

Fran trudged up the steep and narrow stairs to the loft. From her locker she pulled her coat and bag and tossed them onto the scarred table, then sank into a chair to change her shoes. Midway she stopped and let her hands dangle between her knees. She stared at the floor. She'd seen it before, how trouble attracted yet more trouble. So why was she surprised Mr. Truong had suffered a rare and dangerous complication during his catheterization, the one she'd sent him for?

Benny, who had come up behind her, gathered his things, and shut his locker. At the top of the stairs he stopped. "You okay?"

"Yeah." Fran looked up. "No. Not really."

He pushed aside the newspapers scattered across the table, set his things down, and took the chair opposite her.

"I made the mistake of sending Mr. Truong to the cardiologist on the off chance he was having angina."

"And..."

"They put him on a treadmill. The results were indeterminate, so they offered to catheterize him. Then he had an allergic reaction to the dye and nearly died. They got him back, but it left him with some neurological deficits."

"How bad?"

"He's got some arm and leg weakness, he'll need a cane to walk."

"And you think it's your fault."

Fran pushed her palms together, fingers spread. "Funny enough, I'd feel better if they'd found something. Before he crashed they got enough pictures to rule out clogged arteries, which is what I expected. He paid a big price for my diagnostic insecurity."

"You weren't the one who decided to catheterize him."

"But we all play by the same rules. I sent him there and it's not like I didn't know he'd probably get catheterized. That's what cardiologists do. They catheterize people."

"Maybe the rules are bad."

Fran gave a short laugh. "They're the only rules I know."

Benny shrugged.

"I had this thing," she said, "about making things better for him. Now he's worse off than ever."

"You had this thing?"

"Because of the war, you know, he lost so much."

Benny didn't speak right away. "You wanted to make it up to him?"

"I guess. In some small way. But he was so difficult." With her forefinger she traced a scratch in the table back and forth. "How unspeakably horrific it must've been for him. I can't -"

"You thought you could make it better by giving him Prozac?"

Fran jerked her head up. "That's not fair."

"So what would be fair?"

She stiffened. "You ever think about why our patients are so sick and screwed up? It's not because of germs or bad genes or the wrong lifestyle. It's poverty and -"

"Don't take me for a fool, Fran."

"I don't." She shifted uncomfortably on the hard metal of her chair. "I just get tired of shoveling up the shit the world produces."

"So don't."

"Someone has to."

"Then figure out who you're treating, your patient or yourself."

Heat sprang to Fran's cheeks and she looked away.

"I'm sorry," he said. "I had no right to say that."

Neither spoke for several seconds. Fran turned back to him and took a deep breath. "So when you meet some refugee from Viet Nam, how do you feel?"

"Damn glad the war is over." He looked off over her shoulder. In the half-light she could see his eyes glisten.

"I'm sorry," she said.

He looked back at her. "For what?" Around his eyes and mouth the skin had tightened. He sighed and glanced at his watch. "Look, I don't want to miss the next bus." He rose and they looked at each other silently for a long moment before he turned away.

***

Mr. Truong held his left arm motionless in his lap and rubbed the shoulder. A month had passed since his catheterization.

"He says his left shoulder hurts him and the bones don't fit together right," the interpreter said.

Fran frowned. "Is he still seeing the physical therapist?"

"He wasn't able to go. He has to take care of the grandchildren."

Mr. Truong sat on the exam table on top a silver layer of duct tape. Fran coached him to let his arm hang loose. When she tried to raise his arm, he brought his shoulder up in a shrug, which allowed some lift in the arm without moving the shoulder joint at all. The shoulder was freezing up.

At last — a problem she could do something about.

"I'll have our social worker make sure he has child care and transportation so he can go back to the physical therapist. I would like him to take this anti-inflammatory medication and I'll see him again in a couple of weeks." She tore a prescription off her pad and handed it to him.

As she stood to go, he rose and bowed. For a brief moment, a smile broke his face.

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