Emmaus: Field Notes from the Wards
Here vigour failed the lofty fantasy:
But now was turning my desire and will,
Even as a wheel that equally is moved,
The Love which moves the sun and the other stars.Dante, Paradiso, Canto XXXIII
I
I stared at the glass door being splattered with fat, languid drops of rain, blearing my view of a dusky late-autumn city street. Hazy headlights passed over the frame as I released a deep, self-pitying exhalation. The ephemeral beauty of early autumn in Philadelphia had long passed, and we were left with the usual filth. I pulled up my hood, tucked my chin, and backed out onto Tenth Street. Car horns rung like an army of church bells out of sync, one after another, as I strode, eyes downcast, down the half block from my dormitory to the class building. I was late—two minutes tardy according to my laptop’s clock, which I opened as I slunk into one of the seats closest to the seminar door, but it still made my skin crawl. I hated being late.
Being one of only two second-year students in the classroom, I relished playing the role of the grizzled veteran amongst a crowd of chipper first year students still basking in the glory of matriculation. I couldn’t stand their smiles and optimism at the start of their medical journey. If there is one thing the past year had taught me, I told myself, it was that things can and will get so much worse.
Unlike most courses that I had taken during my first two years of medical school, we sat not in an auditorium or huddled in small groups, but in one big circle around the professor. This was no ordinary course, but an elective, one of the precious few offered to preclinical students. I had chosen “Medicine and Literature” because, as a former humanities major turned pre-med, this was my jam. In the isolation of the recent past, my most loyal friends had become writers long dead—they alone seemed to speak truths that we were no longer interested in.
Time ticked by as our professor, a PhD on loan from the undergraduate college, spoke in succession about various assigned readings for the week. The group added their own fragments at regular intervals, doing so with exquisite care, acutely conscious of their new peers’ predilections.
Finally, we approached the week’s final reading. This one had caught my eye the night before, so I perked up and closed my laptop. What I didn’t know when I first signed up for this course was that medical fiction, or fiction of medicine, or medical literature, or whatever permutation it was properly called, is horribly derivative. The handful of well-worn tropes had been well represented in our coursework, and by this late in the semester I had lost most of my interest. However, this story was different. The story was of a young woman named Rosie and her struggle with bipolar disorder, told through her sister’s eyes. It was a story of their family’s struggle to cope with her erratic behavior after the retirement of her heroic elderly psychiatrist. Despite their better angels, the family grew to resent the way Rosie’s illness dominated their lives, the time she consumed, and the heartache she caused them. Rosie struggled to heal, but she also knew all too well the trouble that she caused. The story ended with Rosie’s sister sitting beside her in the woods, calmly watching her die of intentional barbiturate overdose. It was a gut punch, turning to the reader, subtly implicating you in the pain and injustice of this suffering soul. It was horribly beautiful.
“What was your reaction to this story? What does the ending mean?” prompted the professor, seeming to beg us, anyone, to please say something. A few ticks of the clock sounded. Practically bursting with commentary, I resisted raising my hand, knowing my own abrasive tendency. I would wait. A few more seconds was all I had in me. Thankfully another hand shot up—a talkative first year from New York. The die had been cast, and I waited to hear where we would start with this meaty beast of a story.
After some generic commentary on mental health statistics, he began to pivot towards the final act. He was hitting all the beats in my head: the tortured soul, the exhausted family, Rosie made to feel a burden. Waiting for the concluding strike, I knew where he was going, and felt an ever-so slight tinge of vain bitterness that I wouldn’t be the one to say it. I was wrong.
“…this was the only way she could assert her autonomy. This was how she could take back her power from her family and her illness. Her sister realized that and affirmed it… It was her treatment.”
I blinked twice, like someone trying to send an SOS in morse code. Her… autonomy? … Did I misunderstand? … I struggled to formulate a coherent thought over the buzzing numbness that had washed over my mind, blindsided. I refocused on the external world in time to see a tide of heads shaking up and down, down and up. Two others chimed in, reiterating the same synthesis before the clock struck the hour. Class was over. I slung my bag over my shoulder and made for the door. It was still raining outside, but I didn’t bother putting my hood up. The rain felt good in the incandescent, stale city air.
That night I couldn’t sleep. I kept thinking about what had been said: suicide as a treatment for mental illness, for suffering. And everyone loved it. My mind went to family, to friends. I thought of their years of quiet pain. I also thought of pure, wild joys that we shared. My mind turned to myself.
Countless individuals gazed daily into the black pit of despair and isolation that one might call hell and struggled to not dive in. And now we were talking about prescribing it? Is this the reality that my classmates wanted? I struggled to make it seem reasonable and failed. I kicked off the covers and lay bare-chested in the cold room, steaming and convulsing in the dark. Suffering cannot be eradicated with barbiturates; it can’t be eradicated at all. It can only be made near.
I prayed for God to take away my bitterness as my body cooled in the early hours of the morning. The white light of my anger sputtered and died, and I was left with a sort of somber acceptance. Gashes of orange streetlight shone through the cracks of my broken blinds, illuminating the dust-filled miasma of the room. I prayed that He would show them that we can’t weigh the breath of life against pounds of suffering flesh, that we cannot judge—that life is worth more than we think in those black holes of despair and chaos which we all descend, that we as physicians must sit with them as they suffer, sweaty and bleary-eyed, raging on their gurney beds. Nobody is a burden; we are all the very same thing, the one true thing that exists.
II
“Let’s go see your father.”
Mary Jean heeded her mother’s plain-dealing voice and herded her two younger siblings into the front yard. She slipped out sideways as the screen door of their three-room rowhouse slapped shut, careful to avoid dirtying her white holiday dress. Mary Jean was a serious child with a square, broad face, the likes of which would never be picked out in a crowd. She had yet to see her tenth birthday but was born old, and her mother naturally deputized her with charge of “the young ones.” Even into their ripe old age, her siblings would always refer to Mary Jean by her full Christian name as a sign of deference.
The family piled into a neighbor’s motorcar and hobbled out of their neighborhood, past the dark clapboard bar, and out onto 209 towards town. US Route 209, the main thoroughfare connecting their small borough of New Philadelphia to the comparative metropole of Pottsville, had been completed a few years prior as an early route of the New Deal highway plan. Years later, Route 209 would carry Mary Jean and her siblings between home and Pottsville Catholic High, but today the road led elsewhere. The car lumbered along a landscape resembling that of her ancestors—less the whimsical emerald hills of County Cork and more the somber black-earth forests of Slovakia. The Easter sun worked to burn mist off the hills.
There was little holiday cheer as Mrs. Mack and her children arrived at the local hospital. Mr. Mack had been an inpatient here for weeks, if not months, as his condition worsened. He was still a young man, barely in his forties, but years of hard labor had aged him prematurely like all miners. The cause of his decline was a bit muddled—pulmonary tuberculosis, black lung, or perhaps a combination—but the results were the same. He was dying.
Hospital policy forbade in-person visits to his ward, so the Macks walked away from the entryway and towards the hospital garden. They settled in their usual spot below his window and waited. Mary Jean’s mother busied herself making the children look presentable, straightening the girls’ headwear and young Jimmy’s tie. It only took a few minutes for him to approach the window. Three floors up, the children saw their crouched father, hollow-eyed in the half-light, and waved.
Mary Jean grew up without her father. Each one of her older siblings left the tiny borough, some for war and some for work. When it was her turn to graduate high school, she found direction in an additional mission of the Sisters who educated her. A classmate from home was already in training at a nursing school in Philadelphia, and Mary Jean joined her the summer after graduation. Misericordia Hospital had a bustling school of nurses in a vibrant neighborhood of West Philadelphia. Surprisingly, perhaps mostly to herself, the coal miner’s daughter thrived in the big city. She loved shopping in boutiques on fashionable 69th Street and going to the movies, especially when they had anything starring Joseph Cotton, her Hollywood crush.
Two years of nursing school flew by amidst hard work and good cheer, and, after graduation, she took a job in the Misericordia emergency room, where she would eventually rise to departmental head. Her stiff, no-nonsense upbringing came in handy when dealing with the antics of a busy city ER.
One night at a charity dinner, she met a young high school teacher named Bob McCarthy. A few years her senior, the son of a mattress maker and a recent seminary drop-out, Bob taught math and Latin at inner-city public schools. They were wed after a brief courtship and started their family—my family.
I look down at my hands, lying limply in my lap, palms up, and flex my fingers. I’m fighting the warm, languid feeling that I always get when visiting my grandmom. She is a quiet woman, content to sit in silence for long stretches as she reclines across from me on her sofa—a quality that we share. I issue myself a mild reprimand for my drooping eyelids, and a stronger one for my frequent absence.
“… not much there anymore, it’s hard to believe,” concludes her son, sitting beside me on a folding chair. Their routine is familiar, where my dad drags one of a dozen or so stories out of his nonagenarian mother, but the locale is new. We aren’t in the living room of her home, but in a tiny, hotel-style bedroom. Since the last time I was home from school, a series of hospital trips convinced Mary Jean to accept the transition to a nursing facility. As far as these places go, this is a nice, new facility with a brighter than usual euphemistic name—not that this made her any happier about it.
Since I entered medical school, the subjects of these stories have become even fewer, focusing almost entirely on health or healthcare: her career in nursing, her father’s illness, and her own medical conditions and mishaps. In fairness, the lengthy periods between my usual visits means that she very well may forget our last visit’s discussion.
My dad sits with his fingers interlocked behind his head. He was always her favorite child, a handsome scholar-athlete in his youth turned successful lawyer, and she thought he practically walked on water. Leaning against his chair is a grocery bag containing a bottle of cheap white wine, a luxury that my grandmom insists upon, and which has become my dad’s weekly offering. Having successfully shaken myself awake, I hear that they are now finishing the story about her old days at Misericordia Hospital. Their dynamic reminds me of Abbott and Costello, not in the comedic timing but rather their well-rehearsed banter.
“Do you remember any of the doctors who worked with you in the ER?” my dad inquires, teeing her up for my favorite line of the bit.
“Oh yes!” she responds with as much enthusiasm as I have seen from her all day; “I remember all the young residents, they were always so stupid, we had to teach them everything.”
III
My grandmother’s words spun through my mind as I sat bored on a graveyard shift in the Emergency Department during my third year of medical school. Unlike other units, there was no cozy out-of-the-way workroom in which to ride out the minutes of uselessness here. Instead, I sat, vulnerable, smack in the middle of “Core A.” Core A was a rectangular room with two open U-shaped computer bays guarding the doors of thirty-two patient rooms. The northern wall of rooms was broken by two trauma bays, standing ominously vacant.
No matter the day or hour, Core A was buzzing with humanity, which heightened my anxious boredom as I sat taking up space at one of the desktops. This was December, and by this point in my third year of training I was an expert at appearing busy. From a sea of stoic-faced nurses and ornamental scrub caps, a flash of familiar color caught my eye. I looked up to find my resident holding out a mustard yellow, hard-plastic folder. This event occurred with some regularity: once or twice an hour, my assigned resident would recall my existence, swing by my computer station, and hand me a new patient chart. The ED was old-fashioned, being the last hospital department to use physical charts for anything other than nostalgic decor.
“You can take this human,” he said with his usual affectated substitute for patient, “you know where to get a stapler?” In fact, I did not know where to get the aforementioned laceration repair kit, but I nodded and mumbled something like an affirmation. Happy to be rid of this responsibility, the resident turned and made his escape.
After groping in a few supply closets for equipment, I sat back down at my workstation and opened the chart. My patient was an elderly man with Alzheimer’s Disease who made frequent trips to the emergency department for falls. Most of his records consisted of terse triage notes and emergency visits. No outpatient records or consultant notes, often seen as a gold mine of valuable information, were available. I closed the chart marked “HB 8” and walked into the hallway outside Core A, confident that this would be a straightforward case.
The halls snaking between various cores of the Emergency Department are used as space for overflow beds when needed and, for the last several weeks of the Omicron variant surge, they were brimming with patients. Faces mechanically turned up towards me as I walked past a column of hall beds towards number eight: tired faces, angry faces, expressionless faces, but no happy faces. A distinct patient population occupied our hall beds—older patients, “frequent fliers,” patients with cognitive impairment, nursing home residents, the homeless, or those with minor injuries. The hall beds, it seemed to say, could wait.
As I approached bed number eight, I was greeted with only a slight head bob of acknowledgment instead of the usual turn-and-stare. I crouched to meet his eyes and commenced with my usual introductory spiel. He moaned and cast his eyes down, away from mine. In his defense, with my face covered by a surgical mask and safety glasses, I wasn’t much to look at.
The patient was silent, but it didn’t take an expensive medical degree to see what had happened. His long grey hair, which I imagined as a vestige of flowery youthful rebellion, was tangled and misshapen by dried blood covering the left half of his skull. Somewhere under that red-black coagulated shell of hair was a wound that needed dressing; I just had to find it.
Armed with a few towels and a basin of water, I washed his hair. I tried to be gentle, but every few minutes I would tug on a tangle of clotty hair and his tired wail would reveal my error. He was gentle with me too. The rhythm and clear purpose of this task soothed me. After thirty minutes, the basin’s water was opaque, and I had found the mess’s source: a thin two-inch laceration over his left parietal skull. So much had come out of so little. I placed the wet pinkish towels into the basin and picked up the stapler, feeling its smooth plastic contours in my hand. I had, in fact, never used one of these before, but I wasn’t about to pester my resident’s already fractionated consciousness with something so menial. Besides, this was my patient. With my left hand, I approximated the two sides of his wound, feeling the old man’s skin loose under my fingers. I aimed and fired a staple in slow motion, feeling its metal teeth pierce his flesh bit by bit. He remained perfectly still, perhaps asleep, making no sign of recognition. This ritual was repeated four more times in precise order—middle, one end, then the other, and split the differences. I collected my vessels and cloths, my broken alabaster jars, leaving the tired old man snoozing, still unstuck in time but for the moment whole, for the moment clean. He looked like an overgrown baby, hair wet, put down for a nap after his bath.
It felt good to be useful, it felt good to hold split-open flesh and make it one, to wash grime and blood from someone left alone in the timeless limbo of hall beds. It felt even better that he couldn’t thank me, that he didn’t even know I was there. He let me for one precious moment cease to exist, to become something other than “me.” Me, me, me. How exhausting? How banal? I had become something else—nothing but a pair of directed hands on an immortal body. As I drove out of the hospital parking lot in the early snowy hours, I nearly wept with joy.
IV
I’ve never been very good at paying attention. When my wife, Mary, and I go out for dinner or a coffee date, we are always sure to find me a seat situated facing away from the center of the action. She jokes that I am easily overstimulated—I blame my iPhone. That is why I now bow my head and close my eyes, covering my face with two open palms. I breathe in, feeling my lungs expand like bellows, sucking in the sweet smell of incense. I open my eyes and see intricate marble tiles, arrayed in whirling lemniscates of white, deep blue, and gold. A few meters beneath my feet lie two thousand years of ancient Roman ruins, immortalized in earthen tiers, stumbled upon by the son of an Irish farmer.
I hear the sweet reverberations of Italian and look ahead, just making out a white-clad man with arms raised above the schola cantorum, made diminutive by a shining old-gold apse mosaic. His words fall on deaf anglophone ears, but I know exactly what he is saying. I bow my head again and murmur the response, not in the language of this country nor my own, but in the one that everyone here shares—“Domine, non sum dignus, ut intres sub tectum meum: sed tantum dic verbo, et sanabitur anima mea.” I feel each word of the centurion fall from my lips in molten Latin as I desperately beg, like he did, to be healed. I rise and move towards the altar, where the priest places God gently in my mouth. I move my tongue up towards my hard palate, breaking the dusty sacrament in two, feeling His bones break.
A few minutes later my wife and I walk hand-in-hand out into the amber evening sun, leaving San Clemente for the final time. During the daytime hours, these streets are heavy with tourists traveling between the nearby Colosseum and Lateran Basilica. Tonight, they are practically empty. Café owners lean against their door frames smoking cigarettes as the first diners make their way to empty terrace tables. Their tobacco intertwines with the last whiffs of incense escaping the basilica in a dance of two rival deaths.
The sacraments have always made us a rather bizarre bunch. The material world, to many, seems so cheap compared to abstractions of the spirit. The spirit, they say, is what matters—not the body. As I clutch my wife’s hand in the shadow of the Eternal City, running my finger over the smooth surface of her new wedding band, I can’t help but know that her spirit and flesh are but one beloved composite, and that the world is a beautiful place, overflowing with countless lives. I couldn’t bear to leave it. God felt the same—He never left either. I think of the words of the good Dr. Percy: it is pilgrims that we are, wayfarers, not pigs, not angels.
The body ages and breaks because mankind ages and breaks. We doctors put the body back together as best we can, but in the end our efforts will always fail. We are imperfect healers, wounded ourselves, incapable of anything except buying time. When you look down at the hospital bed and see not intricate, exceptional machines, but rather gaze sacramentally—on the little incorporated gods that they are—you can at least love them. You won’t lose heart when you can’t put the machine back together again. You would take solace knowing that this person will be made new one day, body and soul, by the one person who can, the same person who heals me when I remember to ask Him.
Mary pulls me towards a little osteria that caught her eye, and I move to see a menu affixed beside the door. A smiling bronzed woman, about our age, pops out of the open door. “Francais?” she asks—eager but genuine, in a way that only Italians are. I grin, flattered and satisfied in her mistake. “English,” I respond apologetically. We sit down beside the sleepy street. I grasp Mary’s hand across the table and see her flecked brown eyes and darkening olive skin, happy to be back under their ancestral sun.
It is hard to explain the level of actualization that I feel in this city. The profusion of baroque churches, clergy promenading in habits without attracting countless suspicious eyes, Madonnelles watching from every street corner. It is the one place where I haven’t had to think about being foreign. Back home, in a land of burning crosses and fire-bombed churches, Catholics remain unwelcome. America, a country built on a creed, can’t bear a rival. Often, I’ve felt like an orphan.
Perhaps that is why I have found myself drawn to the abandoned. The demented old man left to rot in an emergency room hall, the metastatic cancer patient with precious little time left, those suffering who are no longer seen as “useful.” These people are all left abandoned by our increasingly impersonal healthcare system.
Since starting my journey to become a physician, I’ve come to see that I am no orphan. I am a pilgrim, far from home, but traveling with one closer to me than myself, one who chose to take on those painful burdens of the traveler’s road with me. This is the ultimate personalism—choosing to enter into the pain and messiness of another person’s life and staying there, just staying there with them.
The last vestiges of the day’s sun send long shadows down the Via di San Giovanni in Laterano as the dulcet hum of voices mix with clinking silverware. In a few minutes this city will be clothed in darkness, but for now I can still make out the delicately carved image on the wall above Mary’s head—a sunburst with an image of young woman inside. There I see her, my lovely Mother, eyes cast down, watching us, her wayward prodigal children, as we stumble our way back home.
My mind wanders over memories of past years—countless exhibits of my own foolishness, precious few icons of humble success, epic failures of a broken system in a broken world—seemingly so far from present halcyon days. I know that in a few days, I will be back, and that the years ahead will carry so much of the same, that I will not be living some glorious romance of heroism. Rather, I take it all—and I desperately try to love it all—because You know all things, and You know that I love You.
V
I braced myself against the clear, white morning light that shone blindingly down the sterile hallway. I hurried across the linoleum floor, towards the window from which it emanated, and halted outside the last door on the left. Of all hospitals that I had studied in, this was the cleanest. Reflecting my surroundings, I sported not my usual greasy hospital scrubs, but rather smart business casual—white dress shirt, black chinos, short white coat, and a very cheap pair of black oxfords. All the external features of this rotation on oncology had been immaculate, regular, orderly.
It was nearing 3:00pm on my final day of this rotation at one of my school’s affiliated suburban hospitals. Despite an averseness to nitty-gritty basic science, I had enjoyed my time on service. There seemed to be a real nobility to being an oncologist, an authentic personalism that had been sucked from many of the other fields of medicine. Patients also rarely saw their oncologists as the bad guy—they brought them little offerings, firm handshakes, and tears of appreciation. I would be sad to leave.
I looked at my paper and then up to the door, confirming that I was in the right place. This would be my last patient—a new diagnosis. I knocked on the open door and entered.
On the inpatient oncology consult service, there was usually very little agenda to be discussed with patients. Unlike most other services, almost all necessary information for formulating a diagnosis and plan can be found in the lab and imaging results. Our time face-to-face with patients was largely theirs to determine. A year ago, the idea of walking into a newly diagnosed cancer patient’s room with no agenda would have terrified me but, as a fourth year mere months away from graduation, I had faith.
A woman in her sixties with short, silver hair sat on the armchair beside her bed, head bent over an open book. “Mrs. Biedrzycki?” I ventured, hoping she would have mercy on my pronunciation. She closed her book and looked up. Hazel eyes, crinkled at the corners, looked back at me softly, and she smiled.
We sat together. I asked her what she knew, and she told me. She asked me what our plan was, and I told her. She told me about her family—her hard-working but distant husband, her kids and grandkids, her life all within a ten-mile radius of the room in which we sat. I asked her what brought her joy and how she felt about death. She told me those too.
“Does faith or spirituality play a role in your life?” I asked her. This, too, would have brought me fear a few months ago—the delicate things that we aren’t usually supposed to talk about. However, over the past month I had seen that delicate things were welcome in oncology.
She talked for a long time. Raised Christian in an era when everybody was, she and her husband had fallen away as young adults for no particular reason other than the busyness of family life. She had tried different churches as she had grown older—most of them she had liked, but none lasted. As of late, her husband had become a weekly churchgoer again, but she didn’t go with him. “I believe in God, I read the Bible,” she confessed, “but I don’t know what to do with it.” I nodded in silence and listened.
It was time for me to leave and meet up with the team already on afternoon rounds. As I made to depart, explaining that I would be back in a short while with my “bosses,” I noticed the black rubber bracelet on my wrist. It was not some unique item; countless of these sat in big plastic bags in the consult work room, ordered by one of the fellows. The band read, “The Lord sustains them,” and on the other side, “He will make them well again.” The fellow, a first-year from West Africa, had explained, “I offer them to all my patients; I just say it is a little bit of hope.” I was skeptical at first, but after weeks of seeing his patients’ effusive adoration for the fellow, I began to believe in him.
I removed the rubber bracelet from my wrist and turned towards her. “Miss,” I began, for the first time today feeling a twinge of tremulousness, “one of my bosses made these bands for his patients… just as a little sign of hope.” Then, I looked down at the text and read it to her, asking her if she would like to have it. I was scared to look up. Had I really stepped in it this time?
I always wanted to be the type of doctor who saw people for more than just a collection of interconnected parts. We slice and dice bodies into neat collections, we itemize health on computer screens as lives are reduced to adjectives and data points. Confronted with a seemingly endless stream of pain through our hospital doors, most can only think to laugh at the flesh, to die, or make it sterile. But I didn’t come to do any of that. I don’t want the clean and the sterile, I want the mess, and the messiest part of man isn’t the flesh. I came to heal, the act W.H. Auden once called, “not a science, but the intuitive art of wooing nature.”
I looked up at my dying patient. She looked straight at me, knowingly, and let a huge smile curl from ear to ear. She shook her head yes and began to cry. She took the bracelet from my hand and slipped it on her right wrist, patting it with her left hand as if to welcome it home.