Bedside Manners: A Novel

Chapter One

Marnie

See one, do one, teach one.

The commonly recited medical school adage played over and over in Marnie’s mind as she walked past the nursing station, Room 523 approaching much too quickly. It wasn’t even noon on the first day of her surgery rotation and already she’d been given an assignment way out of her comfort zone. Before turning into the patient’s room, she stopped to wash her hands, willing her heart to slow down. Was she really expected to change a colostomy bag on her first day? Could this be a joke? Maybe it was a rite of passage that all fourth-year medical students went through on their first day on the wards. The floor nurse who had given her the assignment had certainly earned her reputation as a joker. Stories about the clever tricks Darlene played on unsuspecting newbies were always circulating among the students. Though Marnie had known this rotation would be challenging and emotional, she had not expected to be asked to change a colostomy bag on her first day. She’d never even seen one.

She entered Room 523 and assessed the young man lying in the bed who didn’t look any older than thirty. This can’t be the right room, Marnie thought as she slipped her patient list out of her pocket to check the room number. The summary said that patient Adams was status post colectomy for ulcerative colitis, refractory to medical treatment. He was painfully thin, his collarbones protruding prominently on both sides to frame his angular chin. His skin looked like it hadn’t seen the sun in months. Maybe he was pale from anemia. She made a mental note to check his blood count when she got back to the nursing station.

Hello, Mr. Adams, she said, her voice just above a whisper. My name is Marnie Novak. His eyes were closed. Maybe she could figure out what she needed to do without waking him up. Unfortunately, the patient’s translucent eyelids fluttered open at the sound of her voice.

I’ll be the medical student on your team during your post-operative stay. Marnie hoped he wouldn’t notice the waver in her voice. Do you mind if I take a look at your bag?

Go ahead, he answered. My modesty left the building a long time ago.

Major surgery can do that to a person, she said.

She lifted the faded hospital gown to reveal his abdomen. The colostomy bag, filled with murky brown fluid, adhered to his scarred belly like a barnacle attached to the hull of a ship. There was a faint sulfuric smell, mostly contained by the clear plastic of the bag. Marnie had sailed through the more grotesque aspects of medical school. Dissecting her cadaver during gross anatomy hadn’t bothered her at all. She’d looked forward to her lab days, lingering over her cadaver long after her classmates had retired for the night, assuring that every vessel and nerve was perfectly exposed and cleaned of adherent fat. In the operating room, she was so focused on watching her attending surgeons fix the problem—relieving the bowel obstruction, severing the infected appendix, over-sewing the bleeding gastric ulcer—that she didn’t have time to think about how gross it was to be cutting apart people’s insides. But outside the operating room, the one thing that did bother her was foul odors. More than once since she’d started her third-year rotations on the wards, she had gagged as she entered a patient room, an unexpected smell assaulting her head on. The odor of an infected diabetic foot, the flesh rotting off the bone like neglected meat. The odor of blood in the stool, strangely sweet and rotten at the same time. The odor of the homeless man who used the ER as a shelter, his last shower more than a week ago. Hoping that her weakness would not affect her today, she grabbed an alcohol wipe from the bedside table, buying herself some time to figure out her next step.

As Marnie wiped the skin around the edges of the bag’s seal, her mind drifted to last week’s session in the medical student lounge. She had wandered into the student lounge at nine at night, her curly hair pulled back in a loose ponytail, just as her classmates were coming together to hear the war stories of the fourth-year students from their final rotations. They had willed their way through a whole month of grueling sixteen- to eighteen-hour workdays, answered innumerable pages in the middle of the night, learned to dose heparin and cut umbilical cords. Pamela Fishman had delivered five babies, including a set of twins. Eric Johannson had assisted in performing internal fixation of a hip fracture. Judith Gomez had scrubbed in on a heart transplant for a fifteen-year-old boy with severe cardiomyopathy.

Once everyone had settled in, Peter Skolnicki strode to the center of the room, coffee mug in hand, and cleared his throat. As part of the medical school tradition, an intern, chosen by a vote of his classmates right before graduation, presided over this monthly meeting. Peter was the obvious choice this year. He had been president of his medical school class all four years, one of those guys whose leadership potential had declared itself when he was still in diapers. Marnie had met him when he was the second-year student leading a tour during her first week, and he was already cocky back then.

Okay, let’s get started here. Close your mouths and open your ears, people. We have some good ones for you this month. Who wants to go first?

The room was silent, each of the exhausted students hoping someone else would be the first to share.

Someone needs to step up, people. I need my beauty rest. I have rounds at the butt crack of dawn. He turned to Pamela Fishman, Marnie’s best friend and roommate, and beckoned her toward the center of the room with both hands.

C’mon, Pammy, he said. Let’s get this party going.

Pam looked to her left and right before rising from her chair and taking a position at the center of the room. Okay, most of you guys know that I matched in gynecology. I was so excited to finally be doing what I want to do, delivering babies and taking care of women.

Yeah, we got it, Peter said. Get to the good part already.

Pam took a quick a breath and continued. So, on my second week, I was assigned a patient. We’ll call her Mrs. M. She came in with a distended belly, which she claimed had been that way for five days.

We know that routine, someone yelled from the back of the room. If someone says five days, it means five months.

Good teaching point, said Peter. You can’t always take what the patient says at face value. Go on, Pam.

We did a scan which showed a tumor the size of a watermelon filling her belly. We were sure it was going to be ovarian cancer. She needed an operation to remove it and I had to explain everything to her family. The husband cried the whole time, and the patient just stared, unable to process.

Did you get to scrub in? Marnie asked. She had heard parts of the story, but at the end of a long day at the hospital, Pam was rarely in the mood to share all of the gory details of her day. She would usually shovel greasy takeout food into her mouth and promptly retire to her room to get a few hours of sleep before the whole thing started again the next morning. Marnie wanted to hear everything, desperate to gain some tips from Pam that would help her prepare for her final surgical rotation. But every time she asked questions, Pam would respond with one-sentence answers, glossing over the minute-by-minute details Marnie really longed to hear.

Yes. We took her to the operating room the next day. This thing was huge, even bigger than it looked on the scans. It was glistening like a water balloon and, even weirder, it was pulsating from the heartbeat in the aorta right behind it. Seriously amazing. The specimen weighed almost fourteen pounds!

So, what was the verdict? Adenocarcinoma? asked Peter, clearly trying to move the story along so that everyone would have a turn at show and tell.

Nope. When we got the pathology back a few days later, it was totally benign, not cancer at all. The husband was so happy he didn’t know what to do. He stopped me in the hall and hugged me out of the blue. Then he opened his wallet and tried to give me a hundred-dollar bill.

You didn’t take it, did you? another student asked.

Of course not. Is that what you guys think of me? I handed it back to him and congratulated him on his stroke of good luck.

Good story, Pam, Peter said.

I’m not done, Pam said. Post-op she was doing fine, ready to go home the next day. When I went to see her on my daily rounds, she told me that she felt something pull in her groin.

Here comes more drama. Peter said.

So, I lifted up her gown, Pam said. And she was gushing blood all over the place. Her femoral catheter got pulled out by mistake. Of course, I knew that I should put pressure on the area to stop the bleeding, but somehow that common sense flew out of my brain.

It’s not uncommon to panic, Peter said. When your adrenaline levels shoot up, it can be hard to remember things. The best thing to do is take a deep breath and try to think rationally.

I know that’s what I should have done. But I saw the terrified look on my patient’s face and I did the only thing I could think to do. Pam paused for dramatic effect. I pressed the call button and waited for her nurse to handle the situation. A ripple of laughter spread across the room.

Now, Marnie wished that there could have been a story about a colostomy bag as she peeled a corner of the sticky tape around the bag from her patient’s belly. He winced and then glanced up to meet Marnie’s eyes, the corners of his mouth turning up in a knowing smile. She had no idea what she was doing, and he knew it.

Mr. Adams, I think that it’s almost time to advance your diet to solid foods, she announced, in an attempt to distract his attention from her ineptitude. Leaning over the bed, her right hand found the call button on the inside of the side rail while her left hand continued to peel off the remaining tape around the bag. Mr. Adams didn’t seem to notice her stealth maneuver.

It will be nice to move on from broth and generic brand chocolate pudding, he said. Though I’m not sure the hospital food gets rave reviews.

You’d be surprised, Marnie said. The tuna salad is actually edible, and a hungry person might even classify the meatballs as delicious. She was fully prepared to continue with a full review of the hospital menu, item by item, while waiting for the nurse to make her appearance. Luckily, the exhaustive culinary survey wasn’t necessary. Darlene flew into the room, rolling medicine cart in tow.

Mr. Adams, it’s time for your afternoon meds. I was coming in here anyway. Is there something you need from me?

Before the patient had a chance to respond, Marnie said, No, Mr. Adams and I were having an interesting conversation about the ups and downs of hospital cuisine. But now that you’re here, we wouldn’t mind seeing how you change a colostomy bag. We’ve heard you’re the best in the business.

Darlene tossed her auburn curls over her shoulder and pulled on a pair of gloves. Wow, now that’s a compliment if I’ve ever heard one.

She pulled back the seal at the edges of the colostomy bag. One of the most important things for you to learn this month is not to be ashamed to admit when you’re in over your head. She stepped back as the potent smell of feces filled the room. You can’t know everything at this point in your training. Don’t be afraid to call for help when the shit hits the fan.

You might need me again in Room 537, she whispered in Marnie’s ear. Let her know you’re coming. You never know what could be going on in there.

Marnie escaped the room and consulted her patient list. The patient in Room 537 was a woman named Candy O’Neill, thirty-five years old. Marnie had heard gossip about the drug-using model from other medical students and residents. Candy had spent six of the last nine months in the hospital. According to the ridiculously long chart, she had injected bacteria into her bloodstream and developed bacterial endocarditis, a serious infection of the inner lining of the heart. After several long courses of antibiotics, dialysis for kidney failure, and a few close calls with death, she had walked out of the hospital unassisted, a feat none of her doctors would have predicted. Her modeling days clearly over, she had gone home and immediately shot up. Only three months after discharge, she’d landed back in intensive care with bacterial endocarditis again. This time, her heart valves were so severely damaged that she’d required open-heart surgery. Now, she was a month out from surgery and she was gaining strength for discharge.

The door to Room 537 was closed. Marnie knocked and waited for an answer.

Ms. O’Neill?

Still no answer.

Ms. O’Neill, are you there?

What do you want? a throaty voice called from behind the door.

I’m a new medical student on your team. I just wanted to introduce myself.

A few seconds passed. Do whatever the fuck you want, the voice said.

Marnie eased the door open. The stench of stale cigarette smoke coated the walls. Remnants of several meal trays littered the windowsill: Kozy Shack pudding cups, overly ripened bananas, packets of oyster crackers, Ensure protein beverages.

I’m on the potty, Candy yelled through the open bathroom door.

Are you going to be a while? Marnie averted her eyes from the bathroom in attempt to give her patient some privacy.

Nope, I’m done. Candy limped out of the bathroom, pulling a pair of sweat shorts up around her bony hips. Her appearance was shocking. Even though Marnie had known that Candy was critically ill, she’d still expected her to be beautiful. She was thin, not in a Heidi Klum sort of way, but more in an emaciated child-who-needs-your-cost-of-a-cup-of-coffee kind of way. The hospital would not be using her in any of their fancy real patient TV ad campaigns. Her strawberry blond hair was cropped short around her pointed face. Brown, crusted blood encircling both nostrils contrasted with the translucence of her skin. Her abdomen was distended, as if she had a basketball stored away inside. Marnie remembered reading something in the chart about hepatitis C. She must have fluid in her belly from liver failure, Marnie thought as she stepped forward to introduce herself.

Uh, hello, it’s nice to meet you. Marnie said, trying her best not to let her face reveal her shock.

Candy ignored Marnie’s outstretched hand. Yeah, yeah, the pleasure’s all mine or whatever.

Making her way over to the chair, she eased herself down, using both armrests for support. Both of her legs were massively swollen and dotted with festering sores that oozed blood and green-yellow pus. Marnie had read in the chart that these sores were caused by bits of infected heart valve that had broken off and traveled to lodge in her skin. Candy looked down at her legs. Quite a train wreck, I know. It’s the same response whenever I get new house staff.

I didn’t say that. I would never. . . .

You didn’t have to. I can see the look on your face. Candy pulled the footrest closer and heaved her legs up onto it. Are we done for today? Because I’m losing interest.

Well, I’m supposed to interview you. Marnie shifted her weight from one foot to the other. I mean, take a history on you. It’s my first day, and I’m trying to get to know all of the patients on my list.

You’re talking to me like I haven’t been through this a thousand times.

Through what?

People waltzing in here and asking me the same fucking questions over and over, she said.

I’m sorry, I’m just trying to do my job.

I’m sick of the touchy-feely questions and rapport-building shit. I’ve had enough.

It won’t take long, Marnie pulled out her paper to take notes. Let’s start with your family history.

Allow me to suggest an informative place to gather whatever details you might need, Candy said. She grabbed a magazine from a pile on the bed and opened it in front of her face. My chart. It’s a good read. The conversation was over.

Chapter Two

Joyce

This is not a big deal. It’s not really a lump, she thought, just a little ridge of skin, a thickening. She recalled reading an article in O magazine about knowing your breasts. It said something like ridges and lumpiness can be normal, and that neither of these things is cause for alarm. Of course, it also said that any changes should be evaluated by a healthcare professional. All this information had been printed in bright pink, an ad for spray-on deodorant on the opposite page.

She never read these articles too closely. All this hype about breasts was ridiculous. Everywhere she turned there were pink ribbons, public service announcements about mammograms, subway cars and buses wrapped in pink. Breast cancer had become almost like a club. There could even be a sub-section of Hadassah—the Jewish women’s group Joyce belonged to—dedicated to breast cancer survivors. They could meet once a month wearing expensive pink outfits and pink ribbon pins and reminisce about how much they missed seeing their handsome oncologists every week. They could compare lumpectomy scars and plan which 5K walk to do in the coming months. Joyce had no desire to be a part of that club.

She put on a plain white bra, so old that the edges were frayed and the material was almost see-through. Alan didn’t like this bra. He was always nagging her to buy slinky camisoles and sexy underwear. This discussion had been going on for the nearly forty years they’d been married. Every February, he brought up this topic on the off chance that this Valentine’s Day she would finally acquiesce and buy a black lace thong and push-up bra at Victoria’s Secret. Their upcoming fortieth anniversary would be a good time for him to relinquish the quest, she thought. It could be his present to her. He wouldn’t want to see her in those ridiculous garments at this point anyway. At sixty, her muffin top would spill over the lace waistband, and her sagging breasts needed more support than a flimsy lace number could provide. Alan always said that he still found her sexy despite her wrinkles, age spots, and fat rolls, but she never fully believed him.

She put on a tank top and matching hoodie sweatshirt, and a pair of black yoga pants, trying to remember when it had become acceptable to wear gym clothes despite having no intention of engaging in physical activity of any sort. But, there was a quiet freedom in not having to get dressed up. She used to wear layers of makeup just to do errands. Now she barely brushed some powder and light blush over her cheeks before running out the door.

She sat down to put on her socks and picked up her phone. She typed thickening in breast into Google and waited for the results. One of the top search results jumped out at her:

What is breast cancer? Medical News Today

The first symptoms of breast cancer are usually an area of thickened tissue in the woman’s breast or a lump.

Her eyes scanned down the page, hoping to find something positive to latch on to. She saw one result that provided a glimmer of hope:

Non cancerous conditions of the breast—

American Cancer Society.

A thickening can be caused by a number of benign conditions including cysts and benign lumps such as fibroadenomas

See, this couldn’t be cancer. She threw the phone onto the table and sighed. Cancer just didn’t have a place in her life right now. Marnie was getting married in five months. Who had come up with the tradition that the bride’s family should pay for and plan the whole event? Clearly it must have originated with a family of many sons. Thankfully, paying for the wedding was not an issue. Alan had done well for himself. He had been smart enough to open his dental practice in Westport before the vultures descended, opening up their offices in every corner of town, preying on the vain, narcissistic suburbanites who demanded perfectly straight, unnaturally white teeth. By then, Alan’s practice was already well established with a clientele of older, more reasonable residents who had lived in Westport since the old days, when Main Street had only independent stores like Bill’s Smoke Shop, the Remarkable Bookstore, and Country Gal. Now the street was populated with chain stores—The Gap, Ann Taylor, J Crew—all of the merchandise manufactured in China and sold to unsuspecting customers who would watch the garments disintegrate in the washing machine during the first laundering. His patients did not demand Invisalign treatment because one tooth was slightly misaligned and didn’t fit with their perky breast implants and over-processed, keratinized hair. His patients had actual dental problems, not infrequently requiring root canals or complex implant procedures. Between these long-time patients and their friends and family, Alan’s schedule was more than full.

While the success of Alan’s practice was, of course, related to his skill as a practitioner, Joyce had played a significant role in building and sustaining the business, working as his office manager since the beginning. But she was always self-effacing when speaking about her job at the office. How could her contributions compare with Alan’s? He had gone through college, dental school, and specialized training in implant placement. Joyce hadn’t even graduated from Brooklyn College, leaving after two years to move with Alan to New Haven for dental school. At the time, the decision had been easy. Her husband was moving on to create a career for himself. She’d never thought twice about accompanying him. So yes, the money for the wedding they could handle. It was the time commitment that planning a wedding demanded that had thrown Joyce for a loop.

When Marnie called last fall to tell them that Carson had proposed, Joyce had felt a complex mix of emotions. Of course, she was happy for her baby girl, but at the same time, she wasn’t sure Carson was the one for her. Marnie had been a serial monogamist, sliding from one boyfriend to the next as easily as an Olympic swimmer doing a flip turn at the end of the lane. She’d always insisted that Joyce and Alan meet her boyfriends somewhere between months three and five, scheduling awkward meetings at various restaurants and coffee shops in Manhattan. After many of these encounters, her precious time donated in the name of her relationship with her daughter, Joyce had started to secretly resent Marnie for asking them to meet every boyfriend before the relationship had solidified. But there was no polite way to extricate herself. With each new boyfriend, her daughter was always convinced that this was the one. How could Joyce tell Marnie that a man from Staten Island with a subscription to Car and Driver magazine was probably not her perfect match?

Still, Joyce had played the role of supportive mother well, dutifully meeting every boyfriend, shaking hands, and making small talk over cappuccinos and biscotti while Alan sat at the table, his chair pushed back just enough to make it clear to Joyce that he was not invested, checking his email on his phone every three and a half minutes. Joyce had liked Carson immediately. He was completely different from the shy, cerebral guys Marnie usually dated, but Joyce could see why Marnie was attracted to him. He was friendly and handsome, the kind of guy who turned heads when he walked into a room. But, Carson was different in another important way Joyce found difficult to ignore. Carson wasn’t Jewish. Even Mr. Car and Driver had been Jewish. Joyce had always assumed Marnie would marry a Jewish man, but she hadn’t shared her disappointment. She couldn’t imagine how she could communicate her feelings without creating a gaping rift between them, and she didn’t think it would be fair to Marnie. Joyce wasn’t marrying Carson, Marnie was, and if she was happy with him, that was all that mattered.

Immediately after the engagement, Joyce told Alan that she would be taking a leave of absence from the dental office to plan the wedding. There was no way Marnie would have the time for planning. Between finishing her medical school requirements and starting her surgery internship in July, she would barely have time to brush her teeth. She had already booked the location for the reception, the caterer, and the band, but she still had to find a florist, pick centerpieces, and compile the guest list for the invitations. Yvonne, Alan’s assistant, would do Joyce’s work until late September. Yvonne had