Maqua

By Will Smythe

(Narrative)

“I – am – doctor – from – United – Arab – Emirates!”

A short, stocky and heavily black-mustached man, dressed in a tan linen suit, was speaking to me, emphatically, as I approached the exam room of my next clinic patient.  He was standing outside the door, almost as if at attention, his legs stiff and held close together, his expertly polished brown wingtips pointing away from one another, at forty-five degree angles beneath the wide cuffs at the bottom of his pants.

“Um…, okay…, nice to meet you,” I said, “are you with this patient?”

“YES!” he replied.

“Are you related to the patient?” I asked.

“NO!” he replied again, a little too loud, smiling broadly.  He offered his hand and I reciprocated.  He grasped mine firmly and jerked, rather than shook, it violently up and down.  I looked down the hallway to see if anyone else had witnessed this exchange, and might provide some explanation, but we were alone.

“Do you have permission to come in with me…, to see the patient?” I asked expectantly, worried about the delay this discussion might provide, with a long list of patients waiting to be seen.

“I – AM – DOCTOR – FROM – UNITED – ARAB – EMIRATES!” he replied, looking at me as if I was supposed to know why he was there, or what my next move was supposed to be.  I looked down at the patient’s chart in my left hand, my right one still in his grasp.

Arabic name, female, dysphagia, R/O cancer of the esophagus.  I looked up and at the man’s face again, for a long awkward moment.  He continued to smile, raised his bushy eyebrows, and squinted.  He then shook his head up and down as if he had affirmed something with me, or that we had agreed to share some secret during our very brief, and very odd, encounter.  I slipped my hand with some difficulty from his grip, and grabbed the doorknob.

“Excuse me, please,” I offered, smiling with clumsy, feigned politeness.  I opened the door and slipped into the exam room, leaving him standing there as I shut it behind me quickly.

When I entered the room, there were two women waiting.  I was immediately struck by the fact that they looked as if they were from completely different worlds, and if not, at least from very different parts of the same one.  An older woman, whom I assumed was my prospective patient, was sitting on the exam table.  Her size and shape were difficult to discern, with what appeared to be several layers of loosely fitting black thin cotton garments covering her body, from a tight head-dress that covered everything except the area of her face between forehead and chin, literally to her toes – numerous blouses with long sleeves, and multiple skirts.  Her dark figure stood out in sharp, stark contrast to the white walls, and the standard medical exam room light pastels.

The only exposed areas of skin were her face and hands.  They were dark brown and leathery, looking more etched than wrinkled.  Her eyes were an unusual, actually striking color – an amber background, with gold radiating out from the dark center. I hadn’t noted her age when I looked quickly at the paperwork outside, but she seemed ancient – both in dress and general appearance.  I glanced again at the chart, “only sixty-six”, I thought to myself, “wow, no sunscreen I guess.”

I held out my hand expectantly, attempting to smile my best disarming smile, as I always did when first meeting a patient, and addressed her, “hello, I’m Doctor Smythe”.

“NO!” came the other woman’s voice from behind me, “she will not shake your hand, it is…, I’m sorry…, not possible.”

I turned to view the other woman.  She was much younger, about thirty or so, wearing a blue short-sleeved polo shirt, jeans and well-worn Nike tennis shoes – the expensive kind a serious runner would wear.  Her hair was short, dark and styled in a modern way that would be indistinguishable from any other woman that I might pass on the street in this major American city.

“She is Bedu,” she said apologetically, with a pleasant French accent, “she cannot touch you, and you must not touch her without permission.”

“Okay, I’m so sorry, does she speak any English?”

“No, but I am her daughter, and I can translate for you.  I’m a psychologist, I have a doctorate.”

“Great,” I replied, introducing myself again to her.  I started to offer her my hand as well, but thought better of it, and placed it uncomfortably back in the pocket of my white coat.

Out of curiosity, I asked, “where is Bedu?”

She quickly replied, “Oh, it is not a place, it is her life, her heritage, she is Bedu…, Bedoiun, you know, from the desert”.

“Oh, okay, I understand. Say, um, before we get started, can you tell me anything about that man outside?”

She laughed, “Yes, he is from the embassy, but we never met him before today.  He is supposed to be here to help with our arrangements, I guess.”

I sat down on the rolling stool next to the exam table, lowered it so that I wasn’t looking down on the daughter sitting next to me at the desk, and told her that I would like to ask her mother some questions.

“Of course,” she replied.  She then spoke to her mother in Arabic, I assumed explaining to her he interview process to come.  The older women turned and looked at me again. literally with disgust, her eyes gleaming like gold coins in the center of her suddenly even darker-appearing face.  She then closed them and with palms down, waved the back of her hands toward her daughter as if to dismiss her comments, and it seemed, to dismiss me as well.

I proceeded with the daughter’s help.  Initially, it went well, with the exception of the usual inconvenience related to the use of an interpreter.  I asked the daughter questions, while alternating between looking at her, and then at her mother.  The patient kept her head down and only occasionally glanced up at her daughter to answer her entreaties with what seemed to be as few words as possible.  She did not turn to look at me as I asked questions, or as her daughter responded to me in turn.  I started in with the usual questions that I would of anyone being evaluated for a possible cancer of the esophagus.  At one point, after we had gotten through the first few parts of the history, her mother suddenly looked up at her daughter and barraged her with pressured, angry speech, waving her hands and repeating, almost yelling, phrases over and over again in Arabic.  Her daughter tried to interrupt several times, but to no avail.  I sat silently, and waited for them to finish.  Eventually, the older woman stopped, turned her head and again glared at me.

Her daughter took a deep breath and spoke, “she wants to know what good this is if she is going to die anyway?  She says that if she has the cancer in her chest, that this is meaningless, that these questions are meaningless.”

The old woman now watched my face as I spoke.  I stared back at her, but with some difficulty, as it occurred to me that her eyes looked a little frightening.

“Tell her that we don’t know whether or not she has cancer, and if she does, that it may be treatable…, that she might not die from the cancer.  There is no way to know what to do; however, unless we finish here first, and then do some tests. Tell her that I’m only trying to help her.”

Her daughter translated.  This time, the woman didn’t take her eyes off of my face as her daughter spoke, as if trying to catch a small change in my expression that might tell her something that the words her daughter were relaying did not.  Once her daughter was finished, the patient looked down again at the floor, and we resumed.

She related classical symptoms of an obstruction of her esophagus of some type, including the sensation of “food sticking” in her chest when she ate.  I was suspicious that it might be cancer based on her story, and on the X-ray, a barium swallow, that she brought with her from a hospital in the Emirates.  This test involves the patient drinking barium, a liquid metal dye with the color and consistency of thick milk that can be seen on the X-ray images, and then taking films of the fluid as it traverses the back of the throat, the esophagus, and finally down into the stomach.  Any abnormalities along the way appear as a change in the normal pattern of the dye filling and giving shape to the structures as it passes through them.  Her study suggested that there was a partially obstructing mass about two-thirds the way down her esophagus.

The remainder of her history was surprisingly benign, despite her age, and what I assumed must have been significant wear and tear secondary to having possibly lived her life in the desert.  Her overall health was quite good – exceptional actually – she was taking no medications, had no other complaints, and was very active.

When it came time to perform the physical examination, I stood up from where I had been sitting and asked the daughter, “I’d like to examine her now, will you ask her if that is okay?”

“She probably won’t let you,” she replied, shaking her head.

“It’s important,” I continued, “it will be hard for me to know what to do for her unless I do this.  Didn’t the doctors in her country examine her?”

“No, just X-rays,” the daughter said, “but okay…, I will tell her.”  She then drew in another deep breath, looked over at her mother with a look of great trepidation, and spoke to her sternly in Arabic.

Her mother responded immediately by yelling back at her, almost shrieking, and waving her hands over her head violently, the layers of fabric undulating back and forth on her forearms like black warning flags, letting everyone within sight know of some impending danger.  She was yelling so loudly in fact that I was concerned one of the clinic nurses might barge in, or call security.  I walked over to the door and stuck my head out, signaling with a wave to the nurse that had stationed herself expectantly down the hall a few steps away that all was okay, shut the door and sat back down as they continued to exchange verbal blows in a language for which I had absolutely no comprehension.  I looked at my watch and shook my head, contemplating the four other patients already in other rooms waiting to see me.

As I watched the mother arguing, I thought about how different I must have seemed to her – she dark dress, skin and even darker demeanor, and me in starched white labcoat, red-haired complexion, and, for the moment, attempting to be cheerful.  I considered the fact that I had avoided exposing my own integument to the sun religiously since medical school – my family frequently embarrassed by the straw hats, long sleeved shirts and hospital scrub pants I so attractively sported on vacation while they cavorted in bathing suits on the beach.  Finally, the heated discussion between them tapered off.  After a welcome pause, the mother said something quietly to her daughter, then turned her head toward the wall, away from both of us.

Her daughter spoke to me once again, “She will allow you to examine only small parts of her body – but only areas that she exposes herself.  She will not disrobe.  I am sorry, but this is what she is saying she will allow.”

“Sure,” I replied, still optimistic, “let’s take a look.”

It became obvious very quickly that my idea of taking a look, and my patient’s were just as disparate as our appearance.  Over the next fifteen minutes or so this became distressingly obvious.  During this time she exposed two to three centimeters, at most, alternating areas of her chest or abdomen with one hand by peeling back layers of her garment carefully, but then slapped at my hand or stethoscope with the other when I attempted to palpate, or listen to the small area that I thought she was allowing access to.  During this frustrating game of medical examination peek-a-boo, she continually muttered something repetitive in Arabic, and looked away from me.  If it weren’t for the fact that I had other patients waiting to be seen, it might have struck me as funny – but I did, and it didn’t.

I glanced up at her daughter repeatedly and paused with exasperation after each small patch of skin was comically and cursorily examined, at which time she and her mother would begin yelling at one another once again.  This forced me to continually back away from the table – for fear of being caught by one of the mother’s frenzied waving black arm-pennants.

Finally, impatient and worried about getting too far behind, and concerned as well that the commotion might be too much for some of the waiting patients in nearby rooms to bear, I decided to stop and move on.

“Okay, okay, we’re all finished,” I said, trying to maintain a positive expression and an air of authoritative finality, despite the discomfort I felt with the overall interaction and how thoroughly I had actually examined her.

For all I know, she could be hiding another damned person under there, I thought to myself miserably.

I explained to the daughter what would come next, “I’m going to order a couple of tests – an endoscopy and an X-ray.  The endoscopy involves putting a lighted flexible tube in her mouth and esophagus, while she is partially sedated, and the X-ray is a CT scan, where she will just have to lie still on a table while a machine makes pictures of her chest and abdomen.”

“Doctor…, will she have to remove her clothes for either of these tests?” her daughter asked, with a look on her face that suggested an anxious plea for a negative response.

I found this question interesting, as most patient’s family members ask about the potential complications of tests and procedures, rather than whether or not disrobing was involved – but then remembered our physical examination adventure moments earlier.

“I don’t think that she’ll have to remove all her clothing, but the doctors in those areas will tell to you what to expect”.

I actually knew full well what she had to expect, but didn’t want to risk sharing that with them now – she would have to disrobe, and would also be asked to wear a hospital gown.

The basic design of that article of clothing (“clothing” being considered here a very generous designation), the hospital gown, has been unchanged since the turn of the previous century – a dangerously thin cotton garment that one places on the front half of the body, leaving the more posterior “elements” exposed.  It comes complete with two little cotton or rayon string ties in the back to secure it, one upper, and one lower.  These are usually only tied at the top by normal people struggling to get them on, with the lower tie reserved for those that are actually able to tie them – Olympic gymnasts, and Circ Du Soleil contortionists.

My mind wandered…, there’s only one other situation that requires you to wear clothing that only covers the front half of your body.

As my patient and her daughter gathered up their things to go, I recalled a discussion from my past.  I was eighteen when my father died.  My mind often stumbled unwillingly to my own parent’s untimely deaths whenever I was seeing a patient and his or her grown child in my practice, such as these two.

“I guess I’ll take those,” I had told the funeral director sheepishly, choosing from one of the several shirt, tie and coat combinations he had set out for me on the counter.

He wouldn’t really have worn any of these things, but I guess I should pick one, I thought, as I surveyed his offerings.  I started to ask if they had a Sears brown and black houndstooth polyester sport coat, and a clashing striped open collar dress shirt – my father’s usual “nice” attire.  What I was forced to choose instead was an sophisticated-looking charcoal-colored jacket, with white dress shirt, and a grey, red and black paisley tie.

“Hey…, why don’t these have a back part?” I asked, “there’s a big open area in the back of this jacket,” as I lifted it up, and then the shirt as well, to inspect them more closely.

The funeral director looked up from his notepad where he had been gleefully adding up all of my choices, including in addition to the attire – piped-in music, artificial flowers, and of course, color and style of coffin, with a sad, questioning expression.  His mouth opened partially, but he checked whatever he was going to say and stopped.  I suddenly noticed how quiet it was in the room.

“Oh,” I said, tears welling up in my eyes, and reaching up to rub my nose as an attempt to distract him from that fact “…okay, yeah, I get it, sorry.”

I returned to the present moment as my patient and her daughter stood to leave, and winced when I thought about the upcoming interaction between them and the nurses in in the testing areas who would be charged with encouraging my Bedouin patient exhange her current dress for the open-backed gown.  I asked the daughter to report to our front desk, where the tests would be scheduled, and said my goodbyes.  I looked over at the patient, but she turned her head away from me once again to stare at the wall at the back of the exam table as I left the room.

My physician’s assistant, Julie, was standing outside an adjacent exam room with a chart in her hand, and motioned to me toward her as I shut the door.

“Who was that little dude in the tan suit?” she asked.

“Oh yeah,” I chuckled, “evidently he was some doctor from the United Arab Emirates embassy, where this patient is from.”  I shrugged my shoulders shook my head and frowned, “and I have absolutely no idea why he was here…”

“Really?  Weird.  Oh well, you better come on in and see this next patient, she’s pretty mad about the wait”, she said, tapping the door with the corner of the chart in her hand, “what took you so long in there, and what was with all the commotion?”

“That’s a long story,” I replied, “let me just go on record to say that I hope that I don’t have to operate on that patient,” I nodded my head toward the closed door, “taking care of her in the hospital might be, uh, challenging”.

So of course – I had to operate on her.

The endoscopic procedure demonstrated that the patient had a mass in her lower esophagus, and a biopsy indicated it was a cancerous mass.  Interestingly; however, it had been determined by the pathologist looking at the microscopic slides to be a rare type of cancer – one that is caused by a previous infection with the Epstein-Barr virus, and called a lymphoepithelioma.  More than ninety percent of the world’s population has been infected with the Epstein-Barr virus at one time or another, and most will recognize one of the more common manifestations of these particular viral infections as “mono”, or mononucleosis.  For the overwhelming majority, the virus comes and goes, but in rare individuals, especially in certain parts of the world, the virus proteins interact with normal cells to change them into cancer.  This patient’s esophageal tumor was so rare, in fact, that it had never been reported in the United States, only in some countries in Asia.  Most patients with the “usual” type of esophageal cancer undergo chemotherapy and radiation prior to surgery, but for this unusual variety, the determination of the team of doctors involved was that immediate surgical removal was the best option.  Thankfully, there was a very good chance of cure.

“Great,” I said to myself sarcastically, murmuring under my breath as I read the email from the medical oncologist that had seen her after the biopsy results were obtained, “this is going to be interesting…  I wonder if I can do this operation through little areas of exposed skin while she slaps the scalpel away?”

Julie called the daughter, and asked her to bring her mother back to the clinic for a preoperative consultation.  Gratifyingly, they were both somewhat more subdued during the return visit, and didn’t seem to be in the mood to argue with one another, as if some truce had been called.

The mother sat silently from her perch high on the exam table, like a giant black raven puffing out her feathers, looking down at the floor, and only nodding in response as her daughter spoke to her in Arabic.

I explained the procedure in detail, which involved removing the esophagus and replacing it by making a tube made out of her own stomach, and putting this tube up through the chest to the lower neck, where it would be attached to the small amount of esophagus left behind.  I drew the daughter a series of pictures to explain the steps of the operation, which she showed to her mother, who barely gave them a glance.  The older woman simply nodded once more after her daughter completed her explanation, and the daughter signed the consent forms.

“She is illiterate” she had informed me as she signed, “there was no value in learning these things in the desert.”

As they were walking out the door of the exam room ahead of me to leave, the daughter turned and said, “my brother will be here tomorrow.”

I told her that I would look forward to meeting him.  She stood for a moment or two after I said this with a strange expression on her face, and then turned her head and looked down the hall.

“Yes, yes,” she mumbled, and then turned and ran after her mother – who was moving fast, already half-way down the hall, her long black tresses trailing behind her, undulating back and forth in a way that reminded me of the reverse image of a B-movie matinee ghost.

Modern memory theory suggests that we learn to do things in a predictable way with repetitive effort – that mastery and efficiency follow in a fairly reproducible fashion as our acts move from stumbling conscious trial and error, to more perfected “unfocused” activity, and then to an almost involuntary state.  At this level, we may be very expert, but no longer have to think much about what we are doing, and may even actually forget the details once an activity is completed – driving a car is the example most would identify with.

This happens to surgeons as well.  During the training period, and for the first few years in practice, the act of “doing surgery” requires a great deal of conscious effort, but as you progress, things become more and more “automatic” in the operating room.  In time, you infrequently “fret” about the minute details of what you are about to do before the start of the case – the invariable (but seldom admitted) muted fear, indigestion and tachycardia, and the heavy, tight spring-coil of nervous tension that accompany the practice of complex surgery during the first few years of practice gradually diminish and mature into concern, rather than worry.  So it follows, as I walked into the hospital the morning of my Bedouin patient’s case, I wasn’t thinking about it a great deal.  I had performed cases similar to this many, many times before.

I rode the elevator up to my department floor and unlocked my office door, where I dropped off my briefcase, and glanced at my email inbox.  I then walked down a couple of floors of stairs, and traversed the few polished tile and aseptic-smelling corridors to the locker room adjacent to the operating room, where I changed into a set of scrubs, and grabbed my “working bag” from my locker.  This containing my headlight, loupes (magnifying glasses), some tape to keep my mask on my face and prevent those glasses from fogging, and few other items.

The repeated reports of metal on metal, the sounds of locker doors opening and shutting, signaled the beginning of the operating room day.  I exchanged pleasantries with a few other surgeons dressing nearby, and walked out into the hallway, past the doors marking what we call the “red line” (where one must wear scrubs, shoe covers, mask and hat) and into the operating room area proper.

This was the repetitive, routine beginning of another day in surgery.

The first part of the day was the busiest time in the operating room area, as everything later becomes naturally staggered based on the varying types and lengths of cases.  However, all first cases start at roughly the same time.  At this time of day, the operating room floor might remind one of busy train station – like 30th Street in Philadelphia, or Grand Central in New York, at morning rush hour.  Everyone is moving purposefully, into and out of the doors of the operating rooms, like into and out of the doors of subway or train cars.  Stretchers are being guided around people and corners, IV poles being adjusted up and down, equipment is being moved from place to place, and a few people are running down the corridors and bumping into others, trying to catch patients before they “leave the station”.

I stopped at a corner near the main desk, and glanced up at the flat screen monitor to see where I was operating.  I walked down the hall, and absentmindedly pushed open the door to the operating room.  I stepped in as the door swung shut behind me, looked over at the operating room table, and then literally froze where I was standing.  The thin nylon bag slipped from my hand, and it hit the floor at my feet, the hollow wooden box containing the magnifying loupes striking the hard tile floor on one of its flat sides, just at the right angle for maximum sound – “WHACK!”

Everyone -nurses, residents, anesthesiologists and technicians stopped, and looked up at me from their tasks.  I didn’t respond.  The preparation of the patient had reached the point just before her body would be “draped” – covered with sterile paper sheets, so she was lying on the operating room table nude.  I stared at her, my now open mouth hidden by the mask I had put on earlier.

The patient, lying on her back, was covered with hundreds and hundreds of nickel-sized, and slightly larger, pigmented spots.  Some appeared to be randomly placed, but others were in unmistakable patterns, both linear and undulating.  They were everywhere, on her chest, abdomen, arms and legs, and even her forehead, just above where her headdress had been situated.

I moved forward, compelled to understand – not so much as physician, but as any other human being affected subconsciously with curiosity and attraction to things odd and salacious – the compulsion that attracts people to the side show at the circus, or encourages well-paid and highly-educated executives to pick up and read copies of the National Enquirer while waiting in line at the fancy gourmet grocer.  Although perhaps not one of our more enviable traits as homo sapiens – morbid curiosity is one of the things that doctors actually rely on – an ancient inclination to “nosiness” when it came to other human beings.  It is involuntary, and instinctual, and therefore not situated in the outer cortex of the brain, where all the medical knowledge gets packed in during medical school and residency training.  It is much more basic – a curiosity that is lodged somewhere in a dark fold of the ancient hindbrain, right next to the areas that tell you to eat, breathe and procreate.

The others in the room quickly resumed activity, but I was now mesmerized, the clamor of voices and movement, the clanging of metal instruments against one another and as they came into contact with the metal trays where they were being organized for the upcoming procedure, and the rhythmic beeping of the patient’s cardiac monitor had all faded from my consciousness.  I focused only on the image of the patient before me, and the strange marks on her body.

The patterns, I murmured to myself, they must be man-made, not some disease process.  What is this?  I walked up, putting my hands on the edge of the operating room table, and leaned in close to her body – these look like burn lesions…, they are…, they’re all healed burns. 

I looked up again after a few seconds, as the circulating nurse brought me back to the noises and movement.

“Weird, huh?” she said as she tucked a sheet under the patient’s legs, “burns all over her, like she was abused or somethin’, you know?  It’s terrible, just terrible what people do to themselves, and each other.  I think I’ve seen everything down here, you know?  Not many secrets when you’re all splayed out like this in the operating room, right doc?”

I shook my head in affirmation, but thought otherwise, remembering the exam in the clinic a few days ago, and how she had obviously systematically hidden this from me.  Not abuse, I thought to myself, and not accidental either, I don’t think so,… something else, but something meaningful.

The case itself was a blur, but went well.

The esophagus had to be removed, as planned, but the tumor was small, making it technically a little less challenging.   I walked out of the operating room as the resident and his assistant closed the skin incisions.  I then checked in with the receptionist in the patient family waiting area down the hall, and met with my patient’s daughter in one of the small conference rooms that was “budded” off of the main common seating area.

“Hello,” I said, with as much of a positive tone of voice as possible, and with a reassuring look on my face.

I had learned years earlier that patient’s family members begin to make inferences about how things went in the operating room via non-verbal cues as you walk up to them, your posture – your expression, whether or not you make eye contact – all are pieces of data that they are collecting and analyzing carefully, even if they aren’t really aware of it.  The majority of those waiting expect bad news from a trip to the operating room, and are trying to prepare themselves for it.  The operating room is a black box for most, and is assumed to be a common portal to death by many, even though most modern elective surgical procedures are certainly much safer than cab ride in Manhattan.

“Everything went very, very well,” I said, “everything really as planned, no surprises, and she is doing very well so far.  The tumor was removed, and we put everything back together using her stomach, as we had discussed.”

“Praise God.”  The tension, superimposed onto her face like a tense, transparent puzzle, loosened and fell away in pieces.  She lifted her palms upward between her waist and shoulders, and her eyes looked up toward her heaven, “praise God, praise God, and thank you doctor.”  She looked exhausted, and although now happy, seemed suddenly very small, and very alone.

“I thought that your brother was going to be here today, was there a problem?”  I noticed the tension returning, the puzzle partially reassembling itself on her previously relaxed visage.

“No no, no…, just a cancelled flight, he will arrive tomorrow.”

I nodded, and stood to leave.

“Thank you doctor, thank you so much.  You are wonderful, may God bless you.”

I have never become comfortable, or learned how to avoid the squeamish feeling that came with accepting this sort of praise and thanks from family members.  I operated, literally, under the impression that my personal efforts were usually less important than what the disease, and the patient’s anatomy actually allowed me to do.  However, I understood from experiences with my own family members the relief that accompanied hearing that one of them had survived the very unnatural suspension of conscious thought, and corporeal invasion.

I smiled and replied, “You’re welcome.  Lets work together now, over the next few days in the hospital, to make sure that everything continues to go well.  Let’s get her out of here as quickly as possible.”

She took a tissue from her purse, and daubed her eyes as she sat back heavily into her chair.  I turned to leave, and then remembered, the spots

I turned back around, and took a seat across from her.

“Can I bother you for a moment more?” I asked.

She looked at me expectantly, “is there something wrong?”

“No,… I’m sorry.  I just forgot to ask you something, if you don’t mind.  Can you tell me anything about those marks on your mother’s body?” I asked, “It was hard not to notice them.  Was she hiding them from me in the clinic?”

“Marks?  Oh…, oh yes, they are maqua,” she replied, “maqua.”

“Maqua,” I asked again, “what is maqua?”

“It was healing – a form of healing that was used when she was younger, in the desert.”

“Are they…, burns?”

“Yes, burns from fire.  It was usually administered, if I remember correctly, by the tribal elders.”

“Did it work?” I asked, not mocking her in any way, but out of a my desire to understand this very modern and educated young woman’s opinion – culturally connected to, but one generation removed from, her mother’s nomadic life.

“No,” she chuckled, “of course not”.  She then looked contemplative, and more serious, “But the belief in this treatment in the desert was very strong in the past”.  She paused for a moment, as if thinking about her next response.  “Yes, she was probably ashamed for you to see them.  I think she is ashamed of many things about her life, you see.  Her children, and her people…, we are… we are very different now.  But the belief was very strong in the maqua, I think, and as a result, perhaps…, it had value.”

After rounds, I made my way up to my office.  It was just getting dark, and after checking my mail and signing some charts, I stared out the large square window to the right of my desk, dominating that wall of my small space.  Although we were in a large city, the medical center was in an area that was more residential than metropolitan.  My office, several stories above the ground, looked out and away from town, into an area without much light on the horizon at night.  I stared out the window at the dark blue void, and daydreamed about the day’s events.

Her body looked more like some sort of antiquity, or museum piece, I thought to myself, than a patient.  And why would she subject herself to those burns?  It seems crazy…

It was as if she were a living relic, a relic that had been literally imprinted by history, history and beliefs dating back for tens of thousands of years, as long as Bedouins had roamed the Negev, and beyond.

I rested my chin on my hand, and continued to stare, unfocused.  The dark blue rectangle of my office window gradually became dark blue over brown, and I then imagined a golden glow at the center, where the two colors met.  My mind moved in closer to the light.  It was the desert at night, and the glow was a small fire.  Orange and yellow tongues of flame leapt from a small spot on the ground, and the breeze intermittently blew tiny grains of sand past and into them, becoming sparks.

I “saw” the figure of a young girl, her back to me, dressed in layers of white and light brown garments, struggling in the grasp of an old man, who was squatting by the fire and holding her arm, the only exposed limb, above the elbow.  There were others about, in a loose semicircle around the fire, but they seemed disinterested, talking among themselves.  The old man placed a stick into the fire, and then removed it – embers glowing hot at the tip.  He then methodically, but quickly placed it directly onto the young girl’s arm, as he chanted something rhythmic, and unintelligible.

She didn’t scream, or cry out in any way, but turned her head away quickly from the site of a small tendril of acrid grey smoke arising from her skin.  Her eyes were my patient’s  –  amber and gold, a burning color, the color of fire.  Heavy tears welled up in them, but she willed them stay there, and not fall down onto her cheeks.  She stared past me, out into the desert, expressionless, silent.

The next day on rounds, in the intensive care unit, I met my patient’s son.

I glanced up through the sliding glass doors which made up the entire front wall of the patient’s room, designed so that no patient in the intensive care unit would ever be “invisible” to the nurses outside at any time, and noted that the daughter was sitting in the far back corner.  Standing in front of her at the bedside was a man who appeared to be at least ten years younger, if not more.  He was handsome, with short black hair and an immaculately groomed, close-cropped black beard.  He was wearing modern western-style clothing – a red and blue tightly-patterned plaid long sleeved shirt, and jeans.  I walked into the room, and he immediately rounded the bed and reached for my hand.  He moved quickly, almost jumping, with a manner somehow reminiscent of a cat.  He shook my hand vigorously, and spoke in staccato Arabic to his sister, without turning to look at her.

“My brother says he wants to thank you, and he praises God for your efforts.”

I noticed that compared to my previous interactions with her, which were animated and cordial, she was speaking in a quiet monotone voice, and not looking up at me.  The brother continued to speak to me, Arabic phrases and words literally spilling out of his mouth – terse, and rapid.  At one point, he turned and shook his index finger at his sister, as if scolding her.

“He wants to know if she is going to live, and if it was cancer.”

“Sure,” I replied, “you spoke to him about this, right?”

She sat silently, looking down at the floor.

After I waited a few moments in vain for her response, I replied, “yes, as you know, it was cancer, but it was removed completely, and she is doing very well so far.”

The son turned to the daughter, and motioned his hand toward his chest impatiently for her to speak.  She spoke to him in Arabic, looking down the entire time.  He replied to her, in angry, pressured speech.

“Is everything okay?” I asked.

The daughter, still looking down, shook her head up and down, signifying “yes”.

I said that I would be back the following day, and that their mother might be able to be transferred from the intensive care unit to the regular inpatient floor if things continued to go well.  As I was turning to leave, the brother again spoke to me, with what seemed like great concern, and building anxiety.  I looked at his sister.

“He wants to know if it was really cancer,” she asked.

“Yes!” I said, a little more emphatically now, “we are sure, we looked at it under the microscope, it was a form of cancer.”

He finally looked begrudgingly satisfied, and so we left.  I looked back and saw him pacing in the room, like a big cat does at the zoo when the enclosure in which it is housed is a little too small.  At the end of each few steps, and prior to turning to pace the other direction, he would look up at us as we walked away, through the transparent sliding doors.

Over the next several days, this pattern of interaction with the son continued.  We would come to see his mother on rounds, and he would stand at the bedside and ask us questions through his now passive and somewhat muted sister, often repeating the same questions three, four or more times, as if we weren’t being truthful, or trying to determine if we were going to change our minds, or our explanations, under pressure.

At times, he would focus on inconsequential or minor issues, such as on one occasion asking us five times whether or not the intravenous fluids were necessary, and occasionally, he would return to the cancer interrogation, repeating the same suspicious questions over, and over again.

He spoke absolutely no English, and his sister would initiate no conversation, nor return any directed to her when they were in the room together.  Although she served as my interpreter, she would only answer questions from me when they were directed to her brother.   I noted on a couple of occasions as I sat at the nursing station, and I watched the two of them leave the room together that she walked several feet behind him, and that she initiated no conversation when they were alone, waiting for him to speak to her.

Throughout this period their mother simply lay in bed when we were in the room, and moaned.  The son would hover over her, occasionally leaning in and yelling something to her in Arabic, but she would only respond by moaning more loudly.  Although I considered myself a patient man, I began to silently calculate how much longer she would be in the hospital.  I assumed that we were going to be able wrap this all up soon, and that I would be sending the patient on her way in the usual period of time associated with this sort of operation.  However, this would not be the case.  The patient, despite steady improvement, proved to be refractory to hospital discharge.  She initially developed a series of small problems that delayed her mobilization – a small wound infection, some abnormal blood work, a little fluid around the lung on the chest X-ray…, during which the daily sessions with her son and daughter continued in a repetitive fashion.

A little over a week post-surgery, as I walked onto the hospital floor to make rounds, I found the daughter standing outside her mother’s room alone, almost on her tiptoes, appearing very nervous.

“Can I have a moment doctor?  I must hurry,” she said, trembling, and speaking just above a whisper, “I am sorry, but my brother thinks I have gone to the bathroom.”

“Sure,” I replied, “is there something wrong?”

“No, no, but I have to tell you that I am leaving tomorrow.  I trust that my mother will be discharged soon, and cannot thank you enough, or God, for all that has been done for her.  My…, my brother will remain until she leaves.  He cares a great deal for our mother, and I hope that it is no trouble.

“No, it’s no trouble,” I replied, “I’m sure that we have some good interpreters, and that we’ll be fine.  We take care of many patients from other countries here, and a fair number from the Middle East, as you know.  Please travel safely.”  I took out my card and handed it to her, “hopefully your mother will home soon.”

She looked at the card quickly, and then stuffed it hurriedly into the front pocket of her jeans, smoothing her hand over the area, as if to hide the fact that she had placed it there.

“If you will excuse,” she asked anxiously, “I must return, my brother will come and look for me.”  She forced herself to smile, turned on her heels and rushed into the room, taking care to open the door only enough to enter, and then shutting it immediately.  I could hear her brother shouting at her inside as I walked past to another patient’s room.

The next day was my first with the patient and her son alone.  The head nurse on the unit where she was staying called me early in the morning, and informed me that there was, to my substantial delight, no on-site Arabic interpreter, and that we would have to call one by phone when I came by to see the patient on rounds.  She suggested a time later in the day when the interpreter would be available.  I arrived on schedule, and the now familiar sequence with the son started, minus the daughter’s involvement.  He met me shortly after I entered the room, shook my hand smiling and began to talk to me in Arabic, as if I understood him – in a low, seemingly friendly voice.  The head nurse came into the room, and we reached the interpreter on the phone in the room.  I spoke to her for a moment, and explained the situation from my perspective, warning her of some of the issues we had experienced with the family dynamic up to this point.

“No problem, doctor, she said, “I am very experienced, and grew up in the Middle East.  I can handle these issues easily for you, don’t worry.”  Her voice sounded very similar to my patient’s daughter’s voice, but much more confident.

I felt momentarily relieved, this might work out after all.  We then proceeded to go through the usual progression of questions from the son, including five separate rounds of him asking if his mother really had cancer.  Within ten minutes or so into the interaction, he was yelling at the top of his voice at the interpreter and stomping his feet, while he frowned darkly at the phone in his hand, holding it intermittently in front of his face, and shaking it.

At the end of an hour-long session, I spoke to the interpreter again before hanging up the phone.  She was still very calm, and reassuring.

“This is not that bad,” she said, “he is just scared, and is not happy that I am a woman.  He asked for a male interpreter, but I told him that would not be possible, and that I was very good, very experienced.  It will be fine, don’t worry, I know what I’m doing, he will get better with me talking with him, you will see.”

Over the next several days; however, the exchanges between the three of us grew longer, and more contentious.

The comments from the interpreter to me after our discussions rapidly transitioned from the previous confident proclamations of “no problem”, to the confused and irritated – “I don’t know what is wrong with this man.”…  “He repeats the same questions over, and over and over.”…  “I am losing my patience”….  “He is demeaning, and says insulting things to me”…  “He has called me in the middle of the night, and disturbed my family, to ask STUPID questions we have discussed earlier.”

Thankfully, as all this unfolding, my patient was steadily improving.  However, when all of us were in the room, she simply lay in bed and moaned, even though the nurses reported that when she was alone, she seemed, “fine”.  Over the next couple of days, I informed the son repeatedly, through the interpreter, that his mother was ready to go home, but he dismissed the concept, or ignored it, focusing on things such as “is there medicine in this plastic (intravenous fluid) bag?”, “are you sure that this was cancer?”, and “is my mother cured?”.

I knew that like most patients from other countries, this family, or at least someone on their behalf, was paying cash for this admission, as the American version of health care insurance was either not available, or didn’t cover treatment outside of the home country.  In addition to trying to get the patient out of the hospital for safety reasons (the hospital is a dangerous place, if you don’t actually need to be there), I was also concerned about the cost to whomever was paying for this.

Another two days passed, and immediately following the most heated exchange yet between the son and the interpreter, she got on the phone with me, her anger transmitted through the receiver like shrapnel after a bomb blast, wounding anyone within range – in this case, I was the only bystander, and I was in range.

“I cannot deal with this man any longer!  NOT…ANY…MORE!  DO YOU UNDERSTAND ME?  NOT ANY LONGER!” she screamed into the phone so loud that I had to hold the receiver out away from my ear an inch or two.

“Uh…, ma’am,” I replied, trying to speak slowly and without any emotion, “I’m on your side here…, I appreciate how difficult this has been for you, and understand, but please just help me to convince this patient’s son to allow us to discharge her.  If we can do that, we’ll all be better off, and I can leave you alone.”

She paused as if considering my request for a moment, and then replied. “I cannot.  I just cannot.  I am sorry.  I can’t.  I CAN’T!  THIS MAN IS IMPOSSIBLE!  THIS MAN IS THE REASON I LEFT JORDAN!  You must understand this… I LEFT MY HOME, AND MY FAMILY BECAUSE OF MAN LIKE THIS!  I cannot do this… I CANNOT LIVE IN THAT WORLD ANY LONGER!  DO YOU HEAR ME!  WE – ARE – FINISHED!”  (Muffled noise of phone being moved around…, then rattling on the receptacle…, then CLICK!…, then dial tone…)

I looked over at the son, across the patient’s bed.  There were little beads of sweat on his brow.  He was breathing quietly, but heavily – I could see his ribcage rising and falling under his dark t-shirt.  He literally looked crazed.  It was as if he was about to jump over the bed and grab me, or at least grab the phone from me.  He was slowly clenching and releasing his fists at his side, and he was leaning forward slightly, back arched.  He reminded me of a big cat again, but this time one that was threatened and dangerous – I fleetingly recalled the uneasy feeling that I had as a child standing next to a tiger’s cage at the zoo as it paced back and forth and looked at me, with cold ancient animosity and silent feline rage.  His mother lay in bed between he and I, moaning.  I noticed her eyes were only half-shut, and that she was watching me.  I also noticed after a few moments that I was still holding the phone up to my ear even though there was no longer anyone on the other end, so I smiled at them, hung it up, and left the room.

The next several days were almost indescribably frustrating.  I spent more than an hour in her room each day when I came by to see her, despite the fact that she had been ready to go home for several days, and I had other patients to deal with – patients that actually actively required the services of a surgeon.  She continued to lay in bed moaning and watching me out of the corners of her partially shut eyes, as I tried to mime words and concepts for the son, and drew ridiculous stick figures for him – of people getting out of bed, and getting onto airplanes, shuffling on board them in my pictures like ridiculuos little inky skeletons.  I even drew the United Arab Emirates shape for him (after looking it up), a sort of reverse “L”, with one of the stick airplanes landing there, full of little stick people, including one that I tried to make resemble his mother. Understandably, he just looked at me repeatedly as if I were nuts, and shook his head.

The nurses on the floor, no longer able to call the interpreter when the son became agitated, began calling me two to three times in the middle of each night.  “I’m not sure what to do,” I replied sleepily, “I’m sorry, I don’t speak Arabic either.  I’m really sorry that you’re having to deal with this, but I’m trying to discharge her, really, as soon as possible.”  At times, I could hear him yelling in the background somewhere nearby, yelling across the room and into the phone at me, it seemed, as if I would understand him.

I began having dreams, actually, no, actually nightmares, about the situation, likely fueled by a combination of sleep deprivation and frustration.  One particularly unnerving and memorable one involved the son actually turning into a leopard.  During the transformation, he snarled, as spots were appearing on his face and arms, “I am going to EAT YOU!” in Arabic, and ironically, this time I was able to understand what he said.  When fully leopardized, he leapt over the bed (where his mother lay, laughing) at me while I was on the phone trying anxiously to reach the interpreter.  Just as he was clamping down on my neck with a suffocating cat-bite, I woke up struggling to breathe – the phone on my nightstand at home was ringing again.

Eventually, my concerns about my patient’s prolonged stay and the costs associated were noted elsewhere.  The discharge planning coordinator for our inpatient floor, her supervisor, and the Chief Medical Officer for our hospital all weighed in, sending me a number of emails asking why I was “extending this patient’s hospital stay beyond what is medically necessary.”

“Because I am enjoying it so damn much!” I replied, not in writing, but yelling it out in my office alone, as I read his very tactfully worded, but thinly veiled accusatory email.

The patient had now been hospitalized for about three weeks, more than ten days beyond what was truly necessary.  During clinic, I explained to Julie the events of the last week or so.  She didn’t often get to see the patients after surgery once they were hospitalized, as she was busy with the outpatient part of the practice in the clinic.

“Jeez,” she said, “that’s really crazy… what are you going to do?”

“I was thinking of moving in the middle of the night, and under the cover of darkness to another city,” I replied.

“That seems a little extreme,” she laughed, “say…, what about that little stocky dude, you know, the doctor that was here when they first visited?  Has he been around?”

I had completely forgotten about him.  “No, not to my knowledge, but if he had been during the last few days, I would have noticed it because I would have asked him to interpret, and I would have gotten a hell of a lot more sleep.”

“Do you think he could help get her discharged?” she asked, “why don’t you just call the embassy, see if he is around, and can do something.”

I called our hospital’s International Relations Office the next morning and was given the embassy number, as well as a person to ask for – not the doctor himself, but someone I was told would know how to find him.

I thought I would go by the patient’s room, and try to communicate my plan to the patient and her son before I called, just on the off chance that things moved quickly.  I wasn’t particularly optimistic that I would be able to do so, but thought that regardless the problems with communication, they still deserved a chance to know that they might be discharged soon.  As I walked over, I contemplated whether or not I would be able to draw a stick embassy, or perhaps a stick figure short stocky doctor with a giant mustache, and almost turned around and went back to my office.  It was much earlier in the day than usual for me to see patients in the hospital, and when I walked into the room, I found my patient alone, for the first time since she was admitted to the hospital.

She was sitting up in bed watching television, but when she saw me, she quickly switched it off with the remote, closed her eyes and began moaning.  I walked up to the bed and stood there.  I realized that with the language barrier, her obvious mistrust, and the family dynamic that I really had never really connected with her as a patient.  For some surgeons, this is the actual goal – not connecting.  It is admittedly emotionally safer that way, and more efficient.  The existential ramifications of the death of a stranger, even if your patient, is easier to deal with than someone you know.  That being said, I had never really been comfortable with that approach.  I had always found the human connections with patients to be the most rewarding thing about being a cancer surgeon, and therapeutic for me even if the only thing that really mattered to the patient was whether or not the tumor came out.  In actuality, I didn’t believe that any patient actually felt that way either.  We are all social animals, and the need for human touch, interaction and understanding, always present, is heightened during the vulnerability that accompanies illness.

This may be my last chance, I thought.

I reached down, and gently touched her arm.  She reflexively drew away, shook her head from side to side, and moaned.  I tried again, and this time rubbed the back of her arm, gently with my thumb, directly over some of the burn scars.

“Maqua?” I asked.

She stopped moaning, opened her eyes and looked at me, but didn’t pull away.  She seemed stunned.  It was the first time we had held one another’s gaze since that day in the clinic, when she had eyed me so suspiciously.

“Maqua?” I repeated, pointing to the spot on her arm.  Then, I had an idea.  Worth a try, I thought.  I pointed again to the spot, and then to my own chest. “Maqua…,” I said to her, “maqua”.

Her expression softened, and she looked down at her arm where I was touching her, and back up at me again.  I noticed again the amazing color of her eyes – like reflected fire in the desert, no longer ghoulish, but beautiful.  For a moment, I saw the face of that young girl again, the young girl from my imagination I had “seen” in my office that night after her operation, now several weeks ago.

There was a faint smile, the first one I had seen on her face, as she looked up at me and repeated, almost at a whisper, “shukran…, shukran…, shukran.”

When I returned to my office, I called the embassy, and in a few moments heard the familiar voice of the doctor from weeks ago.

“Ah! Doctor!” he said, happily, “how is it going for you?”

“Okay, thanks,” I replied, “this is Dr. Smythe, the surgeon that operated on the woman from the Emirates with an esophageal tumor.”

“Yes, yes, of course, of course!” he replied, “I know you, we are good friends!”

I hesitated for a moment, and then went on to explain the dilemma I was having getting her discharged from the hospital, and hopefully, on her way home to the Emirates. Although I didn’t go into detail, I mentioned that there had been some communication challenges.

“She is ready?” he asked, his voice suddenly sounding very businesslike.

“Yes,” I replied, “she could have left some time ago, actually.”

“DONE!” he confidently replied, “DONE, DONE and OVER!”

“Really?” I asked, incredulous.

“YES, OF COURSE, OF COURSE, DONE!” he emphatically repeated.

“Okay…,” I said, trying to sound upbeat, “Say…, by the way, can you tell me what the Arabic word ‘shukran’ means?”

“Sure,” he replied, and laughed, “it is what you will be telling me tomorrow, my friend!  It is, simply, “thank you”.”

The “Bedu” have developed, in literature and legend, a romantic legacy of graceful restlessness, as well as harmony with their desert surroundings, despite a lifestyle that was demanding and unforgiving.  In modern times, almost all of them have abandoned this mode of living, and although millions in the world are of Bedouin heritage, the majority have been assimilated into more sedentary modern society.  It is fair to say; however, that the fame that they garnered in past times was deserved – an uncanny ability to move great distances, from one locale to another, and to then somehow disappear, leaving no trace of having been there, no marks in the sand.

The following morning, she was gone.

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3 thoughts on “Maqua

  1. This was such an insightful, well-written read. I stumbled upon your blog via Twitter and have really enjoyed your posts. Thank you for sharing your stories!

  2. I want my blog to be about different perspectives of life, since that is what interests me the most. This encounter definitely highlights the differences among people, and the patience and care that you displayed were phenomenal. This is a highly fascinating story, and I am thankful for the chance to have read it.

  3. Roy, your ability to see the humanity in all your patients, foreign, frustrating, or friend, is what makes you such as great a surgeon, as you are a man. Thank you for this wonderful lesson in seeing the connectedness in us all.

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