Four O’Clock
The chart calls it a chief complaint, which always struck me as a strange phrase, faintly accusatory, as though the patient had a list and this one was the only one they were willing to lead with. Mine is back pain. Six weeks. Add the fourteen pounds I had not meant to lose and the half-sandwich in April I could not finish, and you have a cluster I would have read off a stranger’s face in under a minute–would have, in fact, written the order before they finished the sentence. People come to me when it is already clear. No version of me does not know what those three things are when they stand together. I knew. I simply declined, for six weeks, to look at the one patient I have ever had the option not to look at.
Priya read the film. I trained her–she came up through my program, and she has a good eye, better than I was at her age. She did not call me with the result. She walked the length of the hall, stood in front of my office, and did not sit down. I have a chair on the other side of my desk for exactly that purpose, for sitting, and she stood next to it with her hand on the back of it, and I understood the entire situation from that refusal. The staging was in her posture. I taught her that too, probably, without meaning to. We learn to stand a certain way when we are about to take something from someone.
Patient is a fifty-eight-year-old oncologist, no significant history, presenting with metastatic adenocarcinoma, primary pancreatic, with spread to bone and liver. I could write that asleep. I have written it a thousand times, in that order, primary and then the spread, because the order is the trick of it–you name the origin and then the territory, and somewhere in the grammar the person stops being a person and becomes a map of the thing using them. Subject. Verb. Lesion. It is a good sentence. It works on everyone.
It does not work on me; I have spent two days trying to figure out why, because I wanted it to. The words are the same. I am not finding new ones. But they have a weight in the mouth now that I never knew they had, the way you can say a person’s name for years and then say it once at a funeral and hear, for the first time, what it actually sounded like.
They keep telling me that knowing will help—the other doctors, my friends. At least you understand what is happening, they say. At least it cannot ambush you. And I have wanted, each time, to take them by the collar, because it is the exact thing I used to believe and the exact thing I used to offer, and it is not true, and I cannot account for how I went thirty-one years without learning it was not true. I had every finding in my body for six weeks. I could have read myself in an afternoon, the way I have read so many strangers, yet I did not turn around to look. That is the first fact I have learned in this that I did not already know: that knowing and turning to look are two different acts, and I had spent my whole life certain they were one.
There was a single mother eight months ago. Dahlia. She had a daughter, six, who drew pictures in the waiting room and brought them to her mother and me. Dahlia asked me if she was going to live. Not in the bracing way, but plainly, the way you would ask for the time. I told her she was going to make it because I believed she would. The numbers were not great, but numbers are populations, and she was one woman, and I had seen the unlikely happen before.
Six months later, she died.
I did not lie to her. That distinction has come to matter more to me than it should. I wanted her to make it; I believed she would. I sat with her through the afternoons when the unit was quiet, and we talked about the tiles she was going to put in her kitchen, a particular blue, and which of her daughter’s school trips she would be well enough to go on. I was good at those afternoons. I knew what she was asking and what she was not. The longer we sat, the less the chemical smell of the room reached me, until I stopped noticing it at all.
This is what understanding gets you. I know exactly what will happen to me and why it will happen. I know the regimen they will start me on. I helped write the local protocol for it. I know the third night is the bad one, that the nausea comes up from somewhere underneath thought, that water turns to metal, that there is a window in the third week that counterfeits being well so convincingly that people plan their lives inside it. I can tell you the median in months and the shape of the curve I currently reside on, and the long, thin tail on the right side, where a few people go on living as if it were a dream.
I knew all of it before Priya even looked at me. None of it was waiting for me on the other side of comfort. The knowing stayed knowing. The fear arrived completely separate from it, fully grown, asking for nothing.
I thought the fear was about dying. I built whole conversations upon that assumption–soft rooms, my hand flat on the desk, tissues angled towards the patient, the word death produced at the right moment like a key I had been trusted with. I was wrong about the size of it. Dying is large and far and abstract, and you can be brave about large, far things; people are, every day. The fear is about the next ten minutes. It is about the half-second before the contrast goes in and the warmth arrives in the groin, and I, who have ordered that scan ten thousand times, am afraid of the warmth, the body afraid on its own, underneath every fact I own. The fear is small and close, and it has no interest in the future, where all my expertise lives. My expertise is in the disease. There is no one left to correct me anymore. The fear is about Tuesday. They never touch.
There is a thing we say–goals of care. I have said it to families in the worst hours of their lives and felt, saying it, like a competent man. I understand the phrase from the inside now, and it is grotesque, because the goal is not complicated and was never complicated, and I pretended it was complicated so the conversation would take a manageable shape. The goal is more. That is all. A little more. An afternoon. The particular light that comes into my kitchen around four o’clock and lies across the counter, which I have seen a million times and never once observed, and which I now want with an appetite that frightens me more than the scan does. If a patient had told me that was the goal, I would have nodded and thought, privately, kindly, that they had not yet done the work. As if there were work. As if acceptance were a task you completed and were issued a certificate. I made that up. I think I made it up so I could leave the room by five.
I signed the consent this morning. I have handed that form across my desk so many times that I had stopped seeing it as anything, a formality, paper. My hand shook holding the pen, and I watched it shake from somewhere slightly above and behind myself, and I thought, with what I can only place as astonishment: it was never paper. Thirty-one years. It was never once paper, for any of them, and I passed it across the desk like a check at dinner.
It is late now. I am writing this instead of sleeping because sleeping has become those last ten minutes. Lying still in the dark with nothing to be an expert about.
I have been the doctor my entire life. I am very good at it, and that does not come from a place of pride, but precision; I was not careless, I did not earn this by failing at anything, there is no lesson in it, and that is the part no one can stand, and so everyone keeps trying to instill one. I was good, and it made no difference. I leaned over a great many people in a great many beds, and I brought them everything I knew, the names, the numbers, and the gentle correct order of words. There were a few who lived, who went out along the long, thin tail, and I told them it was them–their fight, their attitude–because it was unbearable to tell them it was luck, and because they wanted it to be them. They looked up at me with a particular expression that I caught for one second at a time, ten thousand times, from above, and then I straightened up and went on to the next room because I got to straighten up. That was the whole of my advantage. Not the knowing. I got to straighten up and leave.
I am making the expression myself, at two in the morning, at no one, and there is no one leaning over me to catch it for a second and carry it out of the room. I want it written down by the one person who finally has it from the inside and can be trusted on the matter.
I know everything about my disease. I know its name and its order and its mechanism and every road for the next few months. I keep going over it. I have not missed anything. I have checked, I keep checking, there is nothing in it I have not already held, and it does not help, it was never going to help, and I am so afraid, I am lying here in the dark, and I am so afraid.
Sage Micah is currently a pre-medical student at UCLA. He enjoys many hobbies, including writing, reading, and being immersed in nature. He currently resides in California’s Central Coast and is new to publishing his works.