Professional Documents
Culture Documents
by
C. E. Chaffin
(5,514 words)
He was seventy and thin. His neck was scarred from biopsy and radiation. A denuded
thatch of white hair sprouted from his crown, topping a scalp red and flaky from too
much sun, beneath which a thin monk’s fringe of white barely topped his ears. His
face looked pinched, with a hawk-like nose and hollow cheeks, and seemed fixed in
the frustrated stubbornness of one who believes he will not be believed. His mouth
was straight and grim and his blue irises, circled in senile white, stared at me as if I
were guilty. What was my crime?
“So, Mr. DeVries, tell me a little bit about what brought you to the hospital.”
“I can’t sleep, pure and simple, nothing fancy. about it. I just can’t sleep.”
I suppressed a smile.
“Not a wink, Doc. I lie down at night and pretend to sleep, but I don’t. I just lie there
and stare at the walls and try not to disturb my wife.”
“What would she say if I asked her whether or not you sleep?”
“How would she know? She’s always asleep when I’m not sleeping. How could she
tell if I was?”
“I thought she might have gotten up at night and noticed you snoring or something,” I
replied.
“Not a chance!”
“Hmmm ... This sounds like a very difficult problem. Perhaps it would be helpful if
we went back a little and talked about the things that happened before you couldn’t
sleep.”
“Not much to tell. Earlier this year the doctors said I had some kind of problem in my
neck with the lymph nodes. Took a piece of one of them They said they could cure it
with radiation. So I went with the treatments. Then they had to give me thyroid
medicine ’cause the radiation hurt the gland. At my last check-up they said there was
nothing there. Which makes me wonder if there was ever anything there. And look
how thick my skin is here on my neck where I got the treatments. How could you find
anything there now, anyway?”
“A what?”
“Did they stick you in a big tube and tell you to be still for fifteen minutes while they
played with some dials?”
“Well, Mr. DeVries, that’s the best test we have for monitoring recurrence of tumor.
If the oncologist tested your blood and did the MRI, that’s the best he can do. Or am I
missing something?”
“How did they even know I had something? I felt fine. I was workin’ out in the
garden, minding the cows, doin’ everything I usually do. If I hadn’t noticed the lump
shaving, and if I hadn’t told my wife, none of this might have happened.”
“None of what?”
“My sleep problem, damn it! Haven’t you been listening to me? I can’t sleep. And
this all started after this gland problem.”
“When you say you can’t sleep, do you mean you doze off a little and wake up
frequently, or that you wake up too early?”
“No.”
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“I’m not suicidal or depressed. I just can’t sleep. If this goes on, maybe I will commit
suicide, but only to get some sleep.”
“Of course I feel tired! Wouldn’t you if you hadn’t slept in three months?”
“I think I’d be more than tired. I’d probably be dead, because humans aren’t made to
survive that kind of sleep deprivation.”
“Could it be that you doze off occasionally, but wake up with no memory of
sleeping? For after all, no one knows if they’re sleeping while they’re asleep.”
Mr. DeVries looked puzzled, as if he’d not considered the possibility. Reflexively he
stroked his disfigured neck. Then he shook his head.
“No, not a chance. I wish I could say I had dozed, but I’m up all the time. Always
awake. Sometimes I close my eyes but it doesn’t matter. Sleep won’t come.”
I could see this line of questioning was fruitless, so I decided to role play and let the
patient be the doctor.
“Hell if I know. But I sure didn’t have it before they started messing with my neck.
All I can figure is that all that radiation must have done something to my brain.”
“So you think your sleeplessness may be a side effect of the radiation treatments?”
It was clear that direct confrontation of the symptom only produced increased
resistance. I decided to gather the necessary background information.
“Of course not. Been in the dairy business fifty-five years. And as far as I’m
concerned, this isn’t a psychiatric problem. This is a sleep problem.”
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“Of course. Could you tell me what medications have been tried to relieve your
insomnia?”
“All kinds. Can’t remember them all. Desyrel was the last, which just made me fuzzy
and it took me longer to pee, which is bad enough for a man my age already.”
“Oh yeah; some placebo called Dalmane which didn’t do anything. And something
that sounds like “Maril” which only made me nervous.”
“Right. Didn’t do no damn good, but I had the peein’ problem plus my mouth was dry
as toast. Try staying up all night when you feel like that and it’s even worse.”
“And are you taking any other drugs, over-the-counter or illegal, like stimulants?”
“Are you kidding me? Just what I need, stimulants! I do drink one cup of coffee in the
morning, if you call that a stimulant.”
“Any alcohol?”
“Rarely.”
“What’s there to understand? I can’t sleep, that’s all that’s wrong with me, and I
doubt if you shrinks can do anything to help me, but my wife and my regular doctor
told me this was the place to go, so here I am.”
“Very well, Mr. DeVries. I’ll see you again tomorrow. During the admission process
we’ll be getting some blood tests and the nurses will get your vital signs and take
another history, OK? Do you have any questions?”
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“I wish I could answer that now, Mr. DeVries, but I assure you we will do everything
in our power to help you.”
Problem began after diagnosis and treatment of a lymphoma of the neck, low grade,
now in remission. Denies anxiety or depression. Thinks radiation treatments may
have damaged his brain’s ability to sleep.
Habits: Denies use of stimulants other than 1 cup coffee A.M. Alcohol rarely.
Past Medical History: Pertinent history includes the failure of Dalmane, Mellaril, and
Desyrel to help insomnia.
Mental status: Exam: Patient is well-groomed but has obvious sun damage to his
scalp and hands consistent with his occupation. Affect is somewhat frozen with
touches of anger; patient has very little hope we can help him. Speech is logical and
sequential without slurring. Patient is oriented times three. Recent and remote recall
appear intact though formal memory testing not performed.
Plan: Thorazine 100mg p.o. at bedtime with Cogentin 2mg. to prevent restlessness
with frequent nursing observation to confirm sleep. Therapy directed at underlying
fear of mortality, though patient is a poor candidate for insight-oriented therapy.
After dictating my admission note I looked at the Wyeth print in the corner of my
office, which loomed directly behind the chair in which patients sat. It was a bleak
study of a dead crow, sideways but belly-up, its pencil-thin legs crooked and rigid in
death. Stubbles of wheat in a long-since harvested field formed the background
beneath a wintry slate sky. Some colleagues had questioned my choice of the print, to
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which I replied it could be used as a projective test, like a Rorschach. That seemed to
silence them. Myself, I found a comfort in the portrait of a natural, non-violent death.
On rounds the next morning I read the nursing notes in Mr. DeVries’ chart.
“Judy?”
“Yes, Doctor.”
“Right.”
“Yes.”
“His eyes were closed and he didn’t stir when I moved the flashlight around the room.
He wasn’t snoring or anything, but he didn’t open his eyes.”
“Let me see the chart. Thanks. Here, Linda wrote ‘Lights out at 11PM, in bed at
11:15.” “He got his meds at ten.”
“Did you or anyone else see him stir last night for any reason, wander the hallways,
go to the bathroom, anything?”
“The other nurses are in report but I’ll poke my head in and check.”
She returned in a few minutes, laughing, with a fresh cup of coffee. “Hey, where’s
mine?” I asked.
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“Sorry, nurse’s privilege .. Doctors get their own nowadays. It’s not like it used to
be,” she said, smiling.”
“Yes, yes, I’m well aware of that. But what did the other nurses say?”
“Thanks, Judy.”
His bed was empty but I heard noises in the bathroom. I decided to wait for him to
emerge. His bed was not disheveled but did appear slept in. The covers were pulled
back and wrinkled, and the soft impression of his body persisted on the sheet from the
underlying mattress. The pillow looked well-creased and sported a couple of saliva
stains.
Mr. DeVries emerged from the bathroom showered and shaved, though hardly
refreshed. His brown plaid bathrobe had a tattered hem and a few random holes, but
was still respectable enough for a mental institution. He ran a towel through his hair,
stroked his neck, then noticed me sitting on his bed. He managed a nod of
recognition, as if my appearance was inevitable. He dropped the towel to his side,
then walked unsteadily to the hamper, which reassured me that he had swallowed his
medicine. As he turned back from the bathroom our eyes met.
“I didn’t.”
“Not at all?”
“Not a wink.”
“That’s very puzzling. The nurses recorded that you appeared asleep when they carne
in to check on you last night with a flashlight. Do you remember that?”
“Of course. I remember them corning in, pretending to be quiet as mice when they
were really loud as elephants, and I remember the flashlight in the eyes routine.”
“So why didn’t you open your eyes and tell them you were awake?”
“I didn’t want to bother them. Too much trouble. So I just pretended to be asleep. It
was easier than getting up and explaining.”
“So let me get this straight–although you appeared asleep, you were only pretending
to be so in order to be less trouble for the nurses.”
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“You got it, Doc.”
“But Mr. DeVries, you are in a hospital for your own benefit. Isn’t that taking
politeness to an extreme?”
“What’s the use? I knew I couldn’t sleep. Why did they have to know, too? Isn’t it
enough that I tell my doctor?”
“Even your doctor needs help from other observers. So if this happens again, I want
you to speak to the nurses so they can record that you are awake. By the way, did you
have any trouble with the medication?”
“Just the usual plumbing delay and a little grogginess and dry mouth. It did seem to
make it easier to lie in bed and pretend I was asleep, like a sedative. But it didn’t
make me sleep.”
“Very well, Mr. DeVries. please get acquainted with the ward routine today and
maybe meet some other patients. It’s almost time for breakfast. Which reminds me,
how’s your appetite?”
“Good. I’ll see you in my office at 4PM, unless you’re napping,” I joked.
“Fat chance.”
The knock on my door came promptly at four, and I ushered Mr. DeVries in. He
looked the same–grim and weary. He folded his arms and looked out my window for
a moment, then faced me with his tired blue eyes.
“Tired as usual. The food’s bad. And there isn’t much to do. Don’t have much use for
crafts.”
“Is that what it’s called? what a waste of time. A bunch of whining babies in there,
people who had slit their wrists and what not. And then there’s the real crazies, who
don’t talk much sense and look at you funny. Schizos I guess.”
“That’s for sure. I don’t think I belong here. I can stay awake at the farm just as well
as here. Are any of my tests back?”
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This was the first indication of anything like curiosity in his own condition, so I
decided to make the most of it.
“And?”
“Like what?”
“You seem to have something in mind. Is there something you’re afraid of?”
“Me? No. I just want to know if you have any more answers.”
“But there is no blood test for insomnia, so what answers are you expecting?”
His face went blank for three seconds and his eyes seemed to moisten imperceptibly.
Did his chin tremble? This was the closest he’d come to an emotion since admission.
“Well, I guess--”
“Yes?”
I believe “My doctor said something about checking my white blood cells from time
to time. Did you check them?”
“ “Yes.
“Which kind?”
“Mr. DeVries, you do not strike me as a stupid man. you know which kind you’re
interested in.”
He paused again. A shadow passed over his face, like the shadow the dead crow in
the Wyeth painting behind him. His face slackened, then quickly re-configured into
stubborn granite.
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“The L-kind of blood cells, you know---”
“Lymphocytes?”
I had exposed a chink in his psychological armor. The cancer he didn’t believe he had
was real enough that he wanted to know his test results. I could have told him a
number of things–that lymphoma often doesn’t show up in the blood until the tumors
are widespread and that a normal lymphocyte count was no guarantee he was cancer
free. Or I could have lied to him, tried to pierce his denial with the announcement that
his count had climbed dangerously, just to watch his reaction. The former would fuel
his hidden fears, the latter confirm them, but neither was strictly fair. Deceit may
break denial but afterwards, once discovered, it only hardens it. There was really only
one course for me to take, tempting as the opening had been. But before I took it I
wanted to drive the wedge in just a little further.
.He looked away to the window. He stroked his neck with his sun-reddened hand. He
looked at the ceiling as if the myriad holes in the acoustic tiles might explain the hole
doctors made in his body.
“Yes?”
“Because the doctors said that if those cells went up, those lymphocytes .....
“Uh huh?”
“Like what?”
“Like–I don’t know!” he said in exasperation, now freely rubbing his neck.
He was clearly uncomfortable now, shifting in his seat, avoiding eye contact, crossing
and uncrossing his legs.
“That the thing–the thing they said I had–that it could be coming back.”
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He wiped his brow in relief as if he had expelled some demon, and the lines of
tension on his narrow jaw faded back to the usual mask of resignation. I ought to have
accepted that, but I pressed on to hear the dreaded ‘C’ word from his lips.
He stiffened, then folded his hands together on his knees as if to pray. He looked
down at his lap like a boy in catechism who would rather be out playing baseball.
“A growth,” he mumbled, without raising his head. “I’m sorry, I didn’t hear you.”
“How should I know?” he spat out at me, his hands now clenched in anger. “Some
kind of a growth!”
“Well, sort of …”
“Mr. DeVries, are you telling me you let the doctors cut into your neck and give you
radiation without telling you what this growth was?”
“No!” he yelled. “I wouldn’t let anybody do that. My wife put me up to it. There was
really nothing wrong.”
“Yes!” he said, “Goddamed!” His red face went vermilion. He shook his fist at me
and his lower jaw extended so his platysma muscle fanned out to his collarbones like
a threatened lizard. His defenses were brittle but holding. I waited for him to calm
down.
We stared eye-to-eye. Behind his anger I was seeking to touch the fear that drove him
but he merely re-adjusted his mask, slumped back in his chair, ran his fingers over his
stringy hair and exhaled. Then he fiddled with his hands as if running the brim of a
hat through them.
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“Normal.”
“Figures,” he said, exhaling deeply. “It’s always been normal, just like I’ve been
saying. A bunch of fool doctors tell you you’ve got something serious and you go
through all this baloney and then your tests are still normal. No wonder I can’t sleep!
You can’t trust the doctors, the lawyers, the ministers, or especially the damned
government. Someone’s gotta stay awake to make sure everyone else doesn’t get
ripped off!”
The faint smile that creased his lips was his first attempt at humor, a more advanced
defense than denial. It seemed as close as he could come to expressing relief. I felt the
session was over..
That night I arranged for Carl, our maintenance supervisor, to set up a video camera
in Mr. DeVries’ room. He went over the particulars with the night nursing staff until
they felt comfortable operating it. My only static came from the charge nurse, who
asked me if I’d obtained written permission from the patient. I got around that by
explaining that the recording was part of the general therapeutic treatment to which
he’d consented upon admission. She frowned and made a note in the chart to protect
her ass. I didn’t care.
I also increased Mr. DeVries’ Thorazine dosage to 200 mg. to insure that he would
actually sleep. Since he showed few untoward effects from the 100 mg., I figured a
double dose wouldn’t hurt him.
The nurses crept into his room at midnight while he was motionless and breathing
regularly with his mouth open. They set up the tripod and camera as quietly as
possible and put in a long-running tape. One of them addressed him in a normal
voice: “Mr. DeVries, are you awake?” No answer. They never saw him stir. They
were instructed to remove the camera before dawn to insure he hadn’t seen it.
Everything went according to plan. On rounds the next morning I received the tape. I
put it in my briefcase then went by Mr. DeVries’ room. He was sitting on the edge of
his bed, dressed in blue-striped white flannel pajamas, staring into space, his brown
robe pooled at his feet.
“Mr. DeVries?”
“Doc?”
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“No,” I said, laughing. “I just doubled your sleeping medicine. How are you feeling?”
“Like I was kicked in the back of the head by a Brahma bull. I’m almost afraid to
stand up.”
“Let me help you,” I said, and I put my arm under his armpit and gently yanked him
up.
I walked him over to the bathroom and meanwhile used my grasp of his arm to check
for muscle stiffness, one measure of the drug’s side effects. There was none. He was
just groggy.
Some minutes passed until I began to be concerned. I knew I had given him a stiff
dose, but that was the point–I wanted to prove he could sleep. So I opened the
bathroom door a notch to see how he was doing. He stood doggedly over the toilet,
slightly swaying, trying to pee.
“Damn it, Doc! Did you have to interrupt me just when the old millstream was about
to flow? Now I gotta start all over again.”
Embarrassed, I retreated back to his bed to wait for the telltale flush that would
announce another victory over his aging prostate. Five minutes later I heard it, after
which Mr. DeVries ambled out in slow motion and creakily lowered himself next to
me, looking like the Tin Man in need of fresh oiling, thoroughly dazed. His cupped
his reddish chin in his hands and continued to stare distractedly.
“So?” I began.
“I didn’t.”
“Not at all?”
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“Not a wink.”
“How could they?” he said. “I was so drugged I could hardly move. I probably looked
asleep, but I guarantee you I wasn’t. I just couldn’t move with all that medicine in my
system.
“Hardly.”
“Not unless you mean my eyes going fuzzy and my plumbing shut down and my feet
feeling like lead weights.”
“Sorry about that. Those side effects should improve as the day goes on. I’ll see you
in my office at 4PM today again, OK?”
“OK,” he said and lay back down on his bed. I was dismissed.
I spent my lunch hour fast-forwarding the videotape to find the best segment for Mr.
DeVries to view, though my hope of puncturing his denial with real evidence was
slim. Unfortunately the audio contained no snoring, and he barely moved all night.
The best I could get was slow, shallow breathing and some close-ups of his mouth
half-open and drooling with his eyes closed, and of course, the non-response to the
nurse..
I scanned his eyelids for signs of REM sleep but the resolution wasn’t good enough.
Besides, Thorazine tends to suppress it. By 4PM I had the television and video player
set up in my office. At Mr. DeVries’ knock I had the sinking feeling that it was all for
naught. responses. Still, I could study his reaction.
“Come on in,” I said. He sat down in the usual chair in front of the Wyeth print. “I
have a little show and tell for you today, Peter. You don’t mind if I call you by your
first name, do you?”
“Let me lower these window shades. Last night while you were in bed we made a
tape of you. Since you appeared asleep to us, we thought if you saw yourself on tape
you might believe you slept.”
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“So that’s what all the hubbub was in my room last night,” he said. “I wondered what
was going on.”
“Of course! How could anything disturb me when I could barely move my limbs! But
that doesn’t mean I wasn’t aware of what was going on!”
“I was distracted by that contraption they were setting up. Maybe it was more
radiation, what do I know? I didn’t know you were going to make a movie star out
of me.” His lips curled up with sarcasm.
“Well since you are a ‘movie star’ now do you have any objection to watching part of
the tape with me?
“No.”
I put the tape in and let it roll. We watched the inert form of Mr. DeVries on his side,
covers up, breathing slowly, eyes closed, saliva beaded at his lip’s edge, mouth open.
The nurse spoke; he failed to answer. I watched his face as he watched this and it
displayed only the smug satisfaction of one who knows a truth others are just too
dense to see. For five more minutes I let the tape run in silence. Then I took an
objective approach.
“Peter, if you could imagine this person were not you, and you were a betting man,
would you bet the subject was awake or asleep?”
“I don’t think–I know I was awake. I just pretend to look like I’m asleep because
that’s what you’re supposed to do at night, isn’t it?”
“But what about the breathing? The spittle on your lips? Do you drool when you’re
awake?”
“Sometimes. Got these bad-fitting dentures. And when I take them out at night
sometimes I drool even more while my mouth readjusts. Besides, that drug you gave
me makes it more difficult to swallow and stuff. I still don’t feel right.”
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“So let me get this straight–although you didn’t actually sleep, you give the
impression of sleeping throughout the night for the sake of convenience, to match our
expectations?”
“That’s right. And even if a man doesn’t sleep, he’s got to rest, doesn’t he? So I lie
awake and rest all night.”
“But why don’t you open your eyes, or change position? In six hours of tape you
don’t open your eyes once.”
“What’s what?”
“That thing on the screen, that dark thing upside down right over my face–it looks
like a dead bird or something!”
He finger shook as he pointed. “Like a crow lying on its back with its little feet up–
right there–over my face! What is it? Turn it off, please!”
Somehow the crow had been projected on the screen by light bouncing off the print
and back onto the video. But I was not about to explain how this had happened, for
Peter was sobbing now, sobbing into his callused palms. He wadded a bunch of
Kleenex together but was powerless to stop; his tears kept flowing through his palms
and down the inside of his leathery arms to become dark spots on his brown polyester
slacks, shiny at the knees. I let him weep in silence. After ten minutes he looked up at
me through bloodshot eyes, embarrassed, pleading, pleading for what? Reassurance?
Absolution?
“Yes, Peter?”
“I want to go home.”
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“Home?”
“I’m sorry to hear that. But could you tell me why you were crying?”
“Oh, it’s nothing, I guess,” he said as he rubbed his neck and dabbed his eyes with a
baseball-sized wad of tissues. “It just came over me–I don’t know, the medication,
lack of sleep, you know--”
“My eyes must be playing tricks on me. Just some strange reflection on the TV or
something.”
“The critter just looked so sorry, you know, I felt sorry for it, lying on its back in a
field with no one to care for it, just dead and discarded, you know? I keep a lot of
birdfeeders out in winter and we get a lot of birds. I guess it made me want to be back
at the farm, to have everything back to normal.”
“Oh,” I said.
“Can I go now?”
“Sure,” I said.”
That night I lay awake thinking about Mr. DeVries. I thought about his years as a
farmer, his sturdy belief in the everyday reality of cows and feed, summer and winter,
planting and harvest. He had wept like a baby when the superimposed image of a
dead crow marked his face, though he consciously never made the connection with
his cancer and fear of death. Like most of us he assumed he was immortal until the
day death would surprise him, and he did everything in his power to keep that
possibility out of mind.
Being cannot imagine non-being. We live out the myth of our own immortality each
new day, and we must, because hope cannot tolerate the reality of death, no matter
how old or sick you get. And who was I to bring a man to his knees with a
knowledge too painful to tolerate? If I opened the dam of his grief who would patch
him up so he could go on living and trusting life? And once he went back to his farm
and his church, who could he talk to about such things?
As an intern I could never forget my first patient with a heart attack. Though he
survived, he was terrified and tearful, constantly demanding reassurance because the
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thought of his own death had never occurred to him. Lucky man!-- lucky, like most of
us, to be blind.
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