The retainer

 

The retainer

Early on having patients come in to see me as their doctor was a thrill.  I had to
measure up to prior opinions and styles. I had to develop a style, my style.
Honestly, was faking authority till I had any. I was trying to make good on all that
training I invested in and others invested in me with.  One day I was a fellow and
then the next day I was an attending and the proverbial buck was suppose to stop at
my high heels. 

I inherited a practice of 200 patients. They were shifty and leery. A few I was
grateful for were nonchalant, somehow accustomed to abandonment and reorganization. 

Of those I inherited were Agnes and Lester.

Agnes would walk her husband Lester in each time. She was organized and meticulous. 

"Lester, sit here," she would direct.

They were both my patients. She had high blood pressure. He had the higher
creatinine and thus the worse prognosis. Their combined age was 174 and their
combined renal function was less than 60%.

Lester was a charmer and a very sweet man who loved well his children and wife.
Agnes, a proper mother. Together they had 14 children. Many were nurses. All were in
their 40-60s.

"We always wanted our kids to have two Christmas presents each year," Lester said
one visit eyes mischievous. "One year Agnes and I wrapped one sleeve and one shoe
for one kid, the other sleeve and the other shoe for one kid, the vest and a toy for
one kid!" The two laughed heartily. I burst with laughter! 

I passed by sons at work not knowing for years. They were nurses in the ICU. 

Agnes fed Lester seaweed tablets daily and his creatinine would inch back.
"Chlorophyll as an antioxidant," described the inserts. I said "Sure!"  Seeing no
issues. 

Meanwhile Agnes had the worst labile blood pressure. Her ultrasound showed renal
asymmetry and I had recommended renal angiogram to evaluate and stent what looked
like renal artery stenosis. She said firmly "no." Agnes was here only to be sure
Lester didn't get into "trouble".

One day Agnes went into hypertensive crisis. Her blood pressure shot up and suddenly
her kidneys shut down. She found herself on dialysis. Shocked and confused because
Lester was the sicker one she mentally collapsed. Wasn't he the one with a prior
bypass now thready? Wasn't he the one with 25% function? 

Broad sided she was catatonic. Her sons were at bedside as sons and not nurses. Her
daughters told Lester where to sit. 

Agnes was eventually discharged home to perform outpatient dialysis. 

The daughters would take turns coming into my office and sitting chairside at
dialysis. Mom was very cold at dialysis. Mom was not eating. Mom was tired after
dialysis. She began wearing ski gear to dialysis; a huge puffy pair of ski pants and
a puffy jacket that swallowed her up. 

For a year I dialyzed her.

Meanwhile Lester came to see me on his own now.

One day Lester came holding a small brown paper bag. The bag had a strange grease
stain on the bottom crawling up one side of the bag.

I was busy writing the note in his chart as he sat quietly. I outlined the history
and medications and labs. Paper charts were still widely used but guidelines for
chatting were becoming more extensive. To keep on task I had to prep a little as
patients waited. I was busy, head down scribbling.

"I have been thinking," Lester said. 

"Uh huh," I said not looking up still writing.

"I was thinking, if I stop my plavix and aspirin and then Agnes stops her dialysis
maybe we can die together," Lester said. 

I stopped writing but didn't look up. I stared at the paper for just a second to
absorb what was said. Then I looked up. Our eyes met.

He extended his left arm and placed the brown bag on the table. 

"I brought these," he said. 

I looked at the greasy bag on the table. 

I opened it and looked in.

There were a dozen doughnut holes in the bag. I smiled huge and took one out and
began eating it. I rolled out from behind the desk over to his chair holding the
bag. Still chewing I casually offered him a doughnut hole from the bag too. 

"That's an interesting plan. Have you told your kids?" I chewed. 

"No," he chewed. 

I swallowed. Grabbed another doughnut hole. "Well, it won't work," I admitted. 

Lester chewed slower than me having no where to go and half heartedly shrugged. "It
was just an idea," he smiled. 

"Thanks for the doughnut holes," I said offering the greasy bag back. 

"There's more where those came from. I want to keep you on retainer," he said
pushing the offering back.

I burst in laughter again!

Lawyers are raking it in to stand and be ready to defend a client. Meanwhile, I'm
getting fat on greasy doughnut holes. 

"You are a charmer!" I exclaimed. 

Even on dialysis Agnes would still close each monthly round to ask that I ok the
seaweed pills for Lester. 

A few months later Agnes took a turn. True to literature she didn't last much more
than a year given age alone. 

Lester arrived in my office a month later on queue. 

"Hi," he said.

"You ok?" I hugged.

"Yeah," he said sorted and calm.

He sat and I gave a pause before launching into our agenda. 

"Hey," he said "I have something to ask you."

I readied myself and said, "ok, go."

Lester had been conversing with an old friend from high school for the last weeks.
She lived in New York. She was coming out to see him. 

"I want your permission," he asked as politely and respectfully as if I was his
mother. 

I smiled my huge doughnut hole smile and asked first, "Did you ask your kids?"

Lester said, "Yeah they all don't mind but you knew Agnes and I think if you said it
was ok..."

My god. I guess at some point Agnes became my ward and I became her proxy. I began
to see the fullness of the buck stopping at my feet. 

"Sir, Lester, my dear friend. Agnes would want you to be happy," I hugged him long
and hard. 

He hugged me back.

The story goes the old acquaintance came out for a visit but being herself older and
not well got sick and hospitalized. She eventually returned home to New York.
Shortly after the visit I heard Lester died himself. I wondered if he executed his
little plan  to stop plavix and aspirin and let his tenuous bypass close but it
didn't matter. I like to think he merely died calmly happily having loved hard and
often laughing. 

I can't eat a doughnut hole without thinking of being on a retainer for a greater
calling than algorithms and mandates and outcomes. I am tempted each year to wrap
fragments of gifts for my two children and laugh when they open them with a sting. I
put on ski gear each winter and hope Agnes is plenty warm wherever she is. I respect
the life giving chlorophyll that offered solace to a woman caring for her husband.
Lastly, I think love and romance happens even at 88 years old.