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The Message

Written by Danielle Levinson

Identifying patient data has been changed to preserve anonymity.

An 89-year-old man with congestive heart failure and interstitial lung disease presents to the emergency department with dyspnea and orthopnea. Over the past few months, his tolerance for activity has decreased and he has had increasing trouble breathing at rest. His diet consists mainly of fast food. Exam reveals bibasilar lung crackles and moderate pitting edema in his lower extremities. His son leaves to get a soda, and suddenly I am alone with the patient, trying to work on my auscultation skills. He starts talking, and I have to remove my stethoscope to make out what he’s saying.

“I’ve been trying to cut back on the salty foods.”

“I know it’s hard.” I’m not even halfway through my second year of medical school, and already I’m so exhausted that empathy feels like a show. I replace the stethoscope on his chest, but he starts speaking again.

“I own a fast food joint. It’s just easier for me to eat there, you know? I live right next door. My parents built the restaurant and the house on the same property, way back in the 50s. I was born in that house.”

My posture stiffens. He reminds me of someone. “That’s a long time to stay in one place.”

“I can’t leave. That’s my community. I get a lot of the same customers and they’re like family.”

“It’s nice to have a community.”

“You bet. My children have all moved away, though. It was too stuffy for them, I guess. My son wants me to move down to Durham, but who will keep the restaurant going?”

I want to comfort him in some way, but I can’t think of anything to say. “Well, it’s good you still have some independence,” I say lamely.

“If you lose your independence, what do you have left? The last thing I want to be is a burden.”

In his stern lip and thick glasses, I see the broad strokes of someone who meant very much to me: another man whose independence verged on stubbornness, who was still driving around his small town at age 90 with his thick, edematous fingers on the wheel, complaining about the rise in traffic.

“Well, thanks for sharing so much with me,” I say. “Can I listen to your heart?”

My grandfather died on November 6, 2021, the day of my grandmother’s funeral. I was in Durham at the time, preparing for a test on the gastrointestinal system.

“You don’t have to go to the funeral,” my mom had said. “Nana would’ve understood that you needed to study. You visited her before she died. That mattered more to her.”

I couldn’t decide whether I was grateful or disappointed to have been absent on that day. According to my mom, Poppy had just returned from the service; he’d shuffled up the stairs into the house where he’d lived with Nana for fifty years, and then he’d gone straight to the bathroom. He was in there for a while, so my aunt knocked, but there was no response. When her husband broke down the door, they found him unconscious on the floor. Paramedics came and pronounced him dead onsite. Probably a stroke or a heart attack, they said.

Facts pass through you differently when they happen hundreds of miles away. My grandfather’s death is not a memory, but more like something that I read in a book. I know that it happened and that if I go back to New York and knock on the door of my grandparents’ old red house, I will not recognize the person who answers. Still, I can’t seem to get it into my head that he is really gone. It’s as if I’ve mentally paused the world outside of Duke and Durham. I tell myself that once I finish my training, I’ll finally be able to take a step back and process everything that happened in the interim.

For now, reality feels like a snow globe of medical education. I’m stuck in a glycerin labyrinth of hospital hallways and study spaces, slowed by the thick liquid of my own expectations and anxiety. Occasionally, I glance down at the plastic snow that has settled to the floor, a mix of memories and unprocessed facts that I dare not disturb, for fear that they will cloud my vision and impede my progress.

A 45-year-old woman with intellectual disability and congestive heart failure presents with several days of hypoxia. She is on two liters of oxygen at home but came into the hospital with worsening shortness of breath and saturations in the mid-80s. She has been improving with furosemide, but this morning she has pulled out her IV. I wince at the bloody needle on her bedside table. I am surprised that she seems so content; she is sitting up and kicking her legs against the bed.

I wave at her, and she smiles.

“Can I listen to your lungs?”

She nods, and I hear thick crackles at the bases.

Later, she is given a replacement IV, which she subsequently tears out of her arm. She does not accept oral medications, either. The nurse cannot administer her diuretics without forcing her to consume them. Her lungs begin to drown again. After multiple days of reflection, her primary caregiver authorizes her transfer to hospice.

“She’ll tell you when she doesn’t want something,” her caregiver says. “It seems that she is ready to go.”

Even though I am aware of these conversations, I am not prepared to see her whole body shuddering from deep, hissing breaths. When I say hello, she does not respond, so I put my hand on her shoulder and hope that she understands my touch. Then I place my stethoscope next to the resident’s, and for the first time in my life, I hear death rattles.

Nana was declining quickly, so I skipped my Friday class to fly back to Syracuse, New York. A few days before, I called to tell her I was coming.

“That’s wonderful, dahlin’,” she said in her Lowell accent. “As long as it doesn’t interfere with school.”

Just as I was leaving, my mom warned me that she was fading faster than expected. “Now she’s stopped eating, and she’s sedated by the pain medications. She’s not really speaking anymore.”

I told myself that the medications would wear off by the time I arrived, and we would have a chance to say goodbye in words. But when I entered her bedroom, all my hope flew away. I had not seen her in two years because of the COVID pandemic, and she had lost half her weight in that time. Her chest heaved with deep, mechanical breaths that consumed the little energy she had left.

“Look, Mom, Dani’s here. It’s your favorite girl!” my aunt shouted. “She’s hard of hearing, so you’ll have to speak up, but the nurse said that she can still understand what we’re saying.”

I doubted that. She looked like a wrinkled balloon that was inflating, deflating, inflating, deflating. Breathing, but barely lifeless. There was no evidence of her motherly diligence, her love of learning, her stubborn wisdom, her occasional cantankerousness. She couldn’t sit up, give me one of her suffocating hugs and say, “I love ya, dahlin’.”

Everything I loved about my grandmother was gone.

“I told you Dani was coming, Mom!” my aunt shouted. “Look, she’s moving her eyebrows! She’s moving them a lot now. She knows you’re here!”

I wanted to believe my aunt. If I could have convinced myself that each flicker of Nana’s eyebrows was a secret way of saying “I love you,” then maybe it would have been easier to accept what was coming.

My aunt left the bedroom. It was an October afternoon, and already the daylight had mostly faded. Left alone with the sound of Nana’s ragged breathing, I had no idea what to do. Was I supposed to collapse to my knees, crying? I was too stunned to produce tears. Was I supposed to tell her how much she meant to me? I didn’t know how to put that into words.

“I love you, Nana,” I shouted, feeling uncomfortable with the loudness of my voice.

I fidgeted in my chair. My mind was too congested to make an effusive speech about love and life, so I resorted to what I usually did during a visit with Nana: I told her about my day.

“The flight wasn’t bad,” I said. “And they didn’t really care that I missed class this morning. I mean, they cared, but it wasn’t really a big deal. In my head, I always make missing class into a big deal, but in the end everything’s always fine.”

Her eyebrows scrunched, and I wondered if I had confused her. This was usually when Nana would provide some reassurance, like, “You’re a hard worker, dear,” which I knew was true, but hearing her say it out loud always made me feel better.

I suddenly felt ridiculous for having put off my visit to attend lectures and anatomy sessions and exams.

“I promised that I would call you every night, but that didn’t happen, did it? I was busy studying, or watching TV, or spending time with my boyfriend. I wasn’t thinking of you enough, and you loved hearing from me. I called you once a week, at most.”

Now her eyebrows rose high, and I wondered if she was saying, “You shouldn’t be so hard on yourself.”

But I didn’t know how not to be hard on myself. That was what I needed her for: to bring me back to reality, to be my crutch, to love me like only a grandmother could.

“You’ve done so much for me. You’ve given me so much love, and you’ve motivated me through every step of my life. How could I ever repay you for that?”

I tried to detect some symbol of understanding in her ragged breaths. She wasn’t moving her eyebrows. I wanted her to move her eyebrows. I had just said something deep and important, and if she were conscious, she would’ve responded with something equally deep and important.

I took her hand and kissed it.

“I love you, Nana,” I repeated, waiting in silence to hear her response.

 

An hour later, I was in the kitchen with Poppy, hanging onto every word of the stories that I had already heard so many times. I wanted to cherish the moment; what if this was the last time I heard him speak? I wondered how many details were being missed because Nana wasn’t there to point them out.

“Chester, you’re forgetting about the Connecticut house…Your mother would never say that…No, that was my other sister…”

Still, Poppy could tell a good story. I was surprised that I could smile and laugh so easily, as if I had forgotten the sound of Nana’s desperate breaths in the room above us.

Then my uncle descended the stairs and said, “Can I interrupt?”

I had never seen my six-foot-tall, square-shouldered uncle break into tears. It was disturbing to see his face so red and hear his voice coming out hoarse.

“She’s left us,” he moaned.

 

Only minutes after my grandmother took her last breath, her body already looked very different. Her skin was yellow, and her mouth was hanging open crookedly. It seemed unfitting for a woman who had always been so thoughtful about her appearance. I could still remember her flowery perfume, her thin lips outlined in red, her pearl earrings elegantly dangling and her turtleneck sweaters crisply smoothed. A woman who cared so much deserved to die pretty and composed.

“You can touch her,” my uncle said when he saw me staring. “Go ahead, kiss her goodbye.” But I was reluctant. Her body looked too similar to the cadavers we’d dissected in anatomy lab. As I put my lips to her forehead, I imagined a scalpel running through the cool, rubbery flesh, and I hated that this would be my last memory of her.

A 78-year-old man with a history of major depressive disorder presents with malnutrition and hypokalemia to 2.7. He’s just not interested in food anymore, he says. It’s not that he’s depressed–his mood is actually quite good, and he’s happy with his current antidepressant regimen. He’s just tired of the same old food his wife makes.

“I’m not a good enough cook for him,” she sighs.

After a few focused questions, the resident asks: “Is there anything else going on?”

“Well, I don’t know if it’s relevant, but he had his first fall the other day,” the wife says.

“I was so proud that I hadn’t had a single fall, but then I tripped on the stairs and hurt my arm,” the patient adds.

“May we see your arm?”

His left forearm is wrapped neatly in gauze and bandages, and it takes a good minute for the resident to unravel the dressings.

“I did the best I could,” his wife says. “Did I do it right?”

I flash back to my grandfather sitting in the middle of the stairwell, breathing heavily. It was the first time I had seen him fall. Nana ordered me to grab a blanket to slide under his bottom.

“He’s been falling a lot lately,” she said. “I’m going to have to buy one of those chairs that goes down the staircase.”

“You don’t have to help me,” Poppy protested. “I can get up on my own.”

“Chester, you’re old. You have to get that in your head. Everybody needs help when they’re old.”

I pulled the blanket on Nana’s counts, feeling that I was doing very little to help. What I really wanted was to put a blanket under the world and pull it back, back, back until I had rewound our lives by many years. That way, my grandparents would no longer be hurtling towards the end of their story.

When I turned two, my parents moved to the Syracuse suburbs so that I could grow up closer to my grandparents, but I can’t say that I enjoyed visiting them as a child. They were strict Catholics who brought me to church in uncomfortable dresses and didn’t let me partake in the bread and grape juice. There were things that I couldn’t do in front of them, like lay on my back in the “happy baby” yoga position.

“That’s not ladylike,” Nana would say.

As I matured and my grandparents softened, I began to see their house as a refuge. It was one of my first destinations as a newly-minted driver. They lived forty minutes away, across farms and forests and rolling hills, and those long trips alone made me feel independent and free. Nana became my confidant, and Poppy was the bearer of sepia-colored stories that stretched my imagination. He was once a frequenter of jazz clubs, and at night we listened to Billie Holliday on the record player.

After Poppy had gone to bed and you could only hear the crickets, Nana would put on the kettle and bring out a plate of cookies, and then we would talk for hours about life and love and politics and the hardships of being a teenager. We would sit by the broad kitchen window, where in the winter, I could see the snow falling thickly through a sphere of porch light.

Many summers, I stayed with them for weeks at a time. I would spend the evenings volunteering at the Skaneateles Music Festival, a series of classical music concerts in the small town’s historic churches and vineyards. I adored the sound of wood and brass refracting off rafters or intermingling with the hum of the cicadas. Volunteering earned me a free ticket, but occasionally Nana would accompany me to the outdoor concerts. We would sit side-by-side in lawn chairs, and I would smile with my eyes closed as the music passed through me in the dark.

Sometimes, I want to convince myself that they died for a good reason. Of course, they did: my grandmother was 90, and my grandfather was 96. But sometimes the logic of their passing is not enough; sometimes, I need to know that they left me some kind of message. It’s a self-centered thought and a consequence of a patchwork grieving process. However, during my clinical rotations I have become more certain that they did, unknowingly, leave me a message. I see it in unexpected moments, when I’m talking to a patient who stirs up a memory of Nana or Poppy. All of a sudden, my attention sharpens, and the exhaustion and malaise drop away. I remember that this patient could have been my grandparent, and that someday, their loved ones will feel a grief that is similar to mine. And then I soften, and I put my hand on their shoulder, and I listen to their stories, and sometimes I swallow back a tear, because long before I became a medical student and embarked on this wild, confusing, and sometimes oppressive path—before I became inured and exhausted and already somewhat jaded—before all of this, I was just someone’s granddaughter.