At work I am a neighbor. I serve lunch at a public school. I am a nurse practitioner and a Kum & Go cashier. I am a pharmacy technician and a warehouse manager. I am a phlebotomist, a receptionist. I install drywall. I wrangle toddlers at a day care. I am a woman seeking a pregnancy test, a child afraid of needles, a man with a swollen abdomen on a twenty-day bender. I am diabetic. I have a heart murmur and high blood pressure. I have a history of blood clots, two broken bones in my hand, one kidney, no gallbladder — whatever the job demands.
I am an interpreter.
Once a week I wake up at eight o’clock, shower, and drive across Iowa City, Iowa, the college town where I live, to work a volunteer shift at a medical clinic. The clinic is free, but free means different things in different contexts. At our clinic it means services cost nothing. We fill as many prescriptions as possible, no charge. And we only treat patients without health insurance.
The clinic is a simple building: a single loop of gray carpeting, a series of beige rooms and vinyl-covered exam tables, and a plexiglass window behind which sit receptionists. It’s a clean, modest, and aging place that always seems to be quivering on the edge of bankruptcy. In a back room a mini fridge hums, cooling a supply of free insulin. Through a Dutch door a pharmacist doles out medicine. She hits a dinner bell whenever a prescription is filled.
When I first started volunteering, I shadowed a man named Brian. Brian isn’t exactly the sort I expected to find working as an interpreter. He’s middle-aged with a graying beard that grazes the top of his laminated name tag. He speaks with the flat, stretched vowels of a Midwestern accent. He always has three things on him: pointed leather boots, a faded pair of camo pants, and a coffee mug with the native birds of Iowa darting across its surface. And, like a lot of the longtime employees, he plays many roles at the clinic.
I followed Brian as he weighed patients, led them to numbered examination rooms, and took their blood pressure. Each session began with a question: You’re here for a blood-pressure checkup? You’re here for an STI screening? You’re here because you’ve been having some ankle swelling? It is important to ask and not to assume anything. When the doctor entered the room, Brian formed the third point in a narrow triangle — patient facing doctor, interpreter next to patient but a little behind: forgettable, ignorable. I noticed how Brian sat, hunched over his own hands, staring blankly at the floor or the exam table. If he didn’t know a particular term, he sailed through it with a brief description, barely pausing. He didn’t take any notes; his memory is superb.
When we met, he’d been working at the clinic for more than a decade. He’d originally been a volunteer like me, but he was good enough that they’d offered him a job. By the time I began working there, he knew most returning patients by name, as well as the names of their children, what they did for a living, and their medical histories. Most important, he knew their personalities: who would be irreverent and easygoing; who would be deadly serious; who would need long, detailed explanations; and who would be too nervous to speak.
In the break room he told me stories of patients driving two hours from Des Moines or the Quad Cities each month for dental specialty clinics, people coming in from out of state. We are the only free clinic around. The message was clear: people are desperate for care.
A few weeks after my first shift at the clinic, I abruptly become a patient at the hospital connected to the university where I am both a student and an instructor. The doctors do not know what’s wrong, only that there is a blood clot in my left shoulder, floating like a leaf in water, between my lungs and brain. On the cardiac floor I call my supervisor to cancel my university classes. I email the clinic to explain I cannot attend my shifts. One of my nurses has a tattoo on the underside of her wrist that says, “See you in heaven, promise.” There are things you cannot forget. My eyes are drawn to it every time she comes in to take another blood draw or insert the IV that delivers my high-powered blood thinner.
The problem has been chronic for a long time, but not obvious. Years of tightness under my arm, tingling in my fingers, swelling at the fingertips — all easy enough to ignore. Then suddenly a crisis: Back pain, a stifled throbbing down my arm, color changes in the skin. When I exercised, the back of my hand turned an alarming corpse-blue, and, at random moments, swimming points of pain erupted at the ends of my fingers. A constant tracery of blue veins announced itself across my shoulder.
The morning after a doctor discovered the clot, a handsome and charming surgeon visited me. He had heavy eyebrows and the swaggering confidence of an expert mechanic. He exuded competence and certainty. I liked him immediately.
“My man,” he said, fist-bumping my IV-wrapped hand.
He described my condition as a problem of dimensions: Nerves, veins, and arteries all spill through a gap between the collarbone and the first rib, like wires through an electrician’s hole. In my anatomy the gap is too small. Freestyle swimming, overhead lifts, and, I suspect, the saxophone that hung on my shoulder for years have compressed the area further. There is simply not enough space. The solution is a rib “resectioning,” which actually means something closer to a rib removal.
The surgeon explained how he would cut through the skin just above my collarbone, in the soft well of flesh between neck and shoulder, slice the stabilizing muscle, and pull back two major nerves to reach the rib — he mimed parting a curtain with two hooked fingers. Finally he would saw away the section of bone that had been causing the compression. Simple. He promised I wouldn’t miss the muscles after they were gone. He said the resectioning would solve all of my problems. “I’m 99.9 percent sure,” he told me. He tossed off a list of the common risks: bleeding, infections, a coagulate unlodging and finding its way into my lungs or brain. But these things weren’t common, he assured me, only possible. “Mostly,” he said, “you will have pain afterward and numbness in your chest.”
Months before I started my work at the clinic, I took a crash course in basic theories and common problems of medical interpreting. There were six other students in the class: a future nurse, doctor, and physician assistant; a social worker; a public-health major; and one student missing a single credit needed to graduate. Once a week we role-played dialogues. Our professor would be the doctor while we took turns as interpreter and patient.
The scenarios were always problems situated halfway between medical emergency and human volatility: Ms. Godinez has seen too many doctors, and now her diabetes medication is off; Mr. Kovalenko has not been taking his HIV medication regularly, and we have to explain how this can lead to more-aggressive viral strains; Mr. Abed’s son has retinoblastoma, and, “no, there’s nothing we can do. He will lose his sight. The tumor has already taken over his eye.” Sometimes the patients were resistant and withholding; other times they were aggressive and demanding, bartering with the doctor as one barters with God: fruitlessly. But there was always a patient, always a problem, and usually a misunderstanding we had to lead them through, patiently.
In other class periods we discussed theory. We looked at schemas for the mind in the midst of interpreting and read about famous innovators in the field. Danica Seleskovitch was one of our professor’s favorites. He was always repeating her advice to “consider sense over words,” meaning there is no one-to-one correlation when interpreting; words do not march like ants, single file, across a gulf of understanding. There is more than one path to the truth. Seleskovitch was a French scholar of translation, but unlike other translators of the 1960s, seventies, and eighties, who considered translation an art and interpreting a trade, she gave equal importance to both. Before Seleskovitch theorists had imagined interpreting as a process of transcoding, the mechanical act of moving words and structures from one language to another. The metaphors that ping-ponged around the profession were of a conduit, a bridge, a wire conducting information without interference, or a mathematical function — f(x) — moving vocabulary and syntax from one language to another.
Seleskovitch thought interpreting was more than a simple repositioning of words within a grammatical framework. She believed that an extralinguistic process occurred, which involved context, history, and emotion. She theorized a deverbalized state that language passes through. It is this same state that allows us to retell stories without recalling them verbatim, or to remember the process of driving a car or baking a cake without having to narrate the whole experience. It’s a state where we experience pain, joy, irritation, and love as pure, prelinguistic events, unbound from the heavy concreteness of language.
I’m not sure how I feel about this concept of deverbalization — it suggests something mystical I can’t fully trust — but I know that many times, as I interpret for a teenager with a pulled pectoral muscle or a woman with a scarred eardrum, I find myself touching these parts of my body, massaging my chest absentmindedly, pressing a thumb to the downy lobe of my ear.
I woke from surgery vicious with thirst. At any moment in the recovery room, someone was retching, moaning, or yelling for a nurse. Everyone was starving and begging for water. A cup of ice chips, glistening with condensation, sat next to my head, but my arms were desperately weak and numbed with anesthetic. A pressurized tube drooped down the front of my gown. It took me half an hour to realize it wasn’t just draped over my shoulder but was protruding from my chest.
The greatest risk was infection. “Your chest cavity is all open space,” a nurse explained. My incision was weeping blood and fluid into this baroque vault. The tube was there to suck it out. Breathing would help. The nurse handed me a gadget that looked like a plastic sextant and told me to blow into it in spite of the pain. He measured the strength of my breath and showed me how to read the meter. “The sooner you can breathe right, the sooner you can leave.”
For two nights I lay in an expensive hospital room, relearning how to breathe. Every sensation was painfully new. I felt the tube in my chest as a deep ache. It drained out watery, bloody fluid and bits of pulpy matter. Every six minutes I could press a button, and a new injection of painkillers leaked directly into my veins. How much did they all cost?
I fell in and out of sleep athletically, midsentence, then woke with bouts of hiccups, a mounting need to vomit, or a swollen bladder. I drank a bottle of strawberry-flavored Ensure and immediately vomited it back up just as the handsome and charming surgeon entered my room. “Oh boy,” he said as I deposited a half liter of Pepto Bismol–colored fluid into a plastic container meant to collect stool samples. I gave him a meek thumbs-up, trying to communicate that, despite how things looked, I was, in fact, a very easygoing patient.
At home I took painkillers until I was constipated and nauseous. Each morning I injected spring-loaded vials of oily blood thinners into the pinched fat of my stomach. The needle was hair thin. Its medicine sat just beneath my skin until it diffused, both a searing pain and a strange comfort. Once a day I staggered out into the sunlight and managed a short, unsteady walk around the neighborhood with my boyfriend until my arm began to pulse threateningly. On the windowsill bouquets from friends and family wilted, filling my room with a sweet, wretched scent. The surgical glue around my incision slowly dissolved, revealing a curdled stretch of purple, distended skin, and my deep, cherry-colored bruises faded to sickly yellow.
After several weeks of recovery, I returned to work at the clinic. I brought a paper bag filled with unused medication: individually wrapped syringes of blood thinners, a bottle of the painkiller Dilaudid. “This is really expensive stuff,” the pharmacist told me, peering into the bag with amazement. “I can definitely take the Lovenox.” She held up one of the syringes and examined its plastic casing like a jeweler appraising a gem. “But these Dilaudid are already open. We can’t prescribe them like that.”
“We thought you were a goner, man,” Brian joked, sipping from his bird mug as I stepped into my first session.
That morning I interpreted for an older woman who may or may not have had MS, a man who required a refill for his blood-pressure medication, and a woman on the phone who needed to come in to redo a blood test. My last patient was a sullen young woman, short and tan, with a faded blue handkerchief in her hair and the name tag of some institution clipped to her collared shirt. She held a cinched bag in front of her chest like a shield. At first she seemed unwilling, almost unable, to speak. Her anger was palpable — it bled into the room. She answered the doctor’s questions with combative, one-word replies: How are you sleeping? Bad. Do you exercise? No. Have you ever been diagnosed with diabetes? Maybe. Every word punched its way out of her mouth. Every thought churned wrathfully behind her eyes. Then the dam broke, and she was describing her father, who’d died recently of pancreatic cancer after a lengthy hospital stay. She described how the doctors had first written him off, then misdiagnosed him, then told him there was nothing they could do — all after she’d struggled to convince him to go in the first place. She spoke so fast, my words trailed far behind hers. The doctor looked at me in confusion. I put up my hand as I’d been taught in class — to signal the patient to pause. “Why is your hand up?” she snapped. Her eyes swam with emotion that moved in all directions: annoyance becoming rage; rage becoming sadness; sadness breaking, finally, into sharp, derisive laughter. “He hated the hospital,” she finished, breathless.
In the tense, windswept silence that followed, the doctor said, “I’m afraid you have high blood pressure.” He sounded helpless; the problem had slipped the bonds of medicine, strayed into a complicated mélange of social services and psychology. “I’ll write you a prescription. I can give you antidepressants, too,” he offered. She nodded once, sank back into her silence.
The rib is gone, but my veins have not healed. When I exercise, my forearm still goes rigid with fluid collecting in the layers of subcutaneous flesh, and the back of my hand turns the same dusky color of spent blood that it did before surgery. From time to time a horrible, pulsing pain flares at the end of my fingertips, accompanied by panic and dread. I call the surgeon to report these symptoms. “OK,” he says, and he has me reschedule my follow-up appointment for sooner than originally planned. The following week an ultrasound confirms what I am already convinced of: a new clot has formed, or the old clot has not dissolved as expected.
On an operating table again, my body is mapped. Under a tent of surgical tarp, I can hear the scrape of a guide wire nosing its way through my veins. From the corner of my eye I see the radiologist’s lurid, gleaming implements, their fine, clean blades. To get a sharp image, I have to remain awake and hold my breath at precise moments, just as the X-rays pass through my body. “Deep breath,” the radiologist commands. A moment later I hear the rush and whorl of metallic dyes in my bloodstream, the shutter of the X-ray machine. On a screen overhead, my interior resolves — a tree branch lost in fog. I can see the forking tributaries of my body, the ghostly haze of soft tissue, the sharp bands of rib, humerus, and ball sockets. The radiologist regards the screen gravely. “See here,” he says, pointing to a spot under my arm. “That’s where the clot is. And here,” he indicates a bulging pool of black ink, vaguely the shape of Lake Michigan. “That’s where blood is still backing up.”
In the recovery room the surgeon is as charming as ever, but a touch less patient. He’s diminished in his day clothes: thin tie, brown slacks, nothing like scrubs and the authority they confer. His frown is like the frown of the doctors I interpret for when they lean through the door frame and ask me to follow them. They are deeply competent people admitting they need help, struck mute before a problem they cannot solve on their own.
“This is a difficult one,” he admits, putting his tongue between his teeth. “Your shoulder was the tightest I’d ever worked on.” I’m not sure if I should be proud or alarmed by this. He explains that during my surgery they could not remodel the vein as aggressively as they’d wanted. The area was too sensitive and inflamed by the incision. “But now that the site has had more time to heal, we can go in again, this time using a balloon serrated with blades.” He sounds eager to wage this new attack on my body. He asks if I have any questions.
My first feeling is frustration, and then shame that part of this feeling has nothing to do with my health and everything to do with money. How much will this cost me, and for how long will it go on costing? Money is the place where our base needs turn abstract and fungible.
“Will it work this time?” is all I can think to ask.
The surgeon doesn’t know. “It should,” he offers, cautious now that his initial well-laid plan has failed. He prescribes more blood thinners and instructs me not to “baby” the area: to exercise and stretch, to keep blood flowing. He tells me to let my roommates know what’s happening, in case there is a “catastrophe.” I do not ask what catastrophe means. I already know: a clot breaking free, a spill in my brain from my thinned blood, an accident on my bike that precipitates uncontrollable bleeding. The blood thinners are very strong. I am limited to two alcoholic drinks a day. I am advised to avoid head injuries. “I usually try to avoid those,” I tell the surgeon, and, to my surprise, he laughs.
Bills begin to arrive. Just a few small amounts at first: a ten-dollar co-pay for the initial doctor’s appointment, a few hundred dollars for the ultrasound they used to confirm the clot. Then the bill for a hospital bed on the cardiac floor, for the expensive blood thinners that fizzed ominously in the IV line. A bill for the procedure to insert a catheter in my arm as well as the care required to remove it. And, finally, an enormous bill for the hours I spent with my chest open on an operating table and all the mysterious “surgical supplies and implements” used.
For a while I marvel at how financially disastrous this event would have been for me at any other time. The condition is terrifying, yes, but at least it won’t bankrupt me, not completely, and only because my veins clotted, finally and fully, at a time when I have university-subsidized, union-negotiated health insurance. I joke with friends about how lucky I am. And it is true, I am lucky, but I could not have imagined that this is how luck would feel: like a safety line splitting down to its nylon core.
Even with insurance, my initial hospital stay, the surgery, my follow-up angioplasty, and all the trivial bills in between — aspirin in paper cups, plastic tubs to vomit into — cost me thousands: devastating on a grad-school salary. I consider asking for a loan from my boyfriend or starting a GoFundMe page — for a $500 donation you can take the rib home! I consider selling the leftover painkillers. They’ve given me so many — far more than I need — but I can’t bring myself to do it. I wouldn’t even know where to begin. I browse the handbook the university gave me when I started my graduate program, filled with student tips on how to make money when in financial dire straits. Recommendations include things like selling your plasma for seventy dollars a week: “It’s very cold inside, so take a jacket,” the handbook warns.
Instead I take two of the Dilaudids, go online, and scan for double billings on my itemized receipt. Then I dip into a small pool of savings from a year teaching abroad and pay off a lump sum. I schedule the most aggressive payment plan I can budget for — nearly the same amount as my rent — and try not to notice as the money ticks regularly out of my checking account.
For weeks the incision, still fresh and weeping, peeks out from beneath my collar: not yet a scar, no longer an open wound. People on the street take notice. Cashiers do a double take. At the free clinic I notice patients’ eyes wander to my clavicle. Only one of them ever mentions it — the woman with the cinched bag. Interpreters are supposed to leave the room with the doctors, trailing behind them like an afterthought, keeping our distance from the patients. But sometimes when the doctor promises to be right back, it feels strange to stand awkwardly in the hallway just outside the door. So I stay. When the doctor is gone, the woman asks me about the scar snarling out from under the collar of my shirt. “I had to have a surgery,” I say.
“I saw it when we first met,” she replies. “What a pain to be sick.”
On my drive to work most days I watch a ripple of heat bloom into hard white clouds over the chimney of a power plant by the river. It’s midwinter, months since my first shift, months even since the surgery. The river is frozen and dusted with dry snow. My arm still is not healed, but I have fallen into a rhythm: shifts on Tuesday and Thursday mornings, specialty clinics on Monday nights, or when needed.
When I arrive at the clinic one morning, two windows have been hit by bullets overnight: dime-sized holes and a shower of glass. No one was injured. The windows are boarded up with plywood by the time I arrive. The little free pantry in the parking lot was also demolished. It lies on the grass like a toppled birdhouse, its post bare; a crushed can of SpaghettiOs leaks and freezes on the asphalt. “That poor pantry,” my supervisor says, shaking her head while I hang up my jacket. I suspect this isn’t the first time the clinic has been randomly vandalized. I wonder how much it costs to fix.
This morning I interpret for a man I’ve seen before. He comes to every three-month checkup and tells the same story about experiencing chest pain, arm tingling, jaw pain — all the symptoms the pamphlets in the waiting room give for a heart attack. He uses proper medical jargon. This makes the interaction easy to interpret — the language of medical literature is universal, its syntax familiar. I tick off a list of the most common symptoms of cardiac infarctions as the doctor looks bored. We do our best to take the patient’s pain seriously, even though he interrupts the doctor to extend the session, even though he answers the most basic questions with non sequiturs, even though there has never been any evidence of a heart attack. He pulls his hand through his hair like it’s on fire, describing in precise detail the way the pain worked its way up his scalp. But the doctor’s heard it all before. She has other patients to see — too many. It is clear something is wrong and that it isn’t his heart. But I understand why he keeps insisting.
Once, just after my first catheter was inserted in my arm, I was sent home for a few days to await the rib resectioning. At one in the morning, two nights before the surgery was scheduled, my arm erupted in familiar pain. My fingers felt tight and swollen, then turned bright red and wailed in alarm. My arm ached no matter which way I turned in bed. I was sure the clot was reforming or that the medication hadn’t worked. I worried things were shifting unexpectedly in my body, that something catastrophic might happen. I called the nurse on duty, who said they wouldn’t be able to do much without seeing me. So my partner drove me to the emergency room.
The hospital at night is a bleary, anxious place — simultaneously dull and electrified. We checked in at a bulletproof window and waited for hours in a curtained-off space while doctors and nurses rushed around, attending to accident victims and overdoses. Around 4 AM the surgeon’s resident told us an ultrasound had found superficial clotting, the same as before, but no major change. He told me I should go home and wait for my surgery, that nothing was wrong — or, at least, no more wrong than it had been. I was surprised not to feel any relief. Here was a doctor telling me what I wanted to hear: that I would be fine. Instead I felt angry. I wanted to start talking and keep talking. I wanted to describe in bitter detail the pain I’d felt: how familiar it had been; how uncanny and specific the pressure of fluid damming up in my arm was. I wanted to tell the doctor I knew my body better than he did. I reached for the words, but I knew I would not be able to conjure in him the same certainty I felt.
This is the great sorrow of the world: its loneliness. The clinic doctor cannot tell the man with the false heart attack what is wrong, because she can’t see it, and he cannot make her feel what he knows deeper than words: that something is wrong. We do what we can to help him: wheel in the EKG, glue the electrodes to his chest, and run the process anyway. The machine chuffs out a cardiogram on pink paper, its normal peaks and valleys testifying to no problem it can diagnose. We recommend he go to the hospital immediately if he experiences the symptoms again.
Every Wednesday in the months following my surgery I teach a creative-writing class for medical students as part of their humanities curriculum. I am paid a blessed $850 for my work, around $760 after tax. We watch a video about Jill Bolte Taylor, a neuroanatomist who survived a stroke; then we plot her story onto the hero’s journey — departure, descent, and return — a structure similar to the one medicine implies: wellness, illness, cure. We read essays about people undergoing experimental treatments for depression and obsessive-compulsive disorder. We wonder what the correct form is for a story without a neat conclusion, a story that unspools raggedly into the future — a story, my students tell me, that is much more common in medicine than most people think.
In one of our first classes together we discuss “Taking Care,” by Joy Williams. In the short story a preacher experiences a crisis of faith triggered by his wife’s cancer and his daughter’s sudden departure to Mexico, leaving him with her infant daughter. The preacher is baffled by medicine and, as my students point out, a victim of its institutional apathy. He describes the doctors as “severe and wise,” answering his questions in ways that make him feel “hopelessly deaf.” They speak in words he doesn’t understand, of “leukocytosis, myelocytes, and megaloblasts.” And they insist, as if it were obvious, that there is no such thing as a disease of the blood — an idea my students take issue with. The students see their future in this story, one they are both clawing toward and terrified of.
The class is something of a release valve. For an hour and a half each week we meet and talk about literature, but we also just talk, often about the students’ lives. A young man expresses his disappointment at his neurology rotation: “Medicine is about healing people, but over there we mostly just try to keep people from getting worse.” Another student, a sharp and opinionated young woman who is always blowing into class thirty minutes late, tells a story about caring for a pregnant woman during a difficult birth. She brought the woman water and a damp washcloth and adjusted her doses of painkillers. All of this seemed like a necessary mercy but also cost her precious time. Later her attending physician reprimanded her. They had a schedule to keep.
My students are wary of the tendency of more-experienced doctors to treat an illness rather than a person, a body rather than a mind — but they do not pretend there is an easy solution. There is a problem of subjectivity in medicine: no two people experience illness in the same way. Humanity muddies the water. The manifestation of a disease, the irregularity of symptoms, the way we each perceive pain, and how we express our suffering all introduce unreliability. Medicine is already inefficient, expensive, and time intensive. The desire to help as many people as possible chafes against the desire to offer unique and tender care to each person, and this is the terrible paradox my students find themselves in — caught between breadth and depth of care. Treating a single, predictable illness in an objective field is more practical than trying to treat a unique, irreducible, unpredictable person, which would demand tromping through the subjective swamp of their interior world. Better, then, to treat the disease itself, the body abstracted and reduced to a single dimension.
I think of my arm, how the doctors’ and nurses’ temperaments have gradually frayed as months pass without improvements. It was easy for them to be friendly and listen to my lengthy descriptions and complaints when my symptoms were manageable and straightforward. But the longer my veins remain clotted, the more space that it takes up in their minds, and the less space remains for me.
There are worse illnesses, of course, and there are worse things to experience than medical apathy — no treatment at all being one of them. I can’t say what it’s like to suffer from a severe, chronic illness, the kind that knocks your life into a new orbit. But I can tell you what it’s like to be in the postscript of illness, its undead state, where the crisis has passed but recovery isn’t certain. It’s a dull, heavy place. Each morning I wake up hoping for some internal signal that my arm is improving, and by evening I fall asleep despondent. The problem is not that my arm still hurts, that it still changes color as my heart rate rises, though all of this remains true. The problem is that it isn’t improving, not even slightly. I could wait a lifetime if there was any forward motion. Instead I give up. I take another pill. I stop waiting at all.
In order not to think about my arm, I take long walks through the city. I spend hours in the gym, comparing the shades of my hands like paint swatches. (Don’t baby the arm.) I continue to take the Dilaudid. I count the pills out carefully, rationing them over weeks until they’re gone. I swallow one, then take a bath and sink into the cottony warmth of intoxication. I sign up for more shifts at the clinic, fill out my monthly availability with every possible slot: specialty clinics for dermatology, ophthalmology, and prenatal care; evening shifts from 6:00 to 9:30, followed by 9 AM shifts the next day.
Volunteer work is voracious; it needs and needs. There is always more to do, more money to be raised, more time to be given. Dedicating myself to it isn’t purely altruistic: it’s a way to stay distracted, a way to feel good. I am supposed to be writing a thesis. Instead I’m here. “Careful,” Brian warns me at the end of a long shift, my second in as many nights. “This place will take everything you have if you let it.”
One morning I come in to work and find the refrigerator in the pharmacy is burned out. The insulin must be moved, box by painstaking box, into the snack fridge, where little paper cartons of lispro nestle against cellophane-wrapped pastries and browning bananas. As we work, Brian shares with me his grand theory of altruism — a law of equivalent exchange. It goes like this: Volunteer work is a trade-off. The better the work is in an altruistic sense, the less of a splash it makes. You could try to change the whole system, but then you’d have to break some eggs, morally compromise yourself in one way or another to shake things up. Instead you can do some uncomplicated good; you can help someone for one day. But then you don’t get to change anything big, and you don’t get to change it for long.
I’m not entirely convinced by his theory, but the longer I work at the clinic, the more I understand why Brian feels this way. Here there are no heroic surgeries or coding patients, no lifesaving organ transplants or emergency transfusions — just a blood-pressure cuff that must be wiped clean after each use, another prescription for statins, insulin shuffled between refrigerators. This is stoic, day-to-day care, the kind you rarely hear about. The same patients return with the same problems, each time a little older and a little less healthy. We will treat them, schedule their next appointment, and provide them with as many free refills as possible, for as long as we can.
On the operating table the surgeon enters my arm again — another starved morning, another sleepless night on my back, another thousand dollars gone. I’ve already surpassed my deductible once with the first surgery. Then a new year came, and everything reset — mercy ending at midnight on January 1.
A surgery is like a ritual: The body is wrapped in a stiff gown, cleaned with sponges on plastic tubes, their cruel reek of iodine. The surgeon calls for blades with names like French cutlery. An assistant hands him objects from a clean tray. I hear them talking about me as if from a distant shore: “He seems uncomfortable.” “He says his arm falls asleep in that position.” On the other side of the tarp I am forgettable, spliced and striated on a series of specimen slides. Perhaps this is helpful for the doctors: not to see the grimacing on my face, but just the cold facts of my problem.
After an hour the catheter is inserted, and the guide wires are in place. It is hard to describe the feeling — its strangeness and violation — like someone pushing a straw through the bottom of a paper cup. The balloon expands with a terrible pressure. Every few minutes a nurse delivers painkillers, and a warm rush of relief fills my body. She reads the sweat on my forehead, deciphers the small gasps as the blades seek their target. When the painkillers fail to dissolve the deep discomfort, she places a hand on the top of my head, motherly and firm. I think of the ossified clot being carved away, of the staggering price and pricelessness of this care.
I remember a young man at the clinic for an STI test, recounting a night he regretted, doubling back to amend his story, to add details. I remember his anxiety, borne not just on words but on the uncertainty in his voice. And a woman, eight months pregnant, rummaging around for the right word to describe her pain. I remember her testing out each option — stinging, cramping, burning, stretching, gnawing — and the strange satisfaction we shared when she found the right one: “The pain is crooked.” This is the intimacy of interpreting, a contact not just with words but with patterns and idiosyncrasies, cadences and hesitations. Moments in which the texture of thought itself becomes almost tactile.
I don’t want to romanticize the work. Some days are rote repetition, the same list of problems and questions. Others are pure frustration. But there are moments of flow, when I can almost feel the churn of a patient’s or a doctor’s mind, the grain and texture of their thoughts. I can almost guess the next thing they will say. In these moments I am tempted to say I know them. But of course I don’t.
Interpretation is a contradiction, requiring both a deep intimacy and a necessary distance. I transmit the emotions of the patients, but I do not engage with them. I speak in the first person, but the experiences are not mine. To help patients better engage with the provider, the interpreter is not even supposed to make eye contact if they can help it. As I listen to a man with deep, wet eyes and a glistening bottom lip tell the story of losing his brother to the same cancer he has been diagnosed with, I am supposed to show sadness only if the nurse, surgeon, or pharmacist does. When I deliver the news that a pregnancy has self-terminated, I am supposed to use the same balanced tone as the doctor. I repeat after a patient, I was just so hopeful this time, and try to communicate the same resigned sadness, the same shocked detachment.
Perhaps this is why I am skeptical of the plea for more empathy in medicine. Of course I want my doctors to be nice to me. I want them to know the impact a botched surgery would have on my life or the way my death would ripple through the lives of those left behind. But there is care in staying dispassionate even as a patient comes unraveled. And I worry that calls for more empathy provide cover for material failures; that what limits our humanity in the first place are these material concerns. I think of the med students I teach, how they want to deal empathetically with their patients, and how they are left — even at a large university hospital — without the time or the resources to do so. I think, too, of the physician assistants, the nurse practitioners, and the doctors at the clinic who are overworked and underpaid — if they are paid at all. I think of the man with his faux heart attacks pulling his hand through his hair. I know there is recourse to help him, but it is out of reach, and no single act of kindness can offer him the long-term care he needs. I have seen the work of empathy at its most intimate and most powerful. And I have seen its limits.
Sometimes I wonder about the patient who held her cinched bag between herself and the world until even that wasn’t enough. I am supposed to leave these things behind — shred them with my notes or dissolve them in a haze of impartiality — but of course something remains, floating around a deverbalized space. I interpret for the woman with the bag once more, six months after our first meeting. She says she’s doing better. She seems less angry than before. “It’s healing,” she notes, about my scar. You can still see it under the collar of my shirt if you know where to look. The incision has tightened and softened into a soft pink dent of skin, tracing the curve of my neck. When she sees it, she puts a finger on the same spot of her body, feels the unbroken skin there.
I don’t know if this bridges any divide or opens the sealed vacuums of our skulls. Meaning might be too fragile to make the journey without the armament of language. But I’d like to think so.
After the second angioplasty my veins remained clotted. The back of my hand still turns an ominous color under stress, but less often. My arm still sometimes throbs when the weather changes, or when I exercise too vigorously, or for no discernible reason at all. A final ultrasound revealed that the clot was not gone, but something else had happened, something I found miraculous, though the doctors promised me it was common enough. Auxiliary veins had grown around the blockage, feeding blood back to my core, lessening, if not solving, my problem. It might not be perfect, the surgeon told me, but it would be enough.
