Complete Script of Primary Care
Primary Care
(One-act version. About 70 minutes.)
by Bill Monroe
in collaboration with Thomas R. Cole
Primary Care (PDF of complete script)
The Characters
Eliot “Stony” Marcher Nicknamed “Stony,” he is a big, ruddy, physical man and chief resident at Jeff Davis. His dominating personality and his sarcastic humor reveal the disillusionment he has experienced in his medical education and almost conceal a boyish vulnerability. The med students are slightly in awe of him and he is known as a peerless and uncanny diagnostician. He wears a Mickey Mouse lapel pin on his “cape,” a long white lab coat frayed and split up the back seam. Beneath the lab coat he wears ostrich skin cowboy boots and jeans with a thick leather belt. His brass belt buckle depicts a physician on horseback; the caption reads “Medicine in Texas.”
Sybil Dean Riegel A woman, blind, with advanced Alzheimer’s disease. Widowed and childless. 90s.
Jolanda “Jo” Winstone A nurse, Anglo-Hispanic, working her way through medical school, currently in her third year. BSN degree. Single. Late 20s.
Dr. Marsha LeMarque Attending physician, faculty member, Internal Medicine, at Jeff Davis, a major teaching hospital. Competent, well-respected, efficient. Somewhat strenuously self-fashioned. Unmarried. 40s.
Wynn Brooks A nurse’s aide at Jeff Davis, African-American. Usually works the night shift. Widowed, with five living children. Booker T. Washington High School. 50s.
Margie Dunne Mrs. Riegel’s niece. Semi-retired and living in Beaumont. Married, with grown children in Austin and San Antonio. 60s or 70s.
Three residents at Jeff Davis, Jenn, second year, 28, Doug, fourth year, early 30s, and Keith, first year, 26
• • •
The personal images embedded in the script were assembled by Dr. Thomas Cole and are used with permission.
For more information about Primary Care contact Bill Monroe at williamfmonroe@gmail.com or 713-927-1077.
Prologue
SETTING: An auditorium.
DATE: April 17, chronologically following the action of Scene 1, which begins on March 15.
NARRATOR
We begin the action with a prologue that occurs on April 17th. We are in an auditorium, as if for a Grand Rounds presentation. STONY stands with his back to us, his arms up and out, like a symphony conductor who has just completed his work. As the last, unheard note dissipates, he waits, turns around to face us as if for applause, and bows from the neck and shoulders. A follow spot illuminates STONY as he addresses the audience.
[See slide 1 in “Images for Staging Primary Care“]
STONY
Thank you, ladies and gentlemen. Yes, it is always quite a show here at Jefferson Davis. “Never apologize, never explain — it’s a sign of weakness.” (Identifying the quotation.) John Wayne, She Wore a Yellow Ribbon, 1949. Hey, it worked for the Duke and the British Foreign Office. Why don’t we make it our official slogan? (Letting the audience in on something.) You see, everything we do around Jeff Davis is excusable. We talk, talk, talk to disinfect. You recite the case history, give the numbers, and show some slides at the postmortem, and wah-lah: you make death and dying neat and tidy. Toss in an ethics conference, and the whole mess is scoured clean.
Take the Riegel case.
[See slide 2 in “Images for Staging Primary Care“]
A lost lady is found somewhere and brought in here with advanced AD—uh, Alzheimer’s Disease. She refuses to eat. But since she’s demented, they think they’ve got a right to keep her alive. For one thousand, two hundred, and twenty-five days, they keep going at her, taking blood, running tests, calling in specialists: ophthalmologists, cardiologists, gerontologists. Oh, they may call it practicing medicine, but it’s really a sick habit. It finally ended 10 days ago… just 3 years and 3 months too late.
Thirty, forty years ago, when people were ready, we let them die. When Dr. Hart interned over here in the fifties, there were no geriatric ICUs with ventilators and CT scanners. He says you’d bring in a bowl of mush and before you could set it on the tray the roaches were already running for the spot. Yeah, it was disgusting, but at least it was honest. The patients didn’t want to eat, and the roaches were hungry. (Thinking of an example.) OK, after Bobby Kennedy died, the old patriarch, who’d already lost two sons, he, what’s the phrase, “refused nourishment.” Sirhan shot the senator in June and Joe Kennedy Senior was dead by Halloween. Nowadays we’d put a tube in his nose and keep him alive with Ultra Slim Fast so he could stick around long enough to be told that John John had crashed into the wine-dark sea.
They want you to think it’s about compassion. (Shaking his head.) No matter what the situation, it’s actually about control. We can make them live, so we do. (Reveling in his ability.) I can take a 1-pound lungless neonate and three months later you’ve got yourself a bouncing baby boy. Grangerford—Lord rest the soul of the good doctor—would stand up here and expound on the heroics of his geriatric team when they “saved” some played-out wino. Everybody would applaud the good work of the Grangerford unit. But nobody had the guts to ask, Why. “Why save a man who’s been trying to slip out of this world for two score and ten. Why not just let him go?”
Of course people don’t want to hear this. Yeah, it’d be nice if we could all hoover the crap the marketing people dish up. “Since 1939….We’re here, because we care.” There will always be feces, however, and it must be disposed of oh so carefully. Stony’s rule number one: the shit always runs downhill. That’s why hospitals need shitflow committees: so nobody sees it and none of it gets on the higher-ups. Those of us near the bottom — the residents and third years, the LVNs and aides—we do the work, while they take the credit, and the big money, and present their research at some five-star hotel in Vegas or Miami Beach. Yeah, we burnout, some sooner than others. Because they control our lives. And not just the higher-ups. Scutmonkeys like us are “on call” for anybody who’s got enough strength to push the red button clipped to the bedsheet.
[See slide 3 in “Images for Staging Primary Care“]
Case in point: the other night I draw the black bean and have to work 11 to 7. Some guy’s out on the town, comes in drunk, wants a little piece of his old lady. She says no, he says yes, she starts to fight, he beats her up and rapes her. He’s sound asleep, she gets up, goes in the kitchen, strikes a match, lights the stove, and puts some water on to boil. No, she’s not fixing to have herself a cup of English Breakfast tea. Fifteen minutes later she’s standing up in the bed with an oven mitt and a cast iron kettle pouring smoking water on this SOB’s pecker. So at three in the morning I’ve got to leave some kid in the ICU to come downstairs and tend to this crab boil.
I mean, the only way to deal is zone out. You can klep from the drug cabinet, check yourself into the Stress Center, or you can make a separate space with your buckeroos.
[See slide 4 in “Images for Staging Primary Care“]
And the hospital hypocrites can’t do anything about it. Oh, we’ll say “yes, ma’am” and “yes, suh” to the higher-ups, but when we get amongst ourselves, we cut the crap. Stony’s rule number two: Ventilate to survive. It takes some tenacious truth to withstand the insanity. We use our own code: “the argot of the resident subculture,” the psychobabs call it. “What’s wrong with that guy?” “Looks like another case of PPP.” PPP is epidemic at JD. Shorthand for piss-poor protoplasm, a diagnostic term for the train wrecks we get in here. OTD—“Out-the-door”—and GOMER: “Get Out My Emergency Room.”
(Picking up on the previous story.)
OK, when the Oxy wears off [See slide 5 in “Images for Staging Primary Care“] this guy—the one with the red-hot johnson—he takes one look at his girded loins, recalls the events of the previous evening, and wants to go make it up to his old lady. He starts screaming about how this ain’t Russia, and he has a right to a drink if he wants one, and we can’t keep him against his will. So the nurse calls me at 5:45 and I have to come down again, only this time it’s for an AMA/AMF discharge. AMA: “Against Medical Advice.” “AMF?”: “A-dee-os, muth … my friend.”
(His cellphone sounds.)
Sorry. Gotta run. Another father-raper needs my undivided attention.
Scene 1
[See slide 6 in “Images for Staging Primary Care“]
SETTING: March 15, noon. A month before the prologue. Mrs. Riegel’s room.
STONY
(Responding to some ongoing concern.)
Jo-Jo, you’re gonna make it. Forget about comps for a minute and help me get this tube back in.
JO
I’ve never done an NG tube.
STONY
Nothing to it. See one, do one, teach one. Let’s get her hands in the restraints.
JO
Restraints? There’s nothing about restraints in the chart.
STONY
Gale started using them when the aide went on vacation. Now we don’t get 3:00 a.m. calls from the Geriatric wing to put this damn tube back in.
(They each take a wrist and tie it to the bed rail.)
OK, now try to keep her head still.
JO
This seems weird, Stony.
STONY
Have you got her?
JO
I don’t want to hurt her.
(STONY and JO try to force the NG tube through Mrs. Riegel’s nose into her stomach, without success, while MRS. RIEGEL squirms and struggles.)
STONY
“Hold her, Newt, she’s rarin’.” You want to sing something for us, Hun? Here we go, now. Chord to this now, heah. Doe, doe, doe.
(To JO.)
You know “The Old Rugged Cross”? Come on, Jo, don’t you ever go to church? OK, I know, “Amazing Grace.” That’s right. Doe doe, doe doe, doe doe, doe doe. Easy. Easy. Got it in!
(They step back from the wheelchair or bed.)
JO
I guess the singing calms her down.
STONY
You do whatever it takes. You want to go far around here, just do what I do.
JO
LOL. I don’t need a formal reprimand in my file.
STONY
How about a highly desirable residency in the city of your choice?
JO
I’d settle for a decent case for my clerkship.
STONY
Case? You mean that ethics crap? Don’t worry about the touchy-feelies—
JO
Dr. Grangerford said—
STONY
Dr. Grangerford. He dead.
JO
You need recommendations.
STONY
Stony’s rule number seven: Don’t suck up to the psychobabs. You’ve got it and they don’t. “Watch me, Tess. Learn from me.” (Jo doesn’t get it—shaking her head.) Working Girl, 1988, come on.
(Looking at Mrs. Riegel.) It won’t be long now, Hun.
JO
You’ve been saying that for over a month.
STONY
Things move slower in the “Slough of Despond.” Patience, my dear.
JO
But my write-up is due next week.
STONY
No worries, you’ll have time. (Looking away and pausing to let this soak in). The case conference is this afternoon.
JO
(Scoffing in disbelief.)
You’re kidding, Stony. You are kidding, right?
STONY:
Do I detect anxiety in my protegée?
JO
With LeMarque? Today? Goddammit, Stony, why didn’t you call me, or text me?
STONY
Because I’m still dating Kathleen.
JO
You asshole. You know what I mean.
STONY
(Trying to calm her down.)
Look, Jo, I just found out myself. Since we’re kind of in a hurry to, ah, terminate this case, I thought expedited scheduling might be in order.
JO
But what about my preparation. There’s no way I can be ready.
STONY
Don’t worry. I’ll back you up. Look, Jo, it’s a win-win situation. You get your case, we get our lives back.
JO
This sucks.
(Reluctantly accepting the inevitable.)
OK. OK. Just tell me what to do.
STONY
Compliance. That’s what I like in my patients—
JO
and your women. Yeah, I’ve heard.
(Picking up the chart, still stewing over the turn of events.)
STONY
OK, here’s the drill. First we get Gale to top her off, then we go over to LeMarque’s office in Old Red for the conference.
JO
What about the aide?
STONY
What about her?
JO
She’s got to be there, right?
STONY
“St. Bernadette” thinks case conferences are bogus from the get-go. She doesn’t trust “Ds.”
JO
Ds?
STONY
MDs, PhDs, Any kind of Ds. She’s been here 25 years and she’s still a Nurse’s Aide Level II.
JO
But she’s designated on the chart as the primary caregiver.
STONY
Was. She’s not around. Took a leave last week. Says, “I be sittin’ for a lady for a couple of days.”
JO
She moonlights as a sitter?
STONY
She does it off and on when “somebody be about to pass.” We’ve got to move on this before she gets back. She’d start her “Live, live!” exhortations and we’d never get anything decided.
JO
So who can we get to be there?
STONY
You.
JO
Me? Wait a minute. I’m not —
STONY
Sure. Somebody decided that we have to have a nurse or an aide present at every Ethics conference. Very democratic and egalitarian. There’s so many bleeding hearts around here it’s a wonder we’re not all HIV-positive.
JO
But, Stony, I’m a med student, remember?
STONY
You’re also an RN. Remember?
JO
Not for long.
STONY
You can be a primary caregiver for a few more days.
JO
Look, I didn’t come to med school to be a nurse.
STONY
It’ll be worth it if we can get this one OTD. Come on. As a favor to the staff. Please.
JO
Oh God, all right. But I’m not going to like it. (She goes over to the bed, glances at Mrs. Riegel. Pulling her attention away, trying to move on.) So, Dr. Marcher, what’s this I hear about your heroics in the pediatric ICU?
STONY
Which ones?
JO
You know. Everybody’s talking about how you came in and saved that little baby in the hot dog stand.
STONY
They had a scalp line in, but it was crying so hard the IV backed up. They didn’t flush it out and it clotted off.
JO
I heard she was seizing by the time you got there.
STONY
Totally dehydrated.
JO
So you did a cut down and saved the day.
STONY
Comes with the territory, ma’am.
(There is an electronic ringtone from STONY’s cell phone.)
JO
“Calling Dick Tracy.” Are you wanted for another act of derring-do?
STONY
No doubt.
(He takes out his phone and speaks into it like a microphone.)
What? Spill it…Jesus wept. Isn’t there anybody over there who can handle a needle? All righty then. Yeah, I’m on my way.
(Puts away the device.)
Let’s swing by there before we go see LeMarque.
JO
It won’t make us late?
STONY
No, it’ll take maybe 30 seconds. I can show you what a bunch of bozos I’ve got in the Pediatric ICU. Come on—it’ll make you feel better to observe these helpless scutmonkeys in their natural habitat.
(They walk out of the room together.)
Scene 2
SETTING: An hour later. Dr. LeMarque’s office.
AT RISE: Dr. MARSHA LEMARQUE is at her desk trying to dictate Mrs. Riegel’s case.
LEMARQUE
90-year-old white female presented…How long ago did she come here?
(She is nervous, looking in drawers for some records.)
Where is that file?
(She pulls out a drawer and sees what she needs.)
Bingo.
(She takes out an old pack of cigarettes, succumbing to a craving. She enjoys a few puffs.)
Now where is that file?
(She finds it, removes it.)
(She hears a knock at the door, and hurriedly pulls open a drawer, stubs out the cigarette, and brings out an aerosol can of generic hospital air freshener, which she sprays wildly around the room.)
I’ll be with you in a minute.
(In one motion she returns the can to the drawer, slams it shut, and waves the deodorizer mist away from her face before telling Stony and Jo to come in.)
(Rather short.)
Come in.
STONY
Excuse me. Dr. LeMarque?
LEMARQUE
Hello, Dr. Marcher. Ms. Winstone.
(Embarrassed by the possibility that Stony and Jo can smell her cigarette smoke, she strides around to the front of her desk and grabs her lab coat.)
Let’s get over to the conference room.
STONY
Well, not actually. The nurse’s aide can’t come, and I told Gale that we would be in your office.
LEMARQUE
Good.
(Marching back to her chair.)
Then we’ll just wait until she arrives.
STONY
We probably ought to get started.
(Looking at JO.)
Gale was going to feed the patient after we left.
LEMARQUE
Feed her?
STONY
You know, with the NG tube.
LEMARQUE
Oh yes, of course. All right, then. Why don’t you present the case, Dr. Marcher, and we’ll just take it from there.
STONY
Sure. Mrs. Sybil Dean Riegel, a 90-year-old white female, was brought by ambulance to the Jeff Davis ER three years ago. She was disoriented times three and had no ID. There was a fracture of the right hip; an operation was performed and was successful. Three weeks post-op the patient was transferred to extended care, where she remains today. A DNR has been placed, and the patient continues the classic downward curve characteristic of AD.
LEMARQUE
Thank you, Dr. Marcher. Uh, Ms. Winstone, what other information do we have on her current status?
JO
BP 112/60. White count 9700, hemoglobin 12.4, hematocrit 37.
LEMARQUE
Nutrition?
JO
Via NG tube: 1300-1500 calories Osmolite, multiple vitamins, zinc, and iron. Patient’s weight has fluctuated, initially gaining, then stable, recently losing, now stable again.
LEMARQUE
Physical findings?
JO
(Emotionless, just the facts.)
Her physical exam is unremarkable, lungs are clear, no heart murmur, no tender abdomen, no palpable masses, negative rectal exam, warm dry skin with no breakdown.
LEMARQUE
Extremities?
JO
Good pulses. No edema. Marked muscle wasting and slight flexion contractures of knees and elbows.
LEMARQUE
(After a pause.)
The hip?
JO
Oh yes. A Dawson-Moore prosthesis placed three years ago.
LEMARQUE
(Summing up her questioning.)
And neurological?
JO
Extreme dementia, inability to follow commands, blindness, global confusion…otherwise, unremarkable.
LEMARQUE
Fine, Ms. Winstone. Very good. Dr. Marcher, anything else?
STONY
Incontinent of urine and stool.
LEMARQUE
Family situation?
STONY
Widowed and childless. And now impoverished.
LEMARQUE
Good. I think we covered just about everything. Now—
(Picking up the chart.)
What about what’s-her-name, the aide? Will she have anything to add?
STONY
She had something come up. “Personal business.”
LEMARQUE
Then I guess we’ll have to wait for Gale.
STONY
Jolanda can represent the nurses’ point of view.
LEMARQUE
That’s right, Jolanda, you’re still a nurse. Is your license current?
JO
I still work weekends when I can, Dr. LeMarque.
LEMARQUE
You’re aware that new hospital policy requires that a primary caregiver be present during these conferences?
JO
Yes I am.
LEMARQUE
And you feel comfortable with that?
JO
Yes.
LEMARQUE
Good. Then we’ll just proceed. Does she, in your opinion, want the tube out?
JO
She does say, “Out, out.”
LEMARQUE
Any other verbalizing?
STONY
She mumbles something about wanting to go be with Jesus.
LEMARQUE
I see. Does she still pull the tube out?
JO
(She looks at STONY.)
Not anymore, no.
STONY
They’ve recently started using restraints.
LEMARQUE
Oh really? Why, why weren’t they used before?
STONY
Dr. Grangerford didn’t believe in restraints. But since he died the staff has started using them on his old patients. And now…something is supposed to be decided.
LEMARQUE
What about the aide?
(No answer.)
It would be good to have her input.
STONY
With all due respect, it would be better to get something decided, Dr. LeMarque. I mean, we’re going nowhere with this case. And Jeff Davis doesn’t have the resources. (Stony’s phone sounds. He pulls it out of his lab coat and glances at it, turns it off, puts it back in a pocket.)
LEMARQUE
Do you need to take that?
STONY
They’ll wait.
JO
Isn’t this kind of unusual, Dr. LeMarque—an Alzheimer’s patient with an NG tube…
LEMARQUE
There were three—
STONY
Four, counting that Black man who died in March.
LEMARQUE
Right. Four.
JO
All ADs?
LEMARQUE
Yes. But this is the only tube.
JO
Do we know when it was last evaluated?
LEMARQUE
I’m not certain it has been. Dr. Grangerford wasn’t there for us to ask questions. (Musing.) The wrist restraints are something new.
STONY
(Takes a quick glance at Jo.)
Maybe we could remove the restraints—wouldn’t that be consistent with policy?
LEMARQUE
But then she’d pull the tube out.
STONY
Maybe. Maybe not. But she ought to be weaned off the tube anyway.
LEMARQUE
Yes, but Stony, it’s been two years—almost three now. She’s forgotten how to eat, how to swallow.
STONY
People get it back. And, even if she doesn’t eat again—maybe that’s her decision.
LEMARQUE
But we don’t know what the patient’s wishes would be, if—
STONY
We do know that there’s a natural course of events—if we stop the intervention.
LEMARQUE
Somebody down there left a message on my phone mail. She wanted to try a baby bottle.
STONY
It’s Wynn Brooks.
LEMARQUE
She didn’t sound particularly bright.
STONY
She’s not bright—in any sense of the word.
LEMARQUE
Incompetent?
STONY
More like noncompliant.
(Looking for reinforcement.)
Jo, you know how she is.
JO
It’s true. She’s infamous among the med students.
STONY
You tell her to do something, she’ll do everything but, then disappear.
JO
Unless she thinks it’s a good idea.
STONY
Always knows what’s best for her patients.
LEMARQUE
Why don’t I know this Mrs. Brooks?
STONY
She’s around. Kind of a short, fat lady? Goes in and out of the patients’ rooms singing under her breath.
LEMARQUE
I can’t place her.
STONY
Remember the hassle last year with Mr. Moody’s heirs?
LEMARQUE
So that was her.
STONY
Yep. She was the cause of that whole thing.
LEMARQUE
Isn’t she supposed to have some kind of special relationship with this patient?
STONY
She thinks she has a special relationship with every patient, like she’s related to the whole damn world. Everybody’s family—except the medical staff.
LEMARQUE
She’s not a team player?
JO
She did come up with that baby bottle idea.
STONY
Come on, Jo. A bottle is no better than a tube.
LEMARQUE
Technically, a bottle could be a possibility.
STONY
But it’s already been tried. And it didn’t work.
LEMARQUE
Right. Gale said she wouldn’t take the nipple.
STONY
Would you, if you were her?
LEMARQUE
Probably not. As a physician—
STONY
Of course not. It’s like reverting to infancy.
(Turning.)
What about you, Jo?
JO
Well—
STONY
I mean, here’s this woman, this elderly woman, who’s had a family and dignity. And now they want to take away your independence and autonomy. You’re tied down, you’re humiliated. You’re wearing diapers.
JO
I probably wouldn’t want to go on in that way. The dependency…
(She is at a loss.)
STONY
So, we’re agreed?
(He looks, first at JO, then at LEMARQUE.)
JO
(Avoiding the question, to LEMARQUE.)
What’s the family member going to say?
LEMARQUE
That I don’t know. She seemed indecisive over the phone.
STONY
She’ll go along with what the doctor says—you know she will.
LEMARQUE
Unfortunately, there’s no power of attorney. Maybe something can be worked out.
JO
When is the conference?
LEMARQUE
Eight o’clock…She’s driving over from Beaumont.
Scene 3
SETTING: 10 minutes later, the Residents’ Lounge.
AT RISE: DOUG, JENN, and KEITH, three resident physicians in their late 20’s or early 30’s, are seated in the sterile chairs characteristic of vending machine snack bars. They are joined by STONY and JO. DOUG, a fourth-year resident, is married, as is JENN. KEITH is single, a first-year resident, and anxious to be included as one of the group. They are exchanging the crude banter characteristic of the “resident subculture” of a large, urban, teaching hospital.
STONY
You guys don’t mind if I bring Jo in for a second, do you. It looks like we’re finally going to get Ree-gull OTD. Jo Winstone, meet the Dream Team.
KEITH
Hi.
JO
“The Dream Team”?
DOUG
AKA the God Squad. We just play doctor.
KEITH
So, what’s the story on the Riegel case?
STONY
“Waiting for Godot.”
JENN
Riegel? Is that the AD with the tube?
STONY
You got it.
(To Jo.)
You did OK in there, Jo. Whatcha drinking, babe?
JO
Just a Coke would be fine.
STONY
(Greek accent.)
“No coke, just pecsi.” (No response. He looks around at the group.) “Cheeseburger, cheeseburger?” Come on, doesn’t anybody watch SNL anymore?
KEITH
Oh right! (Laughs a little too hard.)
JO
(Jo realizes that this is a club and that as a mere medical student she is not a member. Stony hands her a Diet Pepsi.)
Thanks.
DOUG
How’d you end up with the tube?
STONY
I’ve wondered that myself. It must be fate
JENN
Or a tragic flaw.
KEITH
What about you, Jo. What’s in it for you.
JO
It’s my Ethics Case.
JENN
Something new?
STONY
It’s the death and dying stuff they cooked up for the new third-years.
KEITH (To Jo.)
So what’s the verdict, Judge Judy? (He snorts at his own joke.)
STONY (Intervening and protecting.)
I told Jo that we ought to untie the old lady and let her pull the tube out.
JENN
Then what?
STONY
Then we offer her an Egg McMuffin and call the morgue.
(The group laughs.)
JENN (Sarcastically.)
Love it when you talk dirty.
KEITH
He’s right, though. I mean, that superannuated babe has been circling the drain for—how long’s it been?
DOUG
Three years. I had her when I interned under Grangerford. How much longer do you think she’ll last?
STONY
(Stony takes a spiral book on medical therapies out of his white coat pocket; in a German accent.)
As I estimate the caloric and mineral requirements, it shouldn’t take more than…about a week.
KEITH
(Directing his Spanish at Jo.)
Maybe less without agua, right?
JENN
(In disbelief.)
Why’d they tube her in the first place?
DOUG
Some nurse said that she came from the ER that way. Found her over on Dowling with a dachshund. She got agitated and wandered off.
JO
Sundown Syndrome?
STONY
Yeah, her little dog took her out for a walk and she broke her hip. No ID when she came in. Disoriented, incontinent—but the doggie did his doo-doo in the right place.
DOUG
(Mock sadness.)
That’s right. She was lost and nobody knew who she was.
STONY
Except they traced the rabies tag and the vet gave them her name.
JENN
No family.
DOUG
A husband, but he was non compos, too.
STONY
Not any more.
(They look at him.)
Dead.
JENN AND KEITH
(In unison.)
Cancer?
STONY
Hung himself last December.
DOUG
Right. After Grangerford did the tuna.
JO
The tuna?
STONY
You know when you go deep-sea fishing?
JO
Not really.
KEITH
(Trying to impress.)
Well, if you catch a tuna, they flip and flop around, and gasp for breath, and make a big mess of your boat.
STONY
But Grangerford was post-tuna by the time they got him to the ER.
DOUG
Aneurysms can be such a blessing.
JENN
And good, clean suicides.
STONY
What would we do without seasonal depression?
KEITH
This place would be overrun with GOMERs.
DOUG
The ER does get some nice corpses at Christmas time.
(Sounds of “Oooh!” “You are too wicked.”)
STONY
It is a wonderful life!
(General murmurs of ironic assent: “couldn’t be better,” “incredibly cool,” “absolutely perfect,” or whatever.)
Scene 4
SETTING: Early evening, same day. Mrs. Riegel’s room.
AT RISE: Night nurse’s aide, MRS. WYNN BROOKS, comes into Mrs. Riegel’s room humming “Just a Closer Walk with Thee.”
MRS. BROOKS
Miz. Riegel? Miz Sybil Dean Riegel? How are you doing tonight, Sybil Dean?
(Pauses.)
Fine, thank you.
(Pulls up a chair.)
I guess you know I been gone for a few days takin’ care of Mr. Benjamin. They carried him home this morning. He sure did look fine. Now, Miz Sybil? How ‘bout you? Can you squeeze my hand?
(Pause.)
Good. That’s real good. Not too hard now, Sybil Dean. I got to bathe you after while. I know that Gale didn’t give you a proper bath the whole time I was gone. I swear, I don’t know what would happen to you if I wasn’t here. You never would get your mouth cleaned and your back warshed.
(Goes to the table and opens a glycerin swab.)
I know you don’t like this, but we got to keep your lips moist and your gums clean, don’t we.
(Mrs. Brooks swabs Mrs. Riegel’s mouth while Mrs. Riegel shakes her head gently from side to side.)
I swear, you’re just as bad as that little grandbaby of mine. She be bobbin’ and dodgin’ around just like you.
(Throws the swab away.)
You feel like singin’ tonight? How ’bout “Were You There?” No, that’s too glum. I feel good tonight, my Ezra done got out of jail. They said he didn’t have nothin’ to do with that mess. Let’s sing “Amazing Grace.” Here we go now.
(She begins to hum. Mrs. Riegel begins to hum with her.)
“That saved a wretch like me. I once was lost but now I’m found, was blind but now I see.” All right. That sho make me feel better. How ’bout you.
(Looks at her.)
Don’t you start that “Out, Out” stuff with me, Sybil Dean. I know you want that old tube out, ‘specially this time of day, but we can’t let you do that just yet. Now you set still ’till I can get back here with your supper.
(She goes out of the room humming “Amazing Grace.”)
(LEMARQUE enters Mrs. Riegel’s room shortly after MRS. BROOKS goes out and tries to interact with the patient.)
LEMARQUE
Hello, Mrs. Riegel. My name is Dr. LeMarque. How are we feeling tonight? How is your nasogastric tube. Any pain inside of the nose?
(Moves the tube around to get a better look into Mrs. Riegel’s nostrils.)
It looks like that mucous breakdown is healing nicely.
(Mrs. Riegel begins to groan. LeMarque draws back her hand.)
Does that hurt you?
(LEMARQUE pats the patient’s arm, restrained at the wrist. Leans over to hear.)
You want out? Out of the bed? No, you need your rest this evening. Maybe we can get you up tomorrow.
(She gets the chart and returns to the bedside to make some notes. MRS. RIEGEL becomes more agitated, reaches for the nasogastric tube, and knocks a pen out of LEMARQUE’s hand.)
Oh, you mean you want the tube out.
(LEMARQUE gropes through the patient’s clothes and blankets for the pen.)
Yes, of course. You don’t like it, do you?
(Finds the pen and steps away from the bed. MRS. RIEGEL becomes more agitated, pulling against the restraints.)
Please calm down, Mrs. Riegel. I’ll get the nurse in here for you. I’m sorry we can’t release the restraints just yet.
(Fixing and fastening them. As she does so, her cellphone goes off loudly. She is startled and shuts it off.)
Well, I’ve got to be going now. You rest and we’ll check in later.
(She goes out. MRS. BROOKS comes in shortly after LEMARQUE leaves.)
MRS. BROOKS
Well…That wasn’t too long to wait now was it? Here’s your supper and your dessert.
(She hangs a bag of formula.)
One of these days I’m going to try a bottle on you. I bet you could learn to like it if you just give it a chance. We could eat and sing all night long—have us a Easter party. We just got to find a way to get a piece of ham and some black-eyed peas through a nipple.
(Laughs and hums “Just a Closer Walk with Thee.”)
Scene 5
SETTING: A hospital room, 8:15 in the evening.
AT RISE: MARSHA LEMARQUE and MRS. DUNNE approach the bed of the patient.
LEMARQUE
(Half-blocking MRS. DUNNE’s access to MRS. RIEGEL.)
Now, Mrs. Dunne, this is not going to be easy. Your aunt has been through a lot, and she may not know you. Are you sure you’re all right?
MRS. DUNNE
Yes, doctor.
LEMARQUE
Let’s go in, then.
(LEMARQUE and MRS. DUNNE approach MRS. RIEGEL’s bed.)
MRS. DUNNE
Aunt Meem? Aunt Meem? It’s Margie. Margie Dunne. Doctor, is she all right? She’s so white, so old-looking . . . .
LEMARQUE
It’s OK, Mrs. Dunne. Your aunt seems to be resting comfortably.
MRS. DUNNE
But that tube, doctor, going into her nose like that. How can she rest with that tube.
(MRS. RIEGEL starts to stir and tries to pull the tube out.)
MRS. DUNNE
(Noticing the restraints on her aunt’s wrists.)
She’s tied down!
MRS. RIEGEL
Owww…Owww…
MRS. DUNNE
What’s she saying, doctor. What’s the matter.
LEMARQUE
I think she’s saying, “Out, out.” It’s the tube.
MRS. DUNNE
Aunt Meem? Aunt Meem? It’s Margie. Your niece, Margie Dunne. Don’t you remember me, Aunt Meem? Look at her eyes, doctor: she’s not showing anything.
LEMARQUE
I thought you knew…your aunt lost her sight about three years ago.
MRS. DUNNE
She’s blind?
LEMARQUE
Yes, I’m afraid so—it was glaucoma, according to Dr. Grangerford’s notes.
MRS. RIEGEL
(Reaches for the tube again.)
Oww…Woww…Oww.
MRS. DUNNE
She’s just tied there—like an animal.
LEMARQUE
Mrs. Dunne, I know this must be a shock for you. But we had to see her. We had to see her so that you would know exactly what her condition is.
MRS. DUNNE
I thought I could do this, doctor, but…I didn’t know that she’d be…I didn’t know about the plastic tube and all.
LEMARQUE
Please, come sit down, Mrs. Dunne.
(She sits.)
MRS. DUNNE
How long…
LEMARQUE
(Walks to the side of MRS. RIEGEL’s bed where there is a nightstand.)
About three years.
MRS. DUNNE
Three years? To have…to be…like that.
LEMARQUE
(Pours MRS. DUNNE a cup of water from a plastic container on the nightstand,
returns and hands it to her. She sits down beside MRS. DUNNE.)
MRS. DUNNE
Thank you, doctor.
LEMARQUE
That’s why we need to discuss our options.
MRS. DUNNE
Our options?
LEMARQUE
We need to reach some kind of decision about your aunt’s care.
MRS. DUNNE
Oh.
(Looking over at her aunt.)
I see.
LEMARQUE
Dr. Grangerford—he didn’t really indicate how to proceed.
MRS. DUNNE
Oh, yes, Dr. Grangerford. He called me once. He was so kind—he must have been a fine doctor.
LEMARQUE
Yes. But unfortunately he didn’t indicate what he wanted to do.
MRS. DUNNE
Oh I’m sure Dr. Grangerford would have done everything possible.
LEMARQUE
I’m sure he did, Mrs. Dunne. But you see, when I agreed to take your aunt, I thought there was something we could do for her. But now…
MRS. DUNNE
She’s not getting any better, is she?
LEMARQUE
No.
(Stands, walks over, and picks up the chart.)
You see, these patients can’t speak for themselves. Your aunt can’t say what she would have wanted. And without some guidance, some idea…
(Turning to face MRS. DUNNE.)
Did you ever have any conversation with your aunt about life support, a living will, anything like that?
MRS. DUNNE
No, I don’t think so.
LEMARQUE
You see, she keeps pulling out her tube, as if she doesn’t want to be fed.
MRS. DUNNE
(A slight accusation.)
Maybe she doesn’t like the way it feels in her nose.
LEMARQUE
Well, there was a problem with the first tube. We had some breakdown. But without a tube…well, sufficient caloric intake would be difficult to maintain. Signs of malnutrition and dehydration would eventually develop, and then, without the initiation of extraordinary procedures, some opportunistic infection…
MRS DUNNE
She’d die.
LEMARQUE
Well, yes.
MRS DUNNE
(Looking over at her aunt.)
She’d starve, wouldn’t she?
LEMARQUE
(Pauses to regroup.)
You see, we were hoping that you could help, since you’re the only living relative.
MRS. DUNNE
(Feeling boxed in.)
But, doctor, I’m not the one to…I’m not the legal guardian.
LEMARQUE
Well, the trust officer at the bank…
MRS. DUNNE
That’s right. Miss Pilot handles all these matters.
LEMARQUE
Legal and financial matters, yes. But our protocol calls for the inclusion of a family member, someone with that kind of relationship to the patient. Miss Pilot has made it clear that she cannot make medical decisions. It’s not her place.
MRS. DUNNE
It’s not my place, either, doctor.
LEMARQUE
Please don’t be alarmed Mrs. Dunne.
MRS. DUNNE
We’ve just tried to stay out of it, completely. Uncle Bob was alive, so there was no reason…and then, when we came over for the funeral, my husband said we had our own problems, that there was nothing we could do.
LEMARQUE
I understand, and I am really sorry this is falling on you.
(Under her breath or as an aside.)
On either one of us.
MRS. DUNNE
(Not really hearing, still upset.)
I’ve only seen Aunt Meem maybe three or four times in the last 15 years. She came to my mother’s funeral. And then we used to send Christmas cards and all, but we just never got over here to see them.
LEMARQUE
I know this must seem sudden, but we really do need to make a decision. The tube’s been in much too long.
MRS. DUNNE
(Looking over at her aunt again.)
I don’t know. With the restraints and all—it’s just such a horrible way to end your life.
LEMARQUE
We have considered an operation.
MRS. DUNNE
An operation?
LEMARQUE
Yes. We could try a gastrointestinal tube.
MRS. DUNNE
Isn’t that a gastro…tube.
LEMARQUE
No, this would be a tube going directly through the stomach wall. A surgical procedure.
MRS. DUNNE
Oh, no, doctor. No more surgery. She wouldn’t want that, I’m sure of it.
LEMARQUE
Well, Dr. Grangerford did try a bottle with formula.
MRS. DUNNE
A baby bottle?
LEMARQUE
She wouldn’t take the nipple, according to the chart.
MRS. DUNNE
(Laughing a little and shaking her head.)
I’m not a bit surprised. You never knew my aunt, doctor, but she was a very special kind of person—very aware of her appearance and all. She wouldn’t want to be treated like a…to be fed like an infant.
LEMARQUE
See, this is the kind of information that we need to make an appropriate decision. What else can you tell me about your aunt?
MRS. DUNNE
Well—wait a minute. I grabbed some old pictures before I left this morning.
(MRS. DUNNE reaches to retrieve some photographs in her purse. During the succeeding dialogue, family snapshots of Mrs. Riegel and her family are projected. While MRS. DUNNE is fumbling in her purse, JO comes up, looks over at Mrs. Riegel, and then hesitantly knocks on the open door.)
JO
Dr. LeMarque?
LEMARQUE
Jolanda. Still at work?
JO
I guess I should have asked earlier. But, I was wondering if I could sit in on the…conference.
LEMARQUE
Well, that would be up to Mrs. Dunne. Mrs. Dunne, this is Jolanda Winstone. She’s one of our best junior medical students.
MRS. DUNNE
Hello, doctor. I’m very glad to meet you.
JO
Hello, Mrs. Dunne. Just call me Jo.
MRS. DUNNE
Have you been taking care of Aunt Meem?
JO
Well, not exactly. But I have looked in on your aunt several times.
MRS. DUNNE
Well, it would be a great help to me…I just don’t know what to do.
LEMARQUE
That’s what this conference is for, Mrs. Dunne. Jolanda, Mrs. Dunne was just about to provide the family background.
MRS. DUNNE
Yes, I brought these pictures. I thought maybe they might be helpful for you all. You’ve all been so nice. Taking an interest in Aunt Meem, and all.
(Here, and as she recalls the memories of her aunt, MRS. DUNNE seems to be in a different, less stressed, state of mind. The lights go down and become warmer to indicate a change of mood and to make the slides more visible.)
MRS. DUNNE
You see, Aunt Meem was the youngest—it was a big Catholic family then. My mamma and daddy went back to live at the old home where she was still staying with my grandmother.
[See slide 7 in “Images for Staging Primary Care“]
You know, in that day and time there were big houses, and families would live together. Aunt Meem was twenty-two when I was born. (Shows picture to LEMARQUE.)
[See slide 8 in “Images for Staging Primary Care“]
She bobbed her hair then. It was the first and only time, but she always had to be in fashion, that’s what mama always said. I remember she wore earbobs, she called them.
[See slide 9 in “Images for Staging Primary Care“]
She used to let me try on her things.
JO
(Looking at a photograph.)
[See slide 10 in “Images for Staging Primary Care“]
Was she married then?
MRS. DUNNE
No, not then, not till much later. Aunt Meem had to run the boarding house for my grandmother after she got too old. It was right over on Fannin. It used to be such a nice big house, with lots of people around—that’s how I remember it. I guess they tore it down for some reason. There’s one of those boxy-looking savings and loans there now, all boarded up. I drove by it on the way over here. Had to go by the street numbers everything looked so different.
JO
Is that her husband?
[See slide 11 in “Images for Staging Primary Care“]
MRS. DUNNE
Yes, that’s Uncle Bob. He was one of the boarders in the house before my grandmother died. From Canada, a real fine carpenter. Came over from Germany originally, but Mama always said “Canadian.” He was always building things for me—you know, doll houses and little churches and things. And Aunt Meem—she just doted on me when I was a little girl. She was like a mother to me…until we moved away. Mama never said, but I don’t think Aunt Meem and Uncle Bob could get married until after Grandma Partlow died. It was a mixed marriage, you know, because of the different religious backgrounds.
LEMARQUE
Did your aunt have strong religious beliefs?
MRS. DUNNE
Well, my husband and I don’t get to church much any more. But, I think that Aunt Meem, well, I just remember how beautiful she used to look when she would dress up and take us to Mass.
(JO puts down the note pad, gets up and goes over to MRS. RIEGEL. She starts attending to the patient, checking her pulse, making her comfortable. JO continues to listen and pay attention to the conversation.)
MRS. DUNNE
But she was always taking me places with her and Uncle Bob. We’d go down to the Ferris wheel they used to have, they had what they called the Derby—and we’d ride on that. [See slide 12 in “Images for Staging Primary Care“] And there was fabulous ice cream places. We would go and get Dardenella—I think it had a little brandy in it. And Grandma Partlow used to make blackberry wine and made the most wonderful fruit cakes and the best fish chowder and coconut cake you ever tasted. And they had lovely furniture, lovely old velvet furniture, a lot of cherry wood. You can’t even buy furniture like that now. They had some furniture so ornate that they gave a bedroom suite, a big armoire with carved legs and all, to the Bishop’s Palace on Broadway.
[See slide 13 in “Images for Staging Primary Care“]
JO
My grandmother in Corpus has some big brown furniture like that.
LEMARQUE
Let’s get back to your aunt’s religious views, Mrs. Dunne. Did she…go to church a lot?
MRS. DUNNE
Oh yes, she never missed. And when I would go down there to visit her before I got married, which was quite a few years ago—I’ve been married 48, going on 49 years—we would go to Mass, and then go down to the seawall and ride a bicycle.
[See slide 14 in “Images for Staging Primary Care“]
Aunt Meem, Uncle Bob, and I, we’d rent bicycles from someplace down there on the boulevard. And then we’d just go to all sorts of different places and then have a big fish dinner. But then, like I say, we all began to live our different lives and so forth, and we didn’t get back much. It was sort of sad—when I’d go and we didn’t have anything to talk about.
JO
Was she maybe frustrated—or upset about something?
MRS. DUNNE
Oh, no. It’s just that, you know, she wasn’t right. She would run off—she was wanting to go home, she said. She would get her little dog—she loved her dog.
[See slide 15 in “Images for Staging Primary Care“]
She loved animals—and just start out. She’d say, “Come on, Cleo, time for us to be going home to our house.” And then she’d start saying goodbye to us, like she was going to leave. I think she wanted to go back to the old home place.
LEMARQUE
Your aunt was confused about her whereabouts?
MRS. DUNNE
Oh, yes. After my mother died, well, Aunt Meem started to wander.
[See slide 16 in “Images for Staging Primary Care“]
Uncle Bob found an apartment that was easier on him. He liked to putter around the old place, but he’d be up in the attic, or somewheres, and then he’d just come out and she’d be gone.
LEMARQUE
You know that he…that his death was ruled a suicide.
MRS. DUNNE
Yes. Miss Pilot told us. The money was running out.
LEMARQUE
And his own prognosis was not good. He had an inoperable neoplasm.
MRS. DUNNE
An inop…Well, at least she didn’t see Uncle Bob suffer.
LEMARQUE
But Mrs. Dunne…
MRS. DUNNE
(Pressing on.)
God does work in mysterious ways. Aunt Meem was a dyed-in-the-wool Catholic, and she even used to have little—I remember, now—altar guild parties. She just did everything for that church—especially the school. She was a volunteer teacher, and helped with all the bake sales and socials.
(To JO.)
I think it was because she didn’t have children of her own.
LEMARQUE
But what would she have wanted to do, in a situation like this?
MRS. DUNNE
I just don’t know, doctor. I don’t think…if she could have had her own will…
(Shaking her head.)
She wouldn’t want to extend it. The more I think about it, and talk about it, she just loved life so much—she wouldn’t want anyone to suffer like this.
LEMARQUE
Did she ever say anything explicit about her illness?
MRS. DUNNE
I don’t think she was aware of anything after she started to slip. I don’t think she knew, you know, about the Oldheimer’s. I think the last time she didn’t even know us. That’s when my husband said there was no point in us driving over.
JO
But after she fell? You never came—
MRS. DUNNE
(Feeling an accusation.)
There was nothing we could do.
LEMARQUE
(Warning JO off with a look.)
Mrs. Dunne, can you tell me what—you said that you’re fairly sure that she never would have wanted to be resuscitated or kept alive artificially.
MRS. DUNNE
Well, she always liked to dress up and if she wasn’t able to do things physically for herself, I think that would have been a great hurt to her.
LEMARQUE
Her independence was important to her?
MRS. DUNNE
Oh yes, yes indeed. She was very ladylike and independent. I don’t think she would want to go on, if she could see herself like this.
[See slide 17 in “Images for Staging Primary Care“]
JO
But she’s stable. She’s still healthy. She’s not dying.
LEMARQUE
(To JO.)
The purpose of this conference…
(Now to MRS. DUNNE.)
What we need to decide…is what a woman like your aunt—whether she wants the tube removed.
MRS. DUNNE
Well, if you take it out, I don’t know how the hunger pains would be.
LEMARQUE
No. We could make sure that she was comfortable.
MRS. DUNNE
You could give her something to alleviate it? Like a B12 shot or something?
LEMARQUE
Don’t worry, Mrs. Dunne. We have many pharmaceutical choices.
MRS. DUNNE
Well. I feel she would be relieved. That’s probably what she wants. That’s probably why she’s not eating
JO
Maybe she’s just frightened, or depressed?
MRS. DUNNE
No, no. She was never depressed—always so full of life.
LEMARQUE
You think that would have been her preference, then? To go in peace?
MRS. DUNNE
If she knew she was tied up in a chair like that…
(Turning directly to LEMARQUE.)
Dr. LeMarque, you’re the professional. There’s no hope for Aunt Meem, is there?
LEMARQUE
No, Mrs. Dunne. The Alzheimer’s is irreversible.
MRS. DUNNE
(Looking back to MRS. RIEGEL.)
She was such a special person . . . She wouldn’t want to keep on this way. Let’s do it, doctor. Let’s let her go.
Scene 6
SETTING: A week later. Dr. LeMarque’s office.
AT RISE: LEMARQUE takes a phone call from a nurse: MRS. RIEGEL still has strong vital signs. STONY strides in, openly listening in on the conversation.
LEMARQUE
You’re sure. Well, thank you, Gale. Let me know if there’s the slightest arrhythmia.
STONY
So you’ve heard.
LEMARQUE
I found out something was wrong yesterday. Gale says she’s still 115/60. Her temp is normal. Pulse solid as a rock. She hasn’t even lost any weight.
STONY
Don’t you know what’s going on?
LEMARQUE
I ordered some blood work. No white cell elevation, PO2 normal, electrolytes fine, respiration even. But Gale says she won’t take anything—not even water. Something’s wrong. Very wrong.
STONY
There’s a simple explanation. The aide.
LEMARQUE
Mrs. Brooks?
STONY
She’s ignoring the feeding regimen and has taken things into her own hands.
LEMARQUE
Ignoring the chart? She hasn’t said anything to me.
STONY
And she won’t. She’s doing this on her own.
LEMARQUE
She’s putting the tube in by herself. She’s risking prosecution.
STONY
That doesn’t bother her. She’s used to it. She’s got a son who was arrested in some kind of gang killing. None of these people respect the law.
LEMARQUE
(Still with her previous thought.)
I wonder where she got it?
STONY
Got what?
LEMARQUE
The tube.
STONY
I don’t know what she’s doing. One of the night staff told me that she was sneaking down there every four hours, like she was breastfeeding an infant, turning the geriatric wing into a nursery.
LEMARQUE
I wonder…maybe she’ll only eat for Mrs. Brooks.
STONY
I don’t see what difference that makes.
LEMARQUE
It would explain the blood gases and electrolytes.
STONY
But it wouldn’t explain why a nurse’s aide thinks she can leave her assigned floor and ignore the orders of an attending physician.
LEMARQUE
You’re right. We can’t have employees freelancing in the hospital. I’m going to go over there this evening and get this cleared up.
STONY
Good, because Mrs. Brooks’s interference is taking its toll on the entire service. If it were up to me, she’d be looking for another job.
(He starts to leave.)
LEMARQUE
Uh, Stony. Before you go. You don’t think this changes anything, do you—I mean, this different feeding regimen.
STONY
You mean about our decision?
LEMARQUE
Well, yes.
STONY
You can’t be serious? We followed all the accepted procedures and reached a determination after an Ethics Case Conference. All parties were heard from, even the family. It was a joint decision agreed to by everyone—everyone except one nurse’s aide who doesn’t even have a high school diploma. She’s not even remotely qualified to make a medical decision of this magnitude.
(Starts to leave again.)
LEMARQUE
Yes, I know, but . . . she must be doing something right.
STONY
I beg to differ, Dr. LeMarque. She’s doing everything wrong.
LEMARQUE
But she is able to feed her. She seems to be the only one who can. She’s keeping Mrs. Riegel alive.
STONY
No. You mean, Mrs Riegel is trying to die and Wynn Brooks won’t let her.
LEMARQUE
Are we sure, right now, that Mrs Riegel wants her life to come to an end?
STONY
What life? Mrs. Riegel has no life—her life already has come to an end. She may be biologically tenacious, but she’s become a vegetable, and the Alzheimer’s is terminal.
LEMARQUE
Well, she’s not technically terminal.
STONY
Maybe not technically, but she’s totally incapable of human interaction. You’ve seen her. She’s begging to die.
LEMARQUE
So. You think the classification should be “living dead”?
STONY
“Living dead,” “nearly dead,” “newly dead,” whatever. The point is, for all intents and purposes, she is not alive.
LEMARQUE
Are you saying we should let her die, or—make sure she dies?
STONY
I’m just saying that we developed a policy, a course of action, and used established procedures—and we shouldn’t lose our nerve just because some uneducated religious fanatic has made things more complicated.
LEMARQUE
More complicated. Yes, it does seem more complicated now.
STONY
Look, if we keep her alive, we’re just wasting staff time and resources.
LEMARQUE
But our first obligation, even at Jeff Davis, is to the patient.
STONY
Excuse me, Dr. LeMarque, but in a case like this, that’s nothing more than a platitude. We ought to be spending our time with people we’ve at least got a chance to save.
LEMARQUE
But Stony, don’t you have any doubts?
STONY
Nope. I mean, either you trust and abide by your procedures or you don’t. The aide is freelancing. If it was a resident, they’d be reprimanded, thrown off the service, maybe prosecuted.
LEMARQUE
I don’t think—
STONY
She’s enforcing her will on the patient. It’s like—remember the ethics course in med school? The first thing we learn is patient autonomy. What Mrs. Brooks is doing is pure paternalism—it goes against the wishes of the family, the physician, the other caregivers, and the patient herself. She’s the one who keeps saying, “Out, out.”
LEMARQUE
And she’s the one who took the tube out, I know. (She pauses—he’s won this round.) Stony. If you felt this way, why did you go into medicine?
STONY
I never did want general practice, especially geriatrics.
LEMARQUE
Right, you’ve it said many times, either Peds or Surgery. But I still say it’s a weird twosome.
STONY
Not really. I told the admissions people that I wanted to be a doctor, not a nurse. I hate sickness and I hate losing.
LEMARQUE
So now you’re going into pediatric ICU.
STONY
I want to make people well. I don’t know how you can stand the ambiguity of Internal Medicine. And Family Practice, gimme a break. At least most of the neonates get better—if you’re good enough.
LEMARQUE
There’s visible success.
STONY
And hope. Those babies have got another 50 years of life ahead of them. I mean, what’s an AD got? Ten years of slow death? Elie Wiesel was right: it’s like systematically tearing the pages out of a book, one after another. Why stretch them out longer? I mean, what are we doing here? Putting as many people as possible, for as long as possible, through progressive hell? You can’t restore health, you can’t restore function. If you “save a life,” what are you saving it for?
LEMARQUE
But you can still relieve symptoms and suffering.
STONY
What happens when the symptom is irreversible dementia? When the worst kind of suffering is just being kept alive?
LEMARQUE
You can avoid harm.
STONY
No, Dr. LeMarque. What we’re doing isn’t practicing medicine. You want to avoid further harm to the patient? Then let her go. Mrs. Riegel’s ready. Let her die.
Scene 7
SETTING: That night. Mrs. Riegel’s room.
AT RISE: LEMARQUE walks into MRS. RIEGEL’s room. She checks the patient’s vital signs. She looks around and in drawers for some evidence of Mrs. Brooks’s “crime.” Then she finds a chair and moves it into an unlit part of the room or behind a curtain that can be drawn around MRS. RIEGEL’s bed or chair; from that vantage point she can observe what happens without being seen. After a short while, MRS. BROOKS comes in.
MRS. BROOKS
How are you this evening, Miss Sybil Dean. I’m doing fine, thank you, but that youngest boy of mine has been giving me fits again. I’m going to raise that boy right if its the last thing I do. You know, the world has changed since you and me was growing up. You right about that. It sure has changed.
(She goes about the room, tidying up, never seeing Dr. LeMarque.)
Come on, let’s get you up in this chair. They think you going to die, but you not going to die ‘long as I’m taking care of you.
(MRS. RIEGEL sits up straighter with MRS. BROOKS’s help.)
Now, let’s see how strong you are. That’s right, that’s right. Oh my Lordy, you got a powerful grip. Now how about your heart. Let’s see how it’s doing.
(She takes MRS. RIEGEL’s pulse and listens to her breathing by putting her head against MRS. RIEGEL’s chest. MRS. RIEGEL’s left arm comes up to lightly embrace her.)
That’s right, you go ahead and give me a hug, and I’ll give you one, too. Are you ready for your supper. I bet you got some appetite tonight, probably thirsty, too. Well, I got something for you, just like always. I’m here to take care of you, Miss Sybil. You know that now.
(She goes to her purse and takes out three half-finished infant bottles of formula. She wipes off the nipple of one and brings it over to MRS. RIEGEL.)
I know, I know. Don’t take it too fast, now. You know it makes you get sick if you takes it too fast
(MRS. RIEGEL starts to take the formula.)
There, now, I told you it was going to be all right.
(Pause.)
It’s like I was saying yesterday, we just got to make do the best way we can. And if you don’t feel like eating from a spoon, I don’t mind feeding you out of a bottle.
(MRS. BROOKS hums a quiet song and attends to MRS. RIEGEL, combing her hair and showing her affection. Eventually MRS. RIEGEL finishes the first bottle.)
I believe you’re still hungry, aren’t you. Well, let me get you some dessert. But you know it’s going to taste ’bout like the main cou’se.
(MRS. BROOKS turns to the formula and the bottles, carefully putting the used bottle back in her purse wrapped in tissue. When she turns back, LEMARQUE has come into the light and is assuming a confrontational stance. MRS. BROOKS is taken aback.)
MRS. BROOKS
Whoa! Lordy, doctor, you ’bout scared me to death.
LEMARQUE
Yes, Mrs. Brooks, I suppose I would be frightened too if I had been doing what you have been up to.
MRS. BROOKS
You scared me. I didn’t say I was frightened.
LEMARQUE
Aren’t you ashamed of yourself. If we weren’t so short-handed in the nursing department, I would have you fired even as we speak.
MRS. BROOKS
You do what you gotta do, doctor. But I ain’t frightened and I ain’t ashamed.
LEMARQUE
Didn’t Dr. Marcher speak to you about this?
MRS. BROOKS
He come around here, try to scare me.
LEMARQUE
What did he do?
MRS. BROOKS
He do the po-lice in different voices.
LEMARQUE
The police?
MRS. BROOKS
He say one thing, then somethin’ else. Talkin’ ’bout how bad this is and what’s gonna happen. Tryin’ to make me ashamed.
LEMARQUE
Well you should be ashamed. Sneaking away from your floor, ignoring the orders moving you to a different service.
MRS. BROOKS
Yes, ma’am, they give me those transfers to 4LP. But I got my own orders and my own chart, and they says to feed Miss Sybil. And that’s exactly what I’m going to do. You see, I got some friends in the neonates. The ICU. Those poor little babies don’t never take all they supper, and so they gives me what’s left over. Miss Sybil, she likes it real good. And they just be throwing it out over there anyway.
LEMARQUE
Do you realize that that formula is not sterile?
MRS. BROOKS
Course I know it’s not sterile. But the food I eat ain’t sterile. And Miss Sybil, she don’t seem to mind.
LEMARQUE
Mrs. Brooks, what gives you the right to come in here and countermand a physician’s orders?
(STONY and JO arrive and start to come in. STONY hears the dispute, motions for JO to stop. They eavesdrop.)
The patient has a right to a death with dignity, just as you and I have rights—
MRS. BROOKS
Rights? This ain’t about rights, doctor, this is between me and Miss Sybil. Where I come from, the Disciples, they got rights—and they put you off the sidewalk. The Blackstone Rangers, they got rights, and they knock you down.
LEMARQUE
Look Mrs. Brooks, I respect your position on this matter. I can tell you, this was not an easy decision to make. We contacted the family, the legal guardian, anyone and everyone who was appropriate.
MRS. BROOKS
You didn’t call me. I woulda told you ’bout Miz Sybil.
LEMARQUE
I beg your pardon, Mrs. Brooks, but you were contacted. You just didn’t show up when we scheduled the Case Conference.
MRS. BROOKS
You doctors just waited till you knew I couldn’t come so I wouldn’t raise no fuss. I know how such things are done.
LEMARQUE
I can assure you, Mrs. Brooks, no such attempt was made to exclude you from what was a very difficult, very painful process. But the point is, a decision was made, steps were taken, and you have refused to keep up your obligation as an employee. You are being paid to do your job, as assigned, and your job is not on this floor.
MRS. BROOKS
I’m not doing no job when I take care of Miss Sybil. She’s my friend, and that’s why I take care of her. I’d do the same thing for any of my friends, and she’d do the same for me, if she could. Ain’t that right, Miss Sybil? Yes sir, we take care of each other, don’t we?
LEMARQUE
Have you thought about how you would feel if you were in Mrs. Riegel’s position. Wouldn’t you want to be allowed to go peacefully.
(STONY and JO come in.)
STONY
(Speaking to LEMARQUE but looking at MRS. BROOKS.)
So you caught her red-handed.
LEMARQUE
I think that Mrs. Brooks now understands that her behavior has been in violation of hospital policy and procedures.
MRS. BROOKS
(Looking at Stony.)
Somebody ‘round here violated somebody, that’s for sure.
(She turns her back on them and goes over to Mrs. Riegel.)
STONY
(Stony gestures to take in the entire room.)
Look at this.
(Speaking directly to Mrs. Brooks.)
Who would want to go on like this? Life is over for her. She’s gone.
MRS. BROOKS
She ain’t gone yet, doctor. She ain’t gone for me. Miss Sybil, she waitin’ on the good Lord to call her home. He knows when the time is ripe. I loves her, and I know she loves me. And I’m going to take care of her till she dies.
STONY
She’s blind, nearly deaf, and completely demented. She doesn’t know who you are.
MRS. BROOKS
Oh, she knows me, all right.
STONY
You’re nothing to her but a feeding machine.
MRS. BROOKS
No, doctor, you wrong about that. Plum wrong. Miss Sybil know I’m her friend. She take the food I gives her to eat, and nobody else can feed her without her choking and gagging. Then, after she eat, sometimes we talk and sing.
STONY
(Sarcastically.)
Isn’t that sweet? You talk and sing.
MRS. BROOKS
Ain’t nothin’ wrong with singin’.
LEMARQUE
But it’s not your job, Mrs. Brooks. You are letting your personal values affect your professional judgment.
STONY
She’s insensate. She’s not listening to you.
MRS. BROOKS
You right, doctor, she ain’t listening. She singin’.
JO
(Sensing the significance of this.)
She sings? Mrs. Riegel can sing?
MRS. BROOKS
She sho does. We sing together, don’t we Miss Sybil. Sometimes we sing spirituals, but sometimes Miss Sybil, she likes them old-timey songs.
STONY
(To JO.)
You’re not buying this?
MRS. BROOKS
Come on, now, Miss Sybil, let’s show these doctors what all we can sing.
(Tries several times to begin, “Were you there…when they crucified my Lord…when they laid him in the tomb,” without success.)
STONY
Come on, Dr. LeMarque, this is ridiculous.
LEMARQUE
Mrs. Brooks…I’m not going to write you up and you will not be reprimanded. But you must abide by the consensus of the committee and the approved policies and procedures, or you will be terminated.
(Pause, waiting for a response that does not come.)
Don’t you think this poor woman should be allowed to go naturally?
(Pause.)
It’s not right for us to keep her alive merely for our own comfort. To satisfy our personal value judgments. We must remember the burden on the patient.
(MRS. RIEGEL starts to get agitated.)
MRS. BROOKS
Don’t you talk that way in front of Miss Sybil, doctor. You’ll get her all upset. Come on, now, honey, I know what you doing—you waiting for me to do your favorite. Here we go now:
Daisy, Daisy, give me your answer do,
I’m half crazy, all for the love of you
(MRS. RIEGEL begins to pick up the tune after the first “Daisy.” She gamely nods and articulates syllables through the second line of the song.)
That’s all I know of that song. I never heard that one, but Miss Sybil, she taught it to me.
JO
(Taken in by the spectacle.)
Mrs. Riegel taught you that song?
MRS. BROOKS
She sho’ did. She sings some more, too, somethin’ ’bout “a bicycle built for two,” but I haven’t been able to figure out the rest. I’m working on it, though, ain’t I, Sybil Dean?
LEMARQUE
Mrs. Brooks…What else can she sing?
MRS. BROOKS
Well, she like school and church songs, mainly. She like “Row, row, row your boat.”
JO
(Pauses, takes in the situation, and then goes over to the bed or chair next to Mrs. Brooks.)
Will she sing it now?
MRS. BROOKS
She gettin tired…but let’s see. Here we go, Sybil Dean, let’s you and me do “Row, row, row your boat.” You ready? Come on, now.
Row, row, row your boat,
Gently down the stream,
Merrily, merrily, merrily, merrily,
Life is but a dream.
(Sung four times. The first time, the verse is sung by MRS. BROOKS alone. Then the image of Mrs. Riegel below is projected. The second time the verse is sung by MRS. BROOKS and JO together. They look at the bed with encouragement and then pleasure as MRS. RIEGEL is nodding and humming. STONY considers the display meaningless and cannot believe that JO is participating. The third time through the verse, LEMARQUE also joins. STONY looks at her incredulously and then looks down and shakes his head. The fourth (and fifth?) time, MRS. BROOKS breaks the fourth wall and encourages the audience to join.)
[See slide 18 in “Images for Staging Primary Care“]
