My Return to Alabama
My first medical mistake that I remember is when I killed an old woman by giving her too much morphine. This occurred during the winter of 1970 in a bed about halfway down the left side of the Women’s Medical Ward at the University of Pennsylvania Hospital. In those days a ward was a ward. Thirty-two beds, sixteen on each side. High altitude ceiling. Institutionally pale walls. Suspended fluorescent lights. And a network of tubes for pulling curtains around beds when privacy was called for.
Alabama’s curtain was drawn. She had appeared gasping for breath in the Emergency Room the night before, a tiny gnarled black woman wearing a knit cap and a heavy red sweater. Hers was a clear-cut case of pulmonary edema. Of course, there were no medical records available and the patient herself was too sick to talk, except to say that she hailed from Huntsville, Alabama, and wanted to go hom. Thirty years ago she had a name, but in my memory, where she continues to live through that same night, that same morning, over and over, she has always been “Alabama.” The ER doc must have dubbed her “hypertensive heart disease,” so that’s what I wrote at the top of the differential, although her pressure was nothing to write home about for a woman about to drown in her own fluids. Accurate diagnosis wasn’t the issue, effective treatment was.
To treat pulmonary edema in those days, we had oxygen, Merc (Mercuhydrin, a diuretic), morphine, and rotating tourniquets. Merc was still widely used, even though the new loop of Henle diuretics were rapidly taking over the field. We also ha a spanking new Intensive Care Unit at Penn, but in those days admission to the Unit was far from routine. Alabama’s condition had stabilized and improved in the ER, so she appeared in my general medicine ward rather than in critical care. I remember how disheveled Alabama looked when I was first called to see her during morning rounds. Her wig was cocky-wampus, the red sweater mashed and twisted around her neck. But she was quiet and breathing comfortably. She even gave me a lopsided smile until I reached over to straighten out the wig. Swatting my hand away, she whispered, “Lawdy, Lawdy, Lawdy.”
I pushed a bit more Merc, adjusted the oxygen, and went back to finish rounds. An hour later I was called back. Alabama was thrashing around, breathing a mile a minute, once again in florid pulmonary edema. I can’t remember exactly what happened at that point – surely it must have included tourniquets, morphine, and a stat call to the ICU team. Those 15 minutes are an impenetrale black box as far as I’m concerned, but I remember standing by Alabama’s bed a few minutes after she died and reading the label of the morphine vial I had given her too much intravenous morphine. Not a multiple of 10, mind you, not egregiously too much, but sufficient (I thought) to make the difference between life and death.
What should I do? I couldn’t focus on the shadows during x-ray rounds later that morning, nor eat the sticky, dry spaghetti they used to serve for lunch. I told my resident about killing Alabama. He pooh-poohed the whole affair. “Makes no difference,” he said. “That lady was dead when she got here. Her heart just wore out.” Later, I screwed up my courage and told my attending physician, a famous cardiologist who lived for supraventricular arrhythmias. He was a small man, shorter even than I was, who sported a crewcut and horn-rimmed glasses. “Not to worry,” he told me. “You’ll learn.”
About twenty years later I wrote the poem called “Alabama.” I sat down one morning and for no apparent reason the poem just appeared – poof! – out of nowhere. Several things about the poem surprised me. For example, who was the stern professor “in some brown place / above her bed”? I can recall the main corridor of the hospital late at night. In my memory the corridor is poorly lit and lined with paintings of famous 19th and early 20th century physicians, but surely there were no paintings on the walls of theWomen’s Medical Ward. And where did the freckled arms come from? Alabama was darker than mahogany. The biggest surprise, though, was that in the poem Alabama whispered, “Let me go.” Let me go. Let me go. I’m pretty sure she never really said those words, at least not in the world of 1970, but who knows? Maybe that’s what she has been trying to tell me all these years.