Sunday, July 20, 2014

Dislocation, Italian Style -

"SCUSI," I said, calling a nurse in the same tone of casual deference used to summon a waiter, trying to ignore the pain that was blaring like a siren in my mind. It was a glorious day in Milan, and I had planned to spend it having lunch with a colleague, visiting a favorite museum, shopping for shoes. Instead, I found myself staring at the emergency room ceiling in the Ospedale Gaetano Pini, which the ambulance driver assured me was the best orthopedic hospital in the north of Italy. "People come from all over to have surgery here," he said.

It seemed safe to say that few, if any, had come as far as I had. The first time I dislocated my artificial hip, in Pittsburgh, where I live, the hospital staff had propelled me from E.R. to O.R. with an all-hands-on-deck sense of urgency. Now I'd done it again. But the attendants in Milan seemed to be in no hurry. They moved among five of us lying broken on our gurneys and asked desultory questions (any allergies?) as if we were making conversation on a train.

A guest in a country not my own, I was determined to be respectful and congenial. Two nights earlier, I'd been out to dinner in Venice when the American couple at the next table asked a woman nearby to stop smoking. The offender obligingly exhaled in the opposite direction while noting that we were outside, for God's sake; the wife continued to wave her arms as if clearing the air after a stovetop grease fire. Even in this hospital, it was clear that there were local customs at work, and I intended to abide by them.

My eyes kept returning to an LED sign like the one behind the counter at my local butcher. Red numbers appeared in no discernible order. Nor did they seem to correspond to my fellow patients' comings and goings through the doorway that led to relief. It was unnerving and disorienting, this failure to make sense of the system. And I couldn't even blame a language barrier. I had lived in Milan for five years at the end of the '90s, and although my command of Italian now wobbles on occasion, I suddenly heard myself speaking complex sentences without hesitation, tossing off words I didn't know I knew. Adrenaline had apparently kicked my brain into a higher gear, as if the past subjunctive might improve my chances of survival.

Eventually, I was wheeled into an examination room and greeted from a desk on the far side by a silver-haired, Hollywood-handsome doctor whose black-rimmed glasses gave him the vaguely preposterous air of Cary Grant in the role of a paleontologist. Remaining seated, he interrogated me on my medical history, as I, still lying flat, turned my head and replied through the bars of the gurney's railing. A resident in scrubs stood alongside. Any surgeries? Two hip replacements. Where? New York. Two revisions to correct the botched second replacement. Where? The Mayo Clinic. "Rochester!" the resident exclaimed. I hoped the fact that I had been to Mecca would work in my favor here, unlike in some American hospitals, where the mention of the Mayo Clinic seemed to set off cherry bombs of intramural resentment.

The interview over, I was remanded to the holding area. Hours passed. The pain got worse. I was running out of charm.

"Scusi," I said, my voice pitched higher than intended this time. The nurse asked me to rate my pain on a scale of 1 to 10. In the past, I'd been instructed to think of 10 as the worst pain I had ever experienced. On that basis, my pain was an 8. Signora, the nurse replied, shaking his head, if it were an 8, you would be unable to speak. I lay there, contorted, wondering whether the Italians had recalibrated the scale to encompass the worst suffering over the course of human history, saving 10 for saints who were beheaded, shot full of arrows, crucified upside down, whose bones were now enshrined in churches all over the country.

At long last, early that evening, I was wheeled to the O.R. Cary Grant would attempt to put my hip back in place by manipulation, without an incision. This is the best-case scenario, but it doesn't work every time.

And it didn't work this time, I was informed when I awoke. They would try again the next day. I was wheeled to a double room upstairs, where a nurse, in response to my request for water, informed me that the hospital didn't provide water; my friends could buy it for me from a vending machine in the lobby.

As a patient in American hospitals, required to recite my name and date of birth at the start of every conversation, to initial my thigh with a felt-tip pen before surgery, I have been amazed at the extent to which our propensity for lawsuits has shaped our system. And yet, annoying and absurd as these crosschecks may be, the absence of them in Milan was disconcerting. As was the lack of obsessive data tracking: no bedside monitors displaying heart rate and respiration, no middle-of-the-night intrusions by nurses wielding blood-pressure cuffs and thermometers.

I was given a pill and told to swallow it. What is it? I asked. The nurse sighed. It's standard, Signora, she said. So much for the patient's right to know. A nurse entered, pulled aside my gown, stabbed a needle into my abdomen and exited. Back home, I viewed doctors as my partners in the healing process, but not here — my life was in these people's hands, and they would decide what information I needed. I recalled a conversation with an Italian friend whose father's doctor diagnosed cancer and gave him two months to live. I asked how he had taken the news. The doctor had told the family, she replied, but not the patient.

The O.R. for the second time was filled with laughter and banter, swirling above and around me like ripples on the surface of a pond as I lay on the bottom. A male nurse feigned annoyance with an attractive colleague. The surgeon made some joke, and I scrambled to find a comeback. The atmosphere was completely out of keeping with the hushed gravity of American O.R.s, which, in my experience, bore more resemblance to a church service than a party. The Italians I have known and loved are fun, funny, cynical, flirtatious, spontaneous, determined not to let their work interfere with their lives. It occurred to me, as I waited for the anesthesia to turn out the lights, that none of these were qualities I wanted when it came to my health care.

But this time, success. I was immobilized in a brace and returned to my room. A priest entered. "Buongiorno," he greeted me, his eyes taking in the other bed, now empty, and my night stand, where a friend had placed a dozen roses and a tiny jade Buddha. Nice flowers, he said, and left.

If Italian patients were expected to be quiescent to a degree I found incomprehensible, perhaps it was because their relationship to their doctors was more paternalistic than any I had ever known — or wanted. My mother, when she underwent thyroid surgery back in the '60s, regarded her doctor as infallible. But our faith in medicine and its practitioners has since been eroded by a growing awareness of side effects, infection, malpractice and class-action suits. Are errors and complications more common in the United States? Or do Italians, however reluctantly, take bad outcomes in stride, resigned to their fate, while we Americans respond with indignation and crusades for restitution?

Edward T. Hall, the cultural anthropologist who advised members of the State Department in the '50s, wrote that you can live in another culture all your life and you will never completely understand it, but you will come to understand your own. You might think that sickness and health would transcend the differences that put people from disparate countries at odds. But over three days at the Ospedale Gaetano Pini, I came to realize that my assumptions when it comes to medicine are completely in keeping with my bedrock American outlook on life, which, like it or not, revolves around money. As a consumer, I go into every transaction, even surgery, with an expectation of the service I'm entitled to and feel shortchanged when I get anything less.

In advertisements featuring athletes and ballerinas, hospitals in the United States claim to make their patients good as new — a foolproof selling point in a nation of perfectionists fixated on youth. Physical decrepitude, to our way of thinking, is not universal human destiny but a condition that can be forestalled by those who have the means and make the effort. This refusal to come to terms with our own decay is, finally, no more realistic than blind faith in fellow mortals ordained as doctors.

Just before I left the hospital, the resident who knew the Mayo Clinic dropped in to say goodbye. I hope we haven't given you a bad impression of Italian medicine, he said. I assured him that I was grateful for everything they had done.