'Little Black Lies' (US 2015): Book Excerpt

Sandra Block is a writer and practicing neurologist. She graduated from college at Harvard, then returned to her native land of Buffalo, New York, for medical training and never left. She has been published in both medical and poetry journals. "Little Black Lies" (Grand Central Publishing, 2015) is her first novel. Block contributed this excerpt to Live Science's Expert Voices: Op-Ed & Insights. 

Excerpted from LITTLE BLACK LIES by Sandra Block. Copyright 2015. Published By Grand Central Publishing. Used by permission of the publisher. Not for reprint without permission.

Chapter One

She picks an invisible bug off her face.

A pink sore swells up, adding to the constellation of scabs dotting her skin, remnants of previous invisible bugs. Tiffany is a "frequent flyer" as they say, in and out of the psychiatric ward. She's been my patient twice already, both times delusional and coming off crystal meth. She does the usual circuit: emergency room, psych ward, rehab, streets, and repeat. A cycle destined to continue until interrupted by jail, death, or less likely, sobriety. Tiffany sits on her hospital bed staring off into space, the skimpy blue blanket over her knees. She is emaciated, her spine jutting out of the back of her hospital gown. A penny-sized patch of scalp gleams through her bleach-blonde, stringy roots, due to her penchant for yanking out clumps of hair (otherwise known as trichotillomania, in case Dr. Grant asks me, which he will.)

"I've got to go now, Tiffany. Anything else I can do for you?"

She doesn't answer or even look at me. Either she's psychotic or ignoring me or both, but I don't have time to figure out which because we're rounding in five minutes, and I still haven't finished my charts. I run down the hall to the nurses' station, which is in chaos. Jason and Dr. A, the other two psychiatry residents, are elbow to elbow in the tiny room, mint-green charts in precarious towers around them. The nurses jog around us, saying "Excuse me" too loudly, as they sort out meds and record vitals, ready to sign out, punch out, and get the hell out of Dodge as the seven o'clock shift drifts in.

Dr. A grabs an order sheet from the stack. "Did anyone discontinue the IV on Mr. Wisnoski?"

"Mr. who?" one of the nurses calls back.

"Bed nine. Mr. Wisnoski. This should be done expediently."

"Whatever you say," the nurse answers, putting on latex gloves and heading to the room. Dr. A's real name is Dr. Adoonyaddayt, and his first name is just as unpronounceable. So everybody calls him Dr. A. He has a strong Thai accent and obsessively studies an online dictionary to improve his vocabulary. He is, as he told me, "building a compendium of knowledge." Dr. A appointed Jason to be his "idiom tutor," to better connect with American patients. He used to be a neurosurgeon in Thailand but is slumming with us in psychiatry now because it's impossible for foreign medical graduates to get into neurosurgery here. Dr. A is easily the smartest of our threesome.

"I thought Wisnoski was mine," Jason says. "He's yours?"

"Mine," Dr. A answers, taking the chart from his hand. Jason is dressed to the nines as usual, with his trademark bow tie (he has more colors than I thought existed, a compendium of bow ties in his closet) bangs gelled up and bleached just so. Jason is gay to the point of cliché, which I pointed out to him over beer one night, though he disagreed. "I'm Chinese American. Cliché would be me tutoring you in math."

The new medical student (Tom?) hasn't picked up a chart yet. He watches us running around like beheaded chickens and yawns. I like to play a little game, figuring out which fields the medical students are headed into, which I can usually guess in the first five minutes. This one, surgeon for sure.

"Zoe," Jason calls. "You got the new one?"

"Which one, Tiffany?"

"No," he says. "The transfer. Vallano."

"Oh, the one from Syracuse. Yup, I got her," I answer, grabbing her enormous chart, which tumbles open. "Dr. Grant's special present for me."

Jason guffaws, cracking open his own charts. "He sure does love you."

"Ah yes, such is my lot," I answer, flipping through her chart. It's obvious Dr. Grant doesn't like me, though I can't figure out why. It could be the Yale thing. But then again, maybe not. Could be a lot of things. Could be that I don't like him, and being a psychiatrist extraordinaire, he senses this.

Footsteps thump down the hall as Dr. Grant appears in the doorway. Beads of sweat mix into the curly hair at his temples from walking up ten flights of stairs. In my opinion, anyone who walks up ten flights of stairs on a daily basis needs a psychiatrist. Dr. Grant is wearing gray pants with a thin pinstripe and a checkered blue shirt, a combination that suggests his closet light burned out. He is a small, slight man. I could crush him in a thumbsie war.

"Ready to round?" he asks.

We file out of the cramped nurses' station, and the medical student strides over to shake his hand. "Kevin," he says.

Kevin, Tom, same thing. We stack the charts into the metal rolling cart and then Jason pushes it, clattering down the hallway. We pass by gray-blue walls, sometimes more blue than gray, sometimes more gray than blue, depending on the soot. The floor tiles are an atrocious teal blue (the approval committee was either color-blind or on mushrooms), dented and scraped from years of residents and food carts rattling down the hall.

"All right, first victim," Dr. Grant says, stopping just outside the room. Dr. Grant always calls the patients "victims" when we round. I haven't taken the time to analyze this, but it does seem peculiar. He says it quietly at least, so the already paranoid patients don't get any ideas. "Mr. Wisnoski. Who's got this one?"

"This is my patient, sir," answers Dr. A. He calls everyone "sir."

"Okay. Go ahead and present."

"Mr. Wisnoski is a forty-nine-year-old Caucasian gentleman with a long-standing history of depression. He was found unresponsive by his wife after overdosing on Ambien.

"How many pills?"

"Thirty pills, sir. He took one month's dose. He was taken by the EMT to the ER, where he underwent gastric lavage and quickly recovered."

"Meds?" Dr. Grant asks.

"Prozac, forty milligrams qd. He's been on multiple SSRIs before without success but had reportedly been feeling better on Prozac."

"So why did he try to kill himself?" Dr. Grant glances around and zeroes in on me, as usual. "Dr. Goldman?"

I'm still not used to the "doctor" thing, telling nurses "Just call me Zoe." "The problem is," I answer, "Prozac actually was effective."

Kevin is chewing a large piece of pink gum, which smells of strawberry. I can tell Dr. Grant is feeling the stress of ignoring this.

"Tell us what you mean by that, Dr. Goldman."

"Oftentimes a patient is most at risk for suicide when there is some improvement in functionality," I explain. "They finally have the wherewithal to commit suicide."

"That's right," he admits, though it pains him. We all head into the room, but it is empty, the patient's disheveled blue blanket crumpled on the bed. The room reeks of charcoal, which stains the sheets from last night's stomach pump. After some consternation, we discover from a nurse that Mr. Wisnoski is off getting an EEG.

So we move on down the list to the next room. The name is drawn in fat black marker into the doorplate. "Vallano." This is my add-on, the transfer.

"Dr. Goldman?"

"Okay," I say, ready to launch. "Ms. Sofia Vallano is a thirty-six-year-old Caucasian female with a history of narcissism and possibly sociopathy on her Axis II. She has been in Upstate Mental Community Hospital since age fourteen for the murder of her mother."

"Holy s---" escapes from Jason, to a glare from Dr. Grant. Still, you can't blame him; she did kill her mother.

"Any other family members?" Dr. Grant asks.

"One brother, listed as a lost contact, one sister the same. The brother was reportedly injured in the incident."

"Go on," Dr. Grant says. 

"After the closure of UMCH, she was transferred here for further treatment and evaluation," I continue.

"And," Dr. Grant announces, "possibly for discharge, pending our recommendations."

"Discharge, really?" I ask.

"Yes, really."

I slide her chart back into the cart. "Based on what findings? Has her diagnosis changed?"

"Well now, Dr. Goldman, that's our job to find out. She's been a ward of the state for over twenty years now. If she's truly a sociopath, I grant you, we may not be able to release her to society. If she's narcissistic, however, maybe we can." He skims through her old discharge summary. "From what I can see, UMCH has been kicking the can down the road on this one for a while now."

"She never went to prison?" the medical student asks, still chewing gum.

"Not fit to stand trial. Okay, let's see how she's doing." Dr. Grant knocks on the door in a quick series.

And there is Sofia Vallano, perched on the bed, reading a magazine. I'm not sure what I expected. Some baleful creature with blood dripping from her eyeteeth maybe. But this is not what I see. Sofia Vallano is a stunning mix of colors: shiny black hair, royal blue eyes, and opera red lips. Something like Elizabeth Taylor in her middle years, curvaceous and unapologetically sexual. They say the devil comes well dressed.

"Hello," she says with a smile. A knowing smile, as if she's laughing at a joke we aren't in on. She does down not put the magazine.

"Hello," says Dr. Grant.

"I'm Dr. Goldman," I say, extending my hand. My skin is damp in hers. "I'll be the main resident taking care of you, along with Dr. Grant, who's in charge. Just saying hello for now, but I'll be back to see you later."

"Okay," she answers and looks back down at her magazine. Obviously she's been through the likes of us before. A cloying scent rises off the magazine perfume ad on her lap. Redolent and musky.

We say our good-byes and all head back to see Mr. Wisnoski, who has still not returned from EEG.

"Who's next?" Dr. Grant asks. "Dr. Chang? Do you have anyone?"

"Yes, I have Mrs. Greene," Jason answers.

"Would you like to present?"

"Fifty-six-year-old African American female with a history of bipolar II. She came in today after a manic episode, now apparently consistent with bipolar I."

"And how was that determined?"

"Last night, she climbed onstage at Les Miserables to sing during one of the solos."

"Which one?" I ask, immediately regretting the question, which is not terribly relevant to the diagnosis and also tells me my Adderall hasn't kicked in yet.

"‘I Dreamed a Dream,' I think," he answers.

"Ah, the Susan Boyle one," says Dr. A in appreciation. "I find that song most gratifying."

Dr. Grant surveys us all with incredulity. "Doctors, could you at least pretend to be professional here?" Dr. A drops his gaze shamefully, and Jason twirls his bangs. Kevin chews on. "Meds?" Dr. Grant asks.

"She was on trileptal," Jason says. "Three hundred BID but stopped it due to nausea three weeks ago. The history is all from her sister because the patient is not giving a reliable history. Her speech is extremely pressured."

"Ah yes," Dr A says. "In bouts of mania, actually,"—he pronounces this act-tually, with a hard t—"the speech is quite rapid, and one cannot get the word in edgily."

"He means ‘edgewise,'" Jason explains.

"Ah, edgewise, so it is." Dr. A pulls the little black notebook out of his lab-coat pocket, where he jots down all his ill-begotten idioms.

Dr. Grant crosses his arms. One summer when I was in high school, my mom enrolled me in ADHD camp (sold to me as a drama camp) to boost the self-esteem of her ever-slouching, moody giant of a daughter. We played this game called Name That Emotion, where one group would act out an emotion and the other group would call out what it was. If I had to name that emotion for Dr. Grant assessing his crop of psychiatry residents, it would be disgust. We head to the next victim, our Broadway hopeful, but alas, she is getting a CAT scan, so we head back to see Mr. Wisnoski, who is still in EEG.

Dr. Grant looks supremely frustrated. "Anyone else to see?"

"I have Tiffany," I say.

"Oh, Tiffany, I know her. She can wait." He chews on the inside of his lip, thinking. "All right. I guess we'll finish rounds this afternoon. Just make sure you see all your patients and write your notes in the meantime."

So we split up to see our respective patients. The nurses' station has slowed to a hum now. I settle down to Sofia's chart, which is massive, not to mention the three bursting manila envelopes from UMCH, but at least I can feel my focus turning on. As I open the chart, the perfume card from the magazine falls out, the heady smell of perfume rising up from the page, like an olfactory hallucination.

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