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Paula Lyons


His history was Dickensian. As a little boy, born with an IQ of about 80 and a wandersome nature, he'd toppled onto the train tracks and gotten run over. How he didn't die is a mystery--this was more than fifty years ago, and he lost both legs up to his hips--but live he did.

I met him in the hospital, where he'd had surgery on the pressure sores that came from long hours perched in a wheelchair. When I asked him to roll over so I could see, he hoisted his whole body (200 pounds without legs!) out of the bed via the orthopedic trapeze. His arms were massively strong, his disposition was sweet, and he spoke and behaved like a well-mannered six-year-old. "My name is Andy," he told me. "I like you."

At the nursing station, the charge nurse teased, "So now you've met the Pencil Man of Western Boulevard." That was how the folks of Baltimore knew him--I was caring for a minor celebrity! Every day except Sunday, Andy sat in his wheelchair on the sunny corner of Western and Eastham, next to a leafy park, selling pencils and chatting with passersby. It was not a bad life, by his account. On Sundays, he told me with secret glee, his brother let him drive his brother's truck in the deserted, furthermost parking lot of the mall. From what I could understand, Andy took the wheel and his brother sat close beside him and worked the pedals.

His brother, also impressively muscled, and resolutely taciturn, looked as if he'd never had a lick of fun in his whole life. It tickled me to think of them careening about the lot. Did they laugh together? I imagined these sixty-year-old men, boys again for a short time, at dusk out behind Penney's.

As an adult, Andy had developed type 2 diabetes, which mystified him with its blood-sugar-tracking requirements ("Too many numbers, Dr. Lyons!"). He also had cirrhosis of unknown cause--he didn't drink, and tests for viral hepatitis, Wilson's disease and hemachromatosis were all negative.

Andy lived alone in a tiny apartment; his brother and sister looked in on him. After his surgery, a visiting nurse and aide visited three times a week to help him change his dressings (he was afraid of blood) and to bathe.

Despite this additional care, he began to show up in my clinic nearly every week with some small complaint: shoulder pain that couldn't be reproduced in the office; a stomachache (now gone); a sore in his mouth. I was mystified: the prior records showed that he came rarely, even to planned appointments. His cirrhosis was stable, his blood sugars weren't too bad, he didn't seem depressed. What was going on? I called his brother.

"Nah, he seems fine to me, Doc."

At each appointment, Andy listened happily to my advice, smiled charmingly, his bad teeth showing, and accepted willingly whatever salve, pill or cream I offered. I commented on this at the clinic desk and saw the nurses' smiles and covert glances.

"What?" I asked suspiciously. "What do you know that I don't?"

"Paula, you are an idiot," said Becky, our gum-cracking nursing tech. "The man is in love with you."

When I'd been a resident, one of our best attending physicians had said, "You'll never make a diagnosis unless you first think of it as a possibility." Becky was right--and I didn't know what to do. Annoyed, I found myself blushing when Andy and I were alone in the exam room. I decided that I was an idiot and carried on in a "professional" manner, though inwardly touched.

Lulled into complacency by Andy's stream of innocuous complaints, I felt startled and concerned when he came in with a new tremor in both arms. Feeling out of my depth, I involved Neurology, who had no answers either.

"Possibly a tiny basal ganglia stroke; did you rule out Wilson's disease? We can try some pharmacotherapy...."

The drugs made Andy feel bad, so he didn't take them, but the tremor was an increasing problem. Pencils fell from his grasp, he could no longer eat soup (his favorite), and he felt "wobbly" when transferring from wheelchair to bed.

With perfect bad timing, his pressure sores finally healed, and his visiting nurse and aide's services were terminated. I tried to get them back on the grounds of this new tremor ("Doesn't require skilled nursing care, Doctor") and that he needed help with finger-sticks ("Not if he's not on insulin, Doctor"). Finally I fudged, saying that I was worried that his liver disease might cause internal bleeding, and that he needed frequent blood tests drawn at home ("Is he truly housebound, Doctor?"). Nothing worked.

Some time later, with a sense of my worst fears being realized, I listened to his brother's gruff voice and watched him turn the brim of his hat over and over in his calloused hands as he described how Andy had fallen between the bed and the wheelchair when trying to transfer; he had lain there almost a day. Now Andy was in another hospital--a quirk of the EMS system--and "not doin' so well."

I went there after rounds. Relying on the happy anonymity of my white coat and stethoscope, I visited the ICU and reviewed his chart. Rhabdomyolysis (muscle breakdown), a heart attack, kidney failure...they also suspected a ruptured disk in his neck, as Andy's arms were now virtually paralyzed. An MRI was planned.

I let myself into his ICU cubicle.

"Andy." I leaned over the bed so that he could see me despite the hard collar on his neck.

"I'm scared," he whimpered. "I hurt. They want to put me in that tube."

I called his docs. They were understanding, and arranged for him to have an accessible MRI at a time when I could be there, as Andy had requested that I come along.

When the time came, he was apprehensive despite the Valium. The techs let me sit at the side of the arc. I stroked his hair. His breath was terrible.

I soothed him as I did my infant daughters: "Shhh, shhh, it's okay, I'm right here."

He giggled nervously, then slept. The MRI pictures added spinal-cord bruising to the list of Andy's woes.

I'd love to be able to report a happy ending to this story, but Andy died. His docs used every possible intervention to assuage his fear without prolonging the inevitable. To me, Andy's death was no less painful than that of any frightened child--for that is what he was, despite his massive biceps and mature frame. Coward that I am, I couldn't bring myself to attend his funeral, fearing that I might cry in public; but I did call his brother and write his sister a note.

I think of Andy often, see his grin and hear the cadence of his slow "Bal'more" speech. My life is richer for having known him. After all, not every doctor can claim that she once won the heart of the Pencil Man of Western Boulevard.


About the author:

Paula Lyons MD is a graduate of Emory University School of Medicine practicing family medicine just outside of Baltimore, Maryland. Some of her other writings have appeared in The Pharos and The Journal of Family Practice.

Story editor:

Diane Guernsey