The Year of the Intern

Day 15

I was already out stone-cold when the telephone rang again, half an hour later. J got it on the end of the first ring, reaching instinctively, almost in a panic, as the surgery book that had put me to sleep crashed off the bed onto the floor. God, what now? The nurse was desperate: "Dr. Peters, the patient you saw earlier has stopped breathing and he doesn't have any pulse."

"I'm on my way."

Fumbling down the phone, I went into my routine: pants, shirt, shoes, a dash down the hall to the elevator as I zipped my fly. I pushed the button and heard the high-pitched whine of the electric motor. Waiting impatiently, I suddenly realized I didn't know which patient she meant. There were so many. Mental pictures of those I had seen that night raced through my head. Mrs. Takura, Roso, Sperry, the new one, an old man with stomach cancer. It must be he. He was a private patient, and the first time I had seen him was when I'd been called away from dealing with the new admissions because he had developed a sudden severe abdominal pain. He had turned out to be emaciated and so weak he couldn't move, could hardly answer questions….

Frustrated at the slowness of the elevator, I slapped my hand against the door.

My information on the old man was meager. The nurse on the case didn't know much. There was no case history on the chart, just a brief note saying he was seventy-one and had been suffering from gastric cancer for three years; his stomach had been removed by surgery about two months earlier. According to the chart, he had entered the hospital this time because of pain, dizziness, and general malaise.

Grinding to the end of its mechanical deliberations, the elevator arrived and the maroon door folded into the wall. I stepped in, pushed the button, and waited impatiently again for the clumsy beast to take me to the ground floor.

My examination of the old man had not revealed anything unexpected. Clearly, he was in great pain, and with good reason — the cancer had undoubtedly spread inside his abdomen. After trying vainly to reach his private physician by phone, I had simply started a new intravenous drip and ordered some Demerol to help him sleep. Nothing else had occurred to me.

The elevator delivered me to the ground floor at last. I quickly crossed the courtyard, entered the main hospital building, and used the back stairs to get to the patient's floor. As I stepped into his room, I saw the nurse standing helplessly in the soft glow of the bed lamp. The man was so thin that each individual rib poked out on the sides of his chest; his abdomen dropped into a pit below the rib cage. He lay perfectly still; his eyes were closed. I looked closely at his chest. I was so accustomed to seeing chests move in steady respiration that my eyes tricked me into thinking this one rose and fell a little, but it didn't. I tried for a pulse. Nothing. But some people have very faint pulses. I checked to make sure I was on the correct side of the wrist, the side with the thumb, and then I held the other wrist. Nothing.

"No cardiac arrest, Doctor. I was told by the attending that we shouldn't call a cardiac arrest." The nurse sounded defensive.

Shut up, I thought, irritated and relieved at the same instant. I wasn't worried about calling an arrest. I just wanted to be absolutely certain, because this was the first time I had been faced with the sole responsibility for pronouncing death. Sure, there had been deaths in medical school, plenty of them, but always back then — only last year, in fact, yet so long ago — always then the house staff had been there to help, an intern or a resident; it wasn't a student's job. Now I was the house staff, and I had to make the decision alone; a judgment call, I thought wryly, like baseball, safe or out and no appeal to the umpire. He was dead. Or… was he? Demerol, thin old man, deep anesthesia — the combination could produce suspended animation.

I took out my stethoscope slowly, postponing the decision, and finally settled the pieces into my ears while I held the diaphragm on the old man's heart. A series of brittle crackling sounds came up to me as his hairs moved under the stethoscope tip in response to my own trembling. I couldn't hear the heart — yet couldn't I, almost? Muffled and far away?… My overheated imagination kept giving me the vital, normal beat of life. And then I realized it was my own heart echoing in my ears. Pulling the stethoscope away, I tried again for pulses, at the wrists, groin, and neck. All was quiet, yet an eerie feeling said he was alive, that he was going to wake up and I was going to be a fool. How could he be dead when I had talked with him a few hours ago? I hated being where I was. Who was I to say whether he was alive or dead? Who was I?

The nurse and I looked at each other in the half-light. I had been so absorbed in my own thoughts that I was almost surprised to see her still there. Holding open the man's eyelids, I peered down into a pair of brown eyes, normal looking except that the enlarged pupils did not contract as my penlight beam passed over the aged cornea. I felt sure he was dead; I hoped he was dead, because I was about to pronounce him so. "He's dead, I guess," I said, looking at the nurse again, but she turned away. Probably thought I was an ass.

"He's the first patient directly under my care to die," she said, turning back to me suddenly. Her hands hung limply at her sides. It took me a moment to realize she was pleading for me to say something about the Demerol, that it hadn't been the Demerol she had given. But how was I to know what killed him? A scene from an old horror movie kept flashing in my head, the one in which the corpse rises slowly from a cement slab in the morgue. I was becoming angry with myself, but I simply had to listen again. The stethoscope went back in my ears. In the still night my own breathing crashed in my head. Dead, death, cold, silent, whispered the rational centers of my brain. I should say something nice to the nurse. "It must have been very smooth and effortless — he died with dignity. I'm sure he's grateful to you for the Demerol." Grateful? What a bizarre thing to say. There I was wrestling with my own uncertainties, barely keeping ahead, and still trying to persuade someone else to be calm. Fighting an urge to feel for the pulses again, I pulled the sheet up over his head. "We'd better call his doctor," I said as we left the room.

The private M.D. answered the phone so quickly his voice was like a cold washcloth on my face. I told him who I was and why I was calling.

"Fine, fine. Tell the family, and get an autopsy for sure. I want to see what happened to that connection I made between the stomach pouch and the small intestine. It was an anastomosis made with only a single layer of sutures. I really think the single-layer technique is the best; if s so much faster. Anyway, the old man has been a curious case, especially since he lived so much longer than we expected. So get an autopsy, okay, Peters?"

"Okay, I'll try."

Plunging back into the silence of my mind after this jovial one-sided conversation, I tried to organize my thoughts. The private doctor wanted an autopsy. Fine. Great. Where was the family's number? A female arm came over my shoulder, pointing to a line on the chart: "Next of kin — son." Really a lousy situation. Unknown stupid intern calling in the night. I tried to think of some neutral word, one to convey the fact without the meaning. "Dead," "demise"… no, "passed away." The ring of the phone was interrupted by a cheerful hello.

"My name is Dr. Peters, and… I'm sorry to inform you that your father has passed away."

At the other end there was a long silence; perhaps he hadn't understood me. Then the voice returned.

"It was expected."

"There's something else." The word "autopsy" was on the tip of my tongue.

"Yes?"

"Well… never mind. We'll discuss that later, but I must ask you to come to the hospital tonight." The nurse had been telling me that in frantic pantomime.

"All right, we'll be there. Thank you."

"I'm terribly sorry, and thank you."

An older nurse materialized from the darkness of the corridor and pushed a number of official papers under my nose, indicating where I was to sign my name and write the time of death. I wondered when he had died; I really didn't know.

"What time did he die?" I asked, looking at the new arrival, who was standing on my right.

"He died when you pronounced him dead, Doctor." This nurse, a night supervisor, was known for pithy rhetoric and a jaundiced view of interns. But not even her acid tone and her obvious scorn for my naivete could erase the scene of the dead man rising from the slab.

"Call me when the family arrives," I said.

"Yes, Doctor, and thank you."

"Well, thank you," I returned. Everybody thanking everybody. In my tiredness small things loomed huge and absurd. The urge to go in and feel again for a pulse was still with me, but with an effort I went rapidly by the dead man's room; the nurses might be watching. Why did I keep worrying about him waking up? What about the man as a person, didn't that matter? Yes, of course, but I didn't know him. I stopped on the landing of the stairway. True, I didn't know him, but he was a person. An old man, seventy-one, sure — but still a man, a father, a person.

I continued down the stairs. I couldn't fool myself. If he woke up now I'd be the joke of the hospital. Confidence in being a doctor was coming slowly enough; that would kill it.

Back in the elevator, I tried to remember when I had changed, but I could only recall scenes, possible small turning points, such as my first visit to the ward during medical school, and the eleven-year-old girl who lay on the bed looking hopefully up at us. She had cystic fibrosis, which is usually terminal. Listening to the house staff discuss the cases, I had melted, unable to look the youngster in the face. "Perhaps there's a chance we can keep her alive until her late teens," the attending physician had said as we walked away. At that instant I almost became a plumber.

The elevator door opened. Somehow, sometime, my responses had changed. Now I was worrying that someone would wake up in the morgue and ruin my image, make me look ridiculous. All right, I had changed, clearly for the worse, but what could I do about it?

Back in my room, the bed squeaked as it took my weight. In the semidarkness, my mind's eye called up every detail of that skinny dead body. Did other interns brood like this? I couldn't imagine it, but then, I couldn't imagine what they would think. They seemed so self-possessed, so certain even when they had no right to be. Before med school, I had imagined an intern's crisis in a different way, as somehow more noble. Always the problem had revolved around the loss of my own patient after a long struggle, the anguish of a life lost. But here I was sweating over whether someone else's patient would start breathing again, and it bugged me that I could dismiss the person part. It was nine-forty-five. I rolled over, picked up the phone, and called the nurses' quarters. At that moment I needed someone to be with, someone to prove that life went on. "Miss Stevens, please. Jan, can you come over? No, nothing's wrong. Sure, bring the mangoes. That’s right, I'm on call."

Through the curtains I could pick out a few stars. For two weeks I had been an intern, the longest two weeks of my twenty-five years, the culmination of everything, high school, college, medical school. How I had dreamed of it! Now nearly everybody I knew was in this blessed state of internship, and it was a crappy job, and when it wasn't crappy it was a confusing mess. "Well, Peters, you've really done it now. I just want you to remember that it's easy to drop out of the big leagues but almost impossible to get back in." That is a direct quote from my surgery professor when he learned that I had decided to intern at a nonuniversity center, away from the ivory-tower medical circuit, out in the boondocks. And to the eastern medical establishment there is no boondock like Hawaii.

In terms of the immutable intern computer-matching system, I had been destined for any Ivy League internship. On that score, it was true enough that I had dropped out. But in the end I couldn't help myself. As med school wore on I began to see that becoming a doctor meant giving yourself over to the system, like a piece of wood on a chipping machine. At the end of the machine I would be smooth and probably salable, full of knowledge. But as the chips flew away, so would those "nonproductive" personality traits — empathy, humanity, the instinct to care. I had to prevent that if I could, if it wasn't too late. So at the last minute I had jumped off the machine. "Well, Peters, you've really done it now."

Losing the skinny old man had me up tight, and I leaped off the bed even before Jan knocked. Thank God it wasn't the phone. I was afraid of the phone. "Jan, it's good to see you, mangoes and all." Mangoes, just what I needed. "Sure, you can turn on the light. I was just sitting here thinking. All right, leave it off. Knives and a dish? You want to eat those mangoes now?" I didn't want mangoes, but it wasn't worth an argument, and, anyway, she looked delicious with the soft light shining on her hair, and she smelled as if she'd just stepped out of the shower, sweeter than any perfume. But the prettiest thing about Jan was her voice. Maybe she'd sing a little for me.

I got a dish and two knives, and we sat on the floor and started eating mangoes. At first, we didn't talk, and that was one reason I liked her, for her reticence. She was good to look at, too, very much so, yet awfully young, I suspected. Before tonight we had gone out twice, yet we weren't at all close. It didn't matter. Well, it did matter, because I wanted to know her, especially right then. There was something poetic about her blond hair and small features; just then I needed us to be close.

The mango was sticky. I peeled the whole thing and went over to the sink to rinse my hands. When I turned back to her, she was facing away from me, and the light from the window was throwing areas of silver sheen on her hair. She was leaning on one arm, with her legs tucked along her other side. I almost asked her to sing 'Try To Remember," but I didn't, probably because she would have — she did almost anything I asked in the way of song. If she started singing now, though, everybody in the quarters would hear it. In fact, they probably could hear us eating the mangoes. As I sat down next to her, she tilted her face and I could see her eyes.

"Something happened tonight," I offered.

"I know," she said.

That almost stopped me right there. J know. Like hell she knew, and I not only knew that she didn't know, but also that I wasn't going to be able to explain it to her. I went on anyway.

"I pronounced a skinny old man with cancer dead, and right now I'm afraid the phone will ring and it’ll be the nurse saying he's alive after all."

She tilted her head the other way, taking her eyes away. Then she really said the right thing. She said that was funny! Funny?

"Don't you think if s crazy?"

Well, yes, it was crazy, but it was funny, too.

"You know that a person died tonight, and all I can think about is that he might still be alive and it’ll be a big joke. A big joke on me."

She agreed that it would be a joke. That was the extent of her analysis on the subject. I persisted: "Don't you think it's strange for me to think such a stupid thing about the final event of somebody's life?"

That was too much for her, I guess, because the next thing she said was to ask if I didn't like mangoes. I like mangoes all right, but I didn't want any just then; I even offered her some of mine. Despite the misfirings, I somehow felt better, as if trying to communicate my thoughts had removed the skinny old man from the front of my mind. I wondered if Jan would sing "Aquarius." This girl made me feel happy in a simple way.

I put my arm around her, and she popped a piece of mango into my mouth, ludicrously throwing up a barrier without meaning to. So, okay, we won't talk about my skinny old man, I thought. I kissed her, and when I realized she was kissing me back, I thought how nice it would be to make love with her. We kissed again, and she pressed against me, so I could feel her warmth and softness. My hands were still sticky from the mangoes, but I ran them up and down her back, wondering if she would make love. The thought chased everything else from my mind. It was ridiculous to be on the floor, and I was pondering how to get us both over to the bed when I realized she wasn't wearing anything under her light dress — I had been too busy caressing her back to notice. She sensed my desire to move, and we stood up simultaneously. As I began to lift her dress, she stopped me, clasping my forearms, undid the back, and stepped out of it, so beautiful in the soft light. She might not have understood my problem, but she certainly had cleared my mind. That poetry I had thought about her enlarged to include her breasts. I peeled off my shirt, dropped the stethoscope on the floor, and moved to her quickly, afraid she might disappear.

The telephone rang. The moment was gone, and the skinny old man was back in my life. Jan lay down on the bed while I stood looking at the phone. My mind had been clear and well directed ten seconds before; now it became a jumble again, and with confusion came the terrible thought: He's started breathing. I let the phone ring three times, hoping it would stop. When I answered, it was the nurse.

"Dr. Peters, the family has arrived."

"Thank you. I'll be right there."

A sense of relief flooded over me; it was only the family. The old man was still dead.

I put my hand on the small of Jan's back; her soft warm skin demanded attention, and the graceful curve of her back didn't help me think how to ask the family for an autopsy. Finding my white shirt was easy, but the stethoscope eluded me until I stepped on it as I was putting the shirt on.

"Jan, I've got to run over to the hospital. I'll be right back, I hope."

Blinking, I stepped from the warmth of the room into the fluorescence of the hall, on my way to face the trial of the maroon elevator.

There is something ominous about the darkness and silence of a hospital asleep. By now it was ten-thirty, and the ward had slipped into the night routine, a kind of half life made up of soft lights and muted voices. I walked down the long hall toward the nurses' station, past rooms marked only by the flow of night lights. At the other end, I could see two nurses talking, although no sound reached me. The hall seemed especially long this time, like a tunnel, and the light at the end reminded me of a Rembrandt painting, sharply bright areas surrounded by burnt umber. I knew that the calm could be shattered at any moment, driving me forward to face some new crisis, but for the moment that world stood still.

Autopsy. I had to ask for an autopsy. I remembered my first one, in the second year of medical school at the beginning of our pathology course, when I still thought medicine made everybody well. "File in here, men, and group yourselves around the table." We had all looked the same in our white coats, marching in like well-behaved school children, which I suppose we were. And then I had seen her, not the one we were there to see, but another one, on the next slab, who was next in line to be autopsied. Her skin was a cold yellow gray, with a pox of herpes zoster extending from the right arm over the breast to the midline. Herpes zoster is a very serious and vivid skin disorder characterized by large crusted lesions. Its visual effect had been doubly startling in those surroundings. The woman lay on a cement table amid a thousand foul stains. Water flowed under and around her down longitudinal channels about three inches apart, falling into a drain at the base with an obscene sucking noise. Some scratchy pencil marks had been made on a manila tag tied around her right arm. Her hair looked brittle. But the thing that had bothered me most was the sickly color of her skin. About thirty, not much older than I am, I had thought. The sight had made me feel not physically ill, as a few of the med students did, but somehow mentally bankrupt.

She was undeniably dead, really dead, and yet she looked so alive except for the color. Dead, alive, dead… those words, absolute polarities, had seemed to fuse in my mind. The body I had dissected in first-year anatomy hadn't been anything like this. It had been dead and hadn't even suggested being alive. It's the surroundings that make it bad, I had told myself, the crumbling dirty-gray room and the half-light, itself seeming foul and decayed as it struggled through grimy windows. What the hell do you want, Peters? A velvet bier, candles, and roses?

But that woman wasn't the patient we had come to see. I had pressed in among the white coats grouped around another examining table, and had caught glimpses of fleshy organs and heard gurgling noises as the pathology professor cut away, demonstrating his technique. I hadn't been able to see enough to appreciate the lesson, and, anyway, what had interested me was back over my shoulder. Everybody else had been transfixed by those organs; I couldn't stop looking at the wrong body. I hadn't wanted to touch her, but I had, and finding that she wasn't very cold had only made it worse. I hadn't been shocked anymore, just scared, and not because I had touched her but because she was slapping me in the face with the elementary fact that the difference between life and death was a matter of time and luck. Neither meant anything to her now. Scared, too, because she had been a young woman, perhaps desired and full of possibility, and now she was dead and yellow, lying on a stained cement slab in a dirty subterranean room. It was one thing to deal with sex when it hummed with life, warmth, and vigor. But I couldn't deal with this. My jumbled mind had registered a hundred thoughts; sex had undeniably been among them, my own memories of sexual love.

That had been a long time ago and six thousand miles away. Right now, I had to deal with the skinny old man's autopsy. "The family is over there, Doctor, on the couch," said one of the nurses when I reached the ward reception area. Two people seemed to appear suddenly where none had been before. As we approached each other, the word "autopsy" kept bringing back that brittle hair and herpes zoster. Maybe I should call it a "post-mortem"; sounds better.

"I'm sorry."

"It's all right, we expected it."

"We would like an autopsy." The word came quite naturally, after all.

"All right, it's the least we can do."

The least we can do? It puzzled me that they felt they had to do anything at all. I had felt rotten enough being the one to call them so late at night and say that their father was dead, and now I felt even more guilty asking for the autopsy permission. But apparently they felt guilty, too. Since no one can be blamed for death, everyone shares the guilt. The least we can do? I was making too much of a simple comment. What response had I expected from them? Accusations? Tantrums? Most people, I would learn, are simply struck numb by death and carried along by their ordinary, civil, reflexive behavior.

"We'll take care of the rest of the paper work, Doctor," one of the nurses offered.

"Thank you," I said.

"We appreciate what you've done, Doctor," said the son as I stepped away from the nurses' station.

"You're welcome." Nice people, I thought, walking away, and how lucky for me that they can't read my thoughts. Even now I felt an urge to go groping over the dead man's body for a pulse. If they knew my secret fear, would they be angry or just shocked? Shocked at first, probably, and then angry. But what would they think if their father woke up in the morgue? At that I smiled to myself, for of course hardly anybody gets taken to the morgue nowadays. Most go to a funeral home. Too many TV programs and bad movies. I was a fool, I mused, especially when I was tired, and at this point I was exhausted.

"Doctor, the phone is for you." The voice came after me as I was almost to the end of the dark hall. It must be Jan, I thought, and remembered suddenly how good she had looked standing naked in my room. Her image fused with the autopsy room in medical school, with that yellow body and the herpes zoster on the breast. But the call wasn't from Jan; it was from Ward A — another frantic nurse. Something about somebody's venous pressure going to zero. The skinny old man's son was still standing there. I caught his eye one last time, for an instant, and I suddenly felt proud to be there, and then foolish at my pride. Running the other way down the hall, I thought my situation was anything but glorious.

Venous pressure? My knowledge of it consisted of a dutifully memorized definition: "Venous pressure is the resting pressure in the large veins of the body." Other than that I knew almost nothing. Regardless, I rushed headlong, as if I knew everything. That was my job.

What little courage I had fell away when I saw that the nurses were gathered around Marsha Potts's room. Marsha Potts was the tragedy of the hospital. On rounds the very first day of my internship two weeks ago we had stood in her room as the story unfolded. Ulcer symptoms had bought her into the clinic, and there it had been, big as life, right on the X ray. It always made everybody happy when you could see an ulcer. The radiologist was pleased because he had gotten a good film, and the surgeons were ecstatic, complimenting one another on their diagnostic acumen and sharpening their scalpels. It was a fine time. Usually it was fine for the patient, too, but not for Marsha.

The doctors had performed a gastrectomy, taking out most of her stomach and sealing the end of the small intestine that normally leads out of the stomach. Then they had selected a point a few inches farther down the small intestine and, after making a hole, had sewed it to the little pouch made from the remains of the stomach, thus giving Marsha a new, if somewhat smaller, stomach. This operation, known as a Billroth II, entails an enormous amount of cutting and stitching, and is therefore popular with surgeons.

Marsha had sailed smoothly through it all — at least, everybody had thought so — until the third day, when the connection between intestine and stomach pouch broke down. This had allowed her pancreatic and gastric juices to leak out inside her abdomen, and she began to digest herself. The digestive enzymes literally ate their way up through the incision, and her abdomen became an open draining wound about twelve inches in diameter. The nurses kept it covered with baby food, in the attempt to absorb some of the pancreatic juice and neutralize the enzymes. For weeks now the putrid and penetrating smell had turned everybody's stomach. But for me the worst thing about the case was that I knew I couldn't handle it. No way.

When I entered the small room where she was isolated, the situation was as bad as it could be. Her skin was a terrible jaundiced gray, and her hands were flapping feebly by her sides. The nurse seemed relieved that a doctor had come, but, instead of gaining confidence from that, I could only think, Oh, you silly girl, if you could see into my mind you'd see nothing at all, a big void.

Marsha Potts had apparently suffered total body failure. Leafing through the stacks of charts and laboratory results, I tried to get some hint of what was going on and buy a little time to collect my wits. A large black cockroach clung to the wall over the bed, but I didn't bother it; we'd get it later. It was hard to imagine that life in any form depended on my thoughts.

Yet a bit of information was beginning to drift across my mind. The pulse, yes. I felt for it and found it strong and full, about 72 per minute, almost normal. Good. Now, if the venous pressure had gone to zero while the heart seemed to be working okay, it must mean there wasn't enough blood on the venous side. At least I was thinking. The last thing I wanted to do was remove the bulky, sodden dressing from her abdomen. Drops of perspiration rolled down my face. It was damn hot in here. Blood pressure? The nurse said it was 110/90. How the hell could her blood pressure and pulse be so good without venous pressure? With no venous pressure the heart wouldn't fill, and if it wouldn't fill nothing would come out, hence no blood pressure or pulse. That's how it was supposed to work, but obviously in this case it wasn't. Damn those physiology professors. In the medical-school physiology lab, they had a dog with tubes sticking out of his heart, arteries, and veins. Everything worked perfectly there, as it usually did in the laboratory. When the professors reduced the blood in the dog's heart by dropping the venous pressure, the dog's blood pressure followed suit and fell rapidly. It was automatic and reproducible, as if the dog were a machine.

Marsha Potts was no machine. Still, why couldn't she work like the animals in the laboratory, instead of presenting me with an insoluble, overwhelming mess? I hardly knew where to start my examination. She didn't have any swelling of her skin from fluid retention, except on her backside — the usual place for such edema, as a result of lying in bed too long; Marsha had been flat on her back for about three months. I bent her left hand back, and it jerked forward. Fantastic. She had liver flap. When the liver fails, the patient develops a curious reflex: if you bend the hand back onto the wrist it jerks forward in a flapping movement, like a child waving bye-bye. Experiencing the joy of a positive finding, I looked again at the chart. Liver flap was not listed. I didn't know much about venous pressure, but I could write whole pages about liver flap, which I had found only once before. I tested her other hand, and the reflex worked again. It meant she was in very bad shape. In fact, while I was slipping into an academic appreciation of my diagnosis the woman was dying before my eyes.

In truth, she was already virtually dead; yet, technically, she was still alive. She had friends and a family who thought of her as a living person. But she couldn't talk, and every organ system was failing. Could she think? Probably not. In fact, for just a moment I knew she'd be better off dead, but I pushed the notion roughly away. How can you know someone's better off dead? You can't; if s sheer presumption. Marsha Potts's case was getting physically confusing, too. The woman with the herpes on her breast had looked alive but was in fact dead. The one in front of me in that small hot room was alive, but… What about the intravenous?

"How much IV fluid has she had over the last twenty-four hours?" I asked the nurse.

"If s all here, Doctor, on the input/output sheet. It's been about 4,000 cc."

'Tour thousand!" I tried not to appear surprised, although it seemed a lot to me. "What has it been?"

"Well, mostly saline, but some Isolyte M, too," she answered.

What the hell was Isolyte M? I had never heard of it. Twisting the bottle that was running, I read "Isolyte M" and, twisting it the other way, "Sodium, chloride, potassium, magnesium…" No need to read farther; this was a maintenance solution. The input/output sheet was a jumble of seemingly random figures, but I liked that. Right from the beginning of medical school I had been fascinated by the balance of fluids and electrolytes, so fascinated that I could sometimes worry about the sodium and almost forget the patient. This patient's input seemed to match her output except for what had soaked into that huge dressing covering the wound. A sump suction had been set up to pull fluid from the bottom of her abdominal wound, but it didn't seem very effective. Also, the bland food she was getting probably didn't have much nutritional effect. It was delivered to her stomach by a tube through her nose; since her own digestive juices had formed a fistula, or passage, between the stomach and the colon, the food was actually going directly from the stomach to the large bowel and out the rectum essentially unchanged.

Although she did not appear to be dehydrated, her urine showed obvious evidence of infection, in the form of blood, bile, and small bits of organic matter floating around in the catheter bag. With so much crud in there, the only way to learn if her urine was too concentrated was to test its specific gravity.

"I don't suppose we have a hydrometer on the floor, do we?" The nurse disappeared, only too pleased to be given a task, regardless of its potential merit. I still had no way to explain Marsha's venous pressure. I continued to examine her, looking for some sign of cardiac failure to explain it and finding none at all. Apparently the inevitable was closing in: I would have to look at her wound. "Is this what you mean, Doctor?" The nurse handed me a bottle of papers designed to test urine for sugar.

"No, a hydrometer, a little instrument you float in the urine. It looks like a thermometer." She disappeared again while I looked at the label on the bottle she had given me. Perhaps I'd test the urine for sugar anyhow; no reason not to.

"Is this it, Doctor?"

"That’s the baby." I took the hydrometer and unhooked the catheter bag. Holding my breath to avoid the smell, I poured into a small vial what I guessed would be enough urine to float the hydrometer. Carefully I lowered the instrument into the urine, but I couldn't get a reading. The damn thing kept sticking to the side of the flask rather than floating free as it was supposed to. I held the flask in my left hand and tapped it with the knuckle of my right index finger, trying to free the instrument. I only succeeded in splashing urine on my arm. By adding more urine to the vial, I finally got the hydrometer to bob up and down. The specific gravity was within normal limits — in fact, was absolutely normal — so Marsha wasn't dehydrated. For some reason, medical people shy away from the word "normal" without its qualifiers; if s always "within normal limits" or "essentially normal."

Marsha groaned again. As I drew in a big breath, I was whacked by a symphony of smells in the room. As far back as I could remember, I'd never been able to cope with bad odors. In grammar school, when one of my classmates vomited I had been sure to follow with a sympathetic reflex once the smell reached me. In medical school, despite three masks and all sorts of mental tricks, I had been known to retch in the middle of pathology lab.

Still trying to think of an explanation for Marsha Potts's condition, I wondered if she might have Gram-negative bacteria in her blood stream, perhaps a bacterial infection like pseudomonas, for instance; pseudomonas sometimes leads to a condition called Gram-negative sepsis, which is one of medicine's most terrifying sights. One minute the patient is all right; then a shiver and everything goes to hell. Maybe that could explain the venous-pressure problem. But I saw no sign of sepsis.

Marsha was moaning regularly now, and each moan was like a new indictment passed down against me. Why couldn't I figure this out? Walking around to the other side of the bed, I directed the nurse's attention to the cockroach, which had moved a few feet, down to shoulder height. She jumped and vanished, returning almost instantly with several yards of toilet paper, which made quick work of the bug. A bug like that didn't bother me much — not like the rats in the hospital in New York. The grounds people there had always said they knew about them and were working on the problem, but I had seen them again and again.

Perhaps something was wrong with the three-way stopcock on the intravenous line. When I opened the stopcock to the position for measuring venous pressure, it didn't budge from zero. Flipping it closed again, I filled the column with the IV solution and then connected the column with the patient. The level stayed up for a few seconds before starting to fall rapidly, then slowly, as the nurse said it would, first to 10 cm. and finally to zero. Confusing, especially those three-way stop-cocks. I had never quite gotten them straight, never quite known which knob to turn for what connection.

I asked the nurse for a large syringe full of saline and unhooked the whole tangle of tubing from the catheter going into the femoral vein, just below the groin. Marsha had been sustained intravenously for so long that her arm veins were useless for IV's, and the doctors had begun using her leg veins. To my surprise, no blood from the vein came back up into the catheter tube, even with the pressure of the maintenance solution gone. When I flushed about 10 cc. of saline fluid through the catheter with the syringe, I felt a definite resistance; then suddenly the saline fluid went more easily. As I withdrew the plunger of the syringe, a red streak of blood appeared in the catheter.

Obviously there had been a plug at the end of the catheter inside Marsha's vein, probably a small blood clot, which had acted like a ball valve, allowing the IV maintenance solution to enter but keeping anything from coming back. A venous-pressure reading depended on blood being able to rise through the catheter. All this I told the nurse, but I didn't tell her that the blood clot was now probably in Marsha's lungs. If so, though, it had to be small, thank God.

Hooking up the column once more, I filled it and lined it up with the patient. After I was certain it showed a normal venous pressure and was going to stay there, I restarted the IV.

"I'm sorry, Doctor, I didn't know," the nurse said.

"No need to be sorry, no sweat." I was glad to have solved a problem, even a miniproblem. Considering that I had started with a blank mind, the achievement seemed notable, although the patient was the same. She moaned again, her lips twitching. She was just a shadow of a person, really, and my awareness of her erased the feeling of accomplishment. All I wanted to do now was get out of there, but it was not to be.

"Doctor, as long as you're here, would you mind looking at Mr. Roso? His hiccups are keeping the other patients awake."

As the nurse and I walked down the corridor toward Roso's ward, I thought what an unusual building the hospital was, something entirely new in my experience. Its halls communicated directly with the outside, at least in the old, low section, and grass grew right up to the edge of the hallway. A large monkeypod tree dominated the courtyard, leaning and rustling in the wind. The ground were immaculately manicured and studded with enormous tropical trees. What a difference from other hospitals I'd worked in. There had been one tree on the grounds of my medical school in New York, but it was cut down before I left. The rest was cement and brick, all yellow. But the wreck of them all was Bellevue, where I had done my fourth-year clinical clerkship (working essentially as an intern, although I was officially still a medical student). The halls there were covered with depressing brown paint, everywhere peeling away and so disgusting to touch that we had been careful to walk in the middle, away from the walls. My on-call room had a broken window and uncertain plumbing. It stood on the other side of the hospital from the medical wards, which could be reached only by navigating the respiratory center, where all the TB patients were. During the journey, I had sometimes unconsciously held my breath as I passed through the respiratory ward and so arrived breathless at my destination.

If Dante could have seen Bellevue, he would have given it a prominent place in the Inferno. How I had hated those two months. I saw a movie once that reminded me of Bellevue; it was Kafka's The Trial, and in it characters were forever moving down endless halls. That was Bellevue, endless halls, especially if you were holding your breath. Any window clean enough to see through revealed only another dirty building with more halls. Even an innocent act of nature could be dangerous. I once went into the men's room rather hurriedly, unzipping as I walked through the door, and literally fell into a group of patients who were busily mainlining heroin with hospital syringes. That was the first time patients threatened to kill me, but not the last.

Hawaii was nothing like Bellevue. Here I hadn't been threatened, not yet, anyway, and all the walls were clean and carefully painted, even in the cellar. I had supposed all hospital cellars looked alike, but here they were clean, even bright.

I don't know why TB worried me so much. Part of the irrational in all of us, I suppose, when you decide some things are bad and others won't affect you. After I read about malignant hypertension, I thought I had it every time I got a headache. Maybe TB bothered me because my first patient for physical diagnosis had had TB.

All of us medical students had been listening to each other's chests, which resulted in a lot of laughs and little instruction. Then we had been bussed out to a chronic-disease hospital to listen to patients for the first time. This place was called Goldwater Memorial, and it made Bellevue look like the Waldorf. After drawing a card with someone's name on it, I had approached the man's bed feeling so transparently new that I might have had a sign on my forehead reading "2nd Year Medical Student, 1st Attempt." Everything had gone fine until I listened to his left-costophrenic-angle area from the right side of the bed. Leaning across his chest, I had told him to cough, which he did, directly in my ear, and I could feel it dripping down the side of my head, all those drops of yellow phlegm teeming with antibiotic-resistant tuberculous organisms. Not even a shampoo in the men's room, using liquid soap from the dispenser, had made me feel right. When I got back to my apartment I had had to shampoo again and again, like Lady Macbeth.

So far, I hadn't had to deal with any of this hospital's TB patients. Maybe there weren't any in Hawaii.

My reverie ended. I looked at the nurse who was walking with me to see Roso. She was another of Hawaii's assets, very pretty, with a mixture of Chinese and Hawaiian blood, I guessed, a good slim figure, almond eyes, and beautiful teeth.

"Do you like to surf?" I asked, as we arrived at the door to the men's ward.

"I don't know how," she said softly.

"Do you live close to the hospital?"

"No, I live in Manoa Valley with my parents." That was unfortunate. I wanted to hear her talk, but we were nearing Roso's room.

"Has Roso been vomiting?"

"No, not at all, just hiccuping. I never thought hiccuping could be so bad. He's miserable."

Glancing at my watch before stepping into the ward, I saw it was going on midnight. Even so, I didn't mind seeing Roso. In many ways he was my favorite patient. Small night lights near the floor gave off a suffused glow that seemed to mix with the even sounds of breathing and snoring. Suddenly a sharp hiccup pierced the tranquility, and the snoring went out of phase. I could have found Roso in inky blackness by those hiccups. We had operated on him my second morning as an intern. Actually, "we" is not quite accurate: the chief resident and a second-year resident had done the operating while I stood and held the retractors for three hours. I was the first to admit my ineptitude in the operating room; and the way things were going, my ignorance was secure. Unlike a lot of medical students, who as a rule are eager for surgery, I was short on operating-room experience, mostly because I hadn't wanted it, but also because I had been more interested in the electrolytes and the fluid problems after the operation. This had suited everybody. The other med students didn't dig the chemistry, while I had trouble bringing myself to stand for six hours in the OR watching other people cut and sew. Especially after the scene that took place the second time I had "scrubbed" back in New York.

It was to be a cancer operation, a complete breast removal, or radical mastectomy, as it is called, by the Big Cheese, the World-famous Surgeon himself. Being only a second-year medical student at the time, I had had a lot of misgivings about it, and the fact that everybody seemed a little tense, even the residents, had added to my anxiety. Suddenly the Big Cheese had come striding into the operating room, regally splendid and late as usual. He had fingered a few instruments in the big sterilizer tray, picked the whole thing up, and crashed it to the floor, swearing that they were scratched and bent and totally unacceptable. The noise had scared the anesthesiologist so much that he jumped and knocked the mask right off the patient. I had disappeared, hoping I wouldn't be missed, which was indeed the case.

Eventually, of course, I began to stay through some operations, start to finish, but I have not to this day figured surgeons out. Another of them back there was such a quiet, pleasant fellow until he was in the operating room, where I once saw him hurl a clamp at the resident anesthesiologist because the patient moved. On another occasion, the same man ordered one of the surgical residents out of the OR, claiming he was breathing too heavily. At any rate, so far there hadn't been much incentive for me to spend time in the operating room, and I was pretty green at surgery when my internship started.

Despite my inexperience, I knew the scrub routine, how to wash my hands, holding them just so, how to dry them, and how to put on the gown and gloves; I could even tie a few surgical knots. This had been learned pretty much by trial and error. My first scrub, in third-year med school, had been for a suture job in the emergency-room OR. I had spent the usual ten minutes scrubbing my hands and forearms, and had cleaned my nails with an orange stick before awkwardly donning the gown. I had on the baggy pants, the hat, the mask, the whole works, and the nurse had finally helped me with the rubber gloves. After twenty-five minutes of concentrated effort, at last I was ready to go; my hands were as sterile as a moon rock. Then I had casually picked up a stool and walked over to the patient, thereby contaminating my hands, my gown, everything. The nurse and the resident had laughed hysterically; even the bewildered patient had joined in as I started over from the beginning.

In Roso's case, even from my limited vantage point behind the retractors, I had known that nothing about his ulcer operation was going smoothly. The chief resident kept cursing the poor protoplasm, and I had to agree that Roso's tissue bled easily. Some heavy bleeding started near the pancreas at the bottom of the hole, but the two of them managed to complete the Billroth I, which meant hooking up the stomach and intestine just about the same as they had been before the operation, although minus the ulcer. Then I was supposed to put in Roso's skin sutures. It was no big deal to anyone except me; for me it was everything. I thought about asking one of the residents to put his finger on my first throw of the knot, like tying a Christmas present. It seemed a funny thought for about a second.

Actually, for a procedure so simple, tying that knot had been aggravating as hell. Sutures are often very narrow and difficult to feel through rubber gloves, especially at the tips, where the rubber is thickest and where you need the most sensitivity. I knew I had to tie the knot so that the edges of the wound came together, just kissing, without tension and without causing the skin to roll under. I also felt everyone watching me, judging. Although I knew a lot of things, nothing mattered then except that knot, because the knot is the thing without which an operation falls apart quite literally.

The end of the black silk in my right hand disappeared in the skin on one side of the wound and emerged on the other. I brought it together with the other end of the silk strand, in my left hand, and laid the first throw, tightening it until the edges touched lightly. Now for the next throw. But as soon as I let up on the tension, the wound popped open. I pulled it together again and put down the other throw as fast as I could, hoping somehow to beat the dehiscence — that gapping. The pitiful result left the edges of the wound dangerously far apart. Then, to my dismay, a hand reached out with scissors and cut the knot while partially suppressed giggles bubbled in the background.

Another hand began the suture again, dipping the curved needle easily under the skin to span the incision and come out the other side. I looked up in supplication to heaven; what good was I here when I couldn't even tie a knot?

I had gotten another chance on Roso's second row of stitches, which went in the opposite direction. By the time the second throw went down, the suture was so tight that the skin was bunched up in little ripples and the edges were rolled under from the tension. Out came the scissors again, courtesy of the second-year resident who had snipped through my first knot, and the wound separated with relief. It looked so easy and rhythmical when someone else did it. I had detected a trick here and there, though, a twist after the first throw, for instance. Instead of leaving the suture flat on the first throw, you pulled it back, both strings toward you. But that was only half of it. I tried again, with a little better result, although it was still too tight. At least Roso had been finished, for the time being.

The first suggestion of trouble was the hiccups, which had started about three days after the operation. Coming regularly every eighteen seconds, they were amusing at first. In fact, Roso became a hospital curiosity with his funny, clockwork hiccups. He was only fifty-five, but years in the pineapple fields made him look much older, all stooped and skinny; his pants kept falling off as he plodded through the ward pushing his IV stand. He, too, had run out of arm veins for his IV's and, like Marsha, had a catheter in his right groin. This caused even more trouble. If he tightened the drawstring enough to keep his pants on, his IV stopped. So he had to walk with one hand on the IV pole, the other holding up his pants.

Roso was Filipino, and his English vocabulary was limited to fifty or sixty trenchant words, which he used to convey emotional concepts. "Body no more strong," he would say, and it sufficed, like haiku poetry. I understood him and liked him very much. There was something tremendously noble and courageous about the man. Moreover, I think he liked me, which I realized later was an important part of my effort to keep him alive. When he saw me on morning rounds, Roso would smile broadly despite his hiccups, which made his whole body jump. Anyone could see that he was exhausted. I had tried every remedy I could find in surgical, medical, and pharmacological books, even folk medicine — breathing into a paper bag did not help him. In a more scientific vein, I had had him inhale a jug of 5-per-cent carbon dioxide, with no effect. Amyl nitrite and small doses of Thorazine hadn't worked, either, nor had calcium, which I tried in an attempt to correlate the hiccups with his general hypernervous state; his reflexes were so brisk that when I hit below his knee with my rubber hammer he'd flip his slipper off. My big mistake all along was in not considering the hiccups as symptoms of something deeper. I kept seeing them as an isolated problem, when in sad fact they were just a side effect of the smoldering catastrophe inside.

The next symptomatic hint had occurred when the resident ordered Roso's stomach tube removed and fluids allowed by mouth. Within an hour his stomach blew up to twice its normal size, and he began to vomit. In no way could we have made him more miserable, what with the hiccups, the vomiting, and the lack of sleep; any one of them would have been enough to drive most people crazy, but valiant little Roso would still be there smiling every time I saw him. "Body no more strong," he'd say, always the same words, but carrying a slightly different meaning each time, depending on how he said them. "Body more strong soon"; I began to use his vocabulary in that curious way you do when talking to someone who doesn't speak very good English. You begin to think he'll understand better if you make mistakes, too. During medical school, with Spanish-speaking patients, I'd catch myself saying, "Operation you need inside abdomen." This made no sense, of course, because if the patient understood the words surely he'd understand them in the right order. Mainly we were trying to reach to these people, to connect.

So poor old Roso had been put on intravenous fluid accompanied by constant gastric suction through the tube that disappeared into his nose en route to his stomach. Racked by constant hiccups, he vomited every time we took the tube out, whether we fed him or not. Just a few days earlier the tube had gotten completely clogged up, so that nothing but food stood between Roso and death. When I irrigated the nose tube to relieve the clogging, out had come a glob of material that looked like coffee grounds. It was old blood. It was lucky that I liked balancing fluid and electrolytes, because several times a day I had to figure out how much sodium and chloride were in those fluids that came out of him and replace them, plus the usual maintenance. I even gave him magnesium, on the chance it might help, after I came across an article in the hospital library on magnesium depletion.

But Roso's big problem was inside, beyond my touch. Like Marsha Potts, he was leaking at the anastomosis site, the connection between the small intestine and the stomach pouch, except that in Roso's case the incision hadn't broken down. It was just leaking steadily all inside him, blocking his stomach and causing the hiccups, keeping him on IV fluids, driving his weight down every day so that now it was no more than eighty pounds. Fighting hard against the weight loss, which also meant loss of strength, I found articles about protein solutions and high percentage glucose solutions and tried everything they suggested; still he lost weight, going from merely skinny to the skeletal appearance of clear starvation. And through all this hell he smiled and talked his haiku. I liked him. Moreover, he was my patient, and I'd see him any time he needed me.

"Roso, how you doing?" I asked, looking down at him now. What a sight he was lying there in the gloom, wearing nothing but pajama bottoms, with an IV sticking in his right groin and the tube hanging out his nose. Every eighteen seconds his body twitched with hiccups.

"Doktoor, no more strong, too weak already." He managed that much without hiccuping. We had to do something. I had been plaguing the attending physician, the chief resident, everybody, but to no avail. Wait, they said. I knew we couldn't wait. Roso still trusted me, but his will was wearing out. "Doktoor, I no wanna live no more—" hiccup " — too much." No one had ever said that to me, and it stopped me cold. Although I could understand how he felt, I wouldn't admit to myself that he'd reached this point, because I had seen what happened to patients when they gave up fighting. They died, just drifted away. Something in the human spirit could hold everything together, even in the face of utter physiological collapse, until the spirit gave way and carried the body down with it. Sometimes the despair was so obvious you didn't ask a patient for normal responses, but Roso had spoken it, and that made his case different. I told myself that he just wanted to let me know he was near to giving up but actually hadn't yet.

He desperately needed sleep. Although I could give him that, it was a two-edged sword. Sparine, a potent tranquilizer, would knock him out, anesthetize even the hiccups. But with that tube down his throat he was in constant danger of pneumonia, especially if he was unconscious; without the tube he might vomit, and if he vomited while he was knocked out, he might aspirate.

The Demerol and the skinny old man upstairs still nagged me, too. His relatives had been splendid about everything, never sensing the doubt in me, taking my words at face value, not cringing at the autopsy request. What if I had told them that I only thought their father was dead? How could they know that the difference between life and death was sometimes not black and white, but gray and indistinct? Marsha Potts, for instance: was she alive or someplace in between? I guessed I could call her alive, because if she got better she'd be fine, maybe; on the other hand, she probably wouldn't get better, and at least part of her brain might already be dead. Some of her liver must surely be gone, in order for her to have jaundice and liver flap; her kidneys, too. Again, it wasn't black and white, any more than my decision about Roso and the Sparine. But Roso was in need of a rest, and I had an irresistible urge to do something. That must be a strong human drive, to do something — just as when somebody in a crowd faints, one bystander is sure to run for a glass of water and another always makes a pillow for the head. Both actions are ridiculous in medical terms, but people feel more comfortable to be doing something, even in a situation that calls for a type of action they are not equipped to give.

I had had the same sensation several times. Once, during a high-school football scrimmage, I had been hurled onto a pile-up just as a guy broke his leg with an audible crunch, the leg bending off at an angle below his knee. Although he wasn't in much pain, the rest of us were panic-stricken, and, true to stereotype, I tried to get him to drink some water. I think that at that moment I set out unconsciously on the road to med school. The idea of knowing what to do, of satisfying an urge to act, was overpowering.

So, all right, Peters, now you're a doctor — do something for Roso. Right, the Sparine it would be, and the second I made that decision, the happiness of positive, directed action flooded over me.

"Roso, I make you sleep you feel more strong."

As I sat down at the nurses' station, the almond-eyed nurse slid Roso's chart across to me. She looked even prettier than she had before. "Are you Chinese?" I asked, not looking at her.

"Chinese and Hawaiian. My grandfather on my mother's side was Hawaiian."

I thought it would be fun to get to know her. "How come you live at home?"

No answer to that. Well, the hell with it. I opened the chart to write the Sparine order. Too bad, though. She looked like all the girls I had expected to see under Hawaiian waterfalls. Only I hadn't been outside the hospital long enough at that point to see any waterfalls, and my sex life, if you could call it that, was restricted to Jan. Would she still be there, even at midnight?

I'd better get the hell out of here, I thought, as I wrote "Sparine 100 mg. IM stat," put a marker in the chart to indicate a new order, and tossed it on the counter. Roso would sleep. The last time I gave him 100 mg. he was out for eighteen hours.

"Doctor, as long as you are here" — the fateful, familiar question—'would you mind seeing a man with a cast, and also the quadriplegic?" I knew the quadriplegic, but not the man with the cast.

"What's wrong with the cast?" I asked with some hesitation, fearing a request for a new cast at that hour.

"He says it cuts into his back when he moves."

"And the quadriplegic?"

"He refuses to take his antibiotic."

Actually, I hadn't really wanted an answer to that question. Paralyzed people caused me about as much psychic distress as those with tuberculosis. My mind went back to the most attractive building and the most depressing service in medical school, neurosurgery and neurology. I remembered examining one patient who answered my questions as I stuck him with a pin. He had seemed so normal I almost wondered why he was in the hospital until, when I pricked him again, his eyes suddenly disappeared into his head and the right side of his body stiffened, pushing him onto his left side and nearly, rolling him off the bed. All I could see were the whites of his eyes, and I was as paralyzed as he was, not knowing what the hell to do. There wasn't even the satisfaction of running for a glass of water. The patient was only having a convulsion, but I didn't know that then. He could have been dying, and I would have stood there with my mouth hanging open. No one outside the medical world can know what a crisis like that means to a medical student. You get so gun shy that you try not to be around when something goes wrong.

Neurology students were expected to stand with hands in pockets enjoying the professor's elegant diagnosis: "Some of the spinal pathways cross over before running to the brain. Others don't. If you have a lesion effectively cutting off one side of the spinal cord, the tracts that cross will still work. Here, notice how this patient is able to feel this temperature change but cannot have any proprioceptive sense, because I can move the toe in any direction without his being conscious of it." And so it went.

Everybody had a ball discussing those tricky little temperature fibers crossing over in the ventral white commissure and running up the lateral spinothalamic tract to the posterolateral ventral nucleus of the thalamus. Great arguments erupted over whether fibers were unmyelinated or myelinated. No field of medicine can match neurology for high-flown jargon. Meanwhile, nobody thought much about the patient. Well, you hardly had time, trying to remember all those tracts and nuclei, and besides, you couldn't do anything, anyway.

Perhaps it was this lack of possibility that made paralysis cases so hard for me to handle emotionally. I particularly remembered one neurology case in medical school, although it was not unusual; in fact, it was a fairly typical case. The patient had lain before us in a respirator, his facial muscles moving constantly. Nothing else about him moved: he could control nothing else because the rest of him was a pile of immobile, unfeeling tissue and bone, completely helpless and totally dependent on the respirator for life. The professor had been saying, "You will find this an extremely interesting case, gentlemen, a fracture of the odontoid process, which caused the spinal cord to be severed just at the point where it comes out of the head." The professor was loving it. His diagnostic triumph had been accomplished, he proudly told us, only after a delicate X-ray procedure through the mouth. Then he was off, puffed like a pigeon and virtually cooing, into a long discussion of how the atlas had been dislocated from the axis.

I had not been able to take my eyes off the patient, who was staring fixedly into the mirror just over his head. About my age and a hopeless case. To know that his body and mine were essentially the same, that the only difference was a tiny disconnection deep in his neck and that this fractional difference was total, had made me conscious of my body at that moment as never before, and ashamed of it. Just then I had felt hunger, my fingertips, a backache, sensations he would never have again. I was filled with helpless rage and a kind of heartsickness. Movement is so much a part of living, almost life itself, that from day to day normal people deny this kind of death. Yet here in front of me was death in life, and my mind was screaming at me that my own body hung on the same fragile string that lay broken there under the respirator. Many times since, in the dark moments, I had thought that the morbidity in medicine made it the wrong road for me, but I kept at it. Do other doctors have such doubts?

For now, however, the man with the cast came first; I'd see the quadriplegic later. I got a cutter out of the closet and walked down the hall with the nurse. Turning into the room, we came upon a man in a gigantic spica cast extending from his navel all the way down his right leg to the toes. The left leg was free. That morning, he had fractured his femur about midway between groin and knee, and the cast had been put on right away. As usual on the first day in such a constricting mold, the man was excruciatingly uncomfortable. I found the edge that was bothering him and began to cut pieces away. It would have been quicker with the power cutter from the emergency room, but midnight is the wrong time for a tool that sounds like a chain saw. Besides, the vibration always scared the patient half to death, despite all your assurances that the power cutter vibrated very rapidly and therefore would cut only something stiff, not soft like skin. He would seem to understand until the cutter whined into action, knifing easily through the rock-hard plaster. I finished my cutting, and the fractured-femur case lay back with a sigh of relief, gratefully moving from side to side. "Much better, Doctor. Thank you very much." Simple things like that make you feel good. Of course, anybody off the street could have cut away the offending piece, but no matter. To know that the man would rest easily now somehow justified me and made my being there worth while. I was learning that an intern is not often allowed to make patients more comfortable. He is usually hurting them, sticking needles into them, putting tubes up their noses, coaxing a cough after an operation to force them to fully expand their lungs. That cough is especially hard and painful for chest cases. In chest surgery, it is a common procedure for the surgeon to split the breastbone down the middle, and wire it together again at the end of the operation. Four or five hours later, it was my job to cram a small tube down the patient's windpipe, irritating the membrane to force a full cough. The method was foolproof. Like anyone with something in his trachea, the patient invariably coughed, thinking halfway through that the convulsion would tear him apart, trying to stop but not being able to, and finally subsiding, sweat-soaked and exhausted, as I pulled the tube out. In the long run I had perhaps helped the patient avoid pneumonia or worse, but in the short run I had put him through hell. So making the man with the cast more comfortable was not to be lightly regarded.

My euphoria didn't last long, however, for now I had to face the quadriplegic. Completely paralyzed from the neck down, he lay in a Striker frame on his stomach. A stream of anguished profanity poured out of him. A tube twisting out from underneath his body was connected to a dear plastic bag half full of urine. Urine was always a big problem in these cases. Since a paralyzed patient loses control of his bladder, he requires a catheter; with the catheter comes infection. Most cases of Gram-negative sepsis that I had seen came from urinary-tract infections. Criminal abortions were the not-so-rare exceptions. At the end of my gynecology service in third-year med school, we had so many septic criminal abortions that an epidemic seemed to be sweeping New York. Young girls, mostly, who generally waited until the infection was roaring before they came in, and even then they gave us no help with the diagnosis. Never. Some of them died denying the abortion right up to the end. With the legalization of abortion, I suppose the picture has changed, but many times back then I saw Gram-negative sepsis set in, with the irreversible combination of zero blood pressure, failing kidneys, and dying liver. Those Gram-negative bacteria like the urine, especially after a patient has been taking the usual antibiotics.

Looking at this fellow as he lay there crying and cursing, I knew all those things. Figuratively, I had my hands in my pockets, not knowing what to say or do. What would I want if I were twenty and lying in that contraption with everybody saying take it easy, you'll be all right, and knowing it was a lie? I thought maybe I'd like someone strong, who wasn't trying to fool me, who acknowledged the bald truth. So in an effort to be firm, I told him he had to take the antibiotic, that we knew it was tough, but still he had to take it. He had to take the responsibility of being human.

Sometimes we surprise ourselves, talking out of unknown places inside us. I didn't know whether I believed what I was saying or not, but out it came. While I stood there the boy stopped crying long enough for the nurse to give him the injection. It suddenly became important for me to know whether he was relieved or only furious, but I couldn't see his face, and he didn't say anything. Neither did I. The nurse broke the silence and told him to try to get some sleep. Since I couldn't think of anything to say, I put my hand softly on his shoulder, wondering if he could feel my touch and my sorrow.

I knew I had to get away from the ward now or collapse. At any time, in any hospital, a thousand small chores are there to be done, like looking at someone's drain, checking an incision, responding to a complaint about a stiff neck, restarting an intravenous. Actually, the nurses in Hawaii were pretty good about starting IV's; back in medical school it had been a primary job for the student. Neither rain nor snow could spare us from being called at three-thirty in the morning to trudge off across the deserted New York streets to restart an IV. One winter night I had braved the elements only to be confronted by a veinless man. I had poked and cursed, and finally started an infant scalp-vein needle on the back of his hand. Then back through the rain, eventually sliding into my bed after being up for more than an hour, whereupon the phone rang again. It was the same nurse, half apologetic and half aggressively defensive. While putting on some more tape to reinforce the IV, she had accidentally cut the tubing.

In any case, there is always a lot to be done on any ward. Although the nurses will normally cope, if a doctor is around he's sure to be kept busy, and I was fading fast. There was only one job I wanted to do before going back to my room — to see Mrs. Takura in intensive care. I hoped that Jan had had enough sense to crawl under the covers before going to sleep. It was well after midnight.

We never called the intensive care unit by its full name, just ICU. Of all the names, initials, abbreviations, and jargon an intern hears, none can make him jump like ICU, because this is where the action is, a room in perpetual crisis. The chances of being called to the ICU at least twice a night were very high, and the chances of not knowing what to do were impossibly higher. That the nurses were efficient and knowledgeable only made it worse. You began to wonder what you had learned during those four expensive years of medical school. Schwartzman reaction, that's what we had learned. Two lectures on that, and no one was even sure it existed. Something's screwy when a doctor knows all about a disease that might not exist, but less than the nurse about any ICU situation. Of course, if the patient happened to have a Schwartzman reaction, I'd be an instant success: I could discourse at length on what the distal convoluted tubule of the kidney would look like under a light microscope, among other things. As for practical measures, however, we hadn't had time in medical school, nor had the pathologist cared, a fact that truly bugged me. The nurses had mostly carried bedpans through their three years of training. That's not fair, I realize, but, still, their training was trivial compared to the stacks of mechanism, enzymes, and Schwartzman reactions we had to memorize. Yet in the ICU I might as well have been carrying the bedpans. I often felt I'd better get the hell out of there before something happened that required an intelligent response.

An intern is supposed to pick up the practical stuff as he goes along, but if he got more of it in medical school he'd be a lot better off and so would the patients. In a working hospital nobody cares what you know about the Schwartzman reaction. The surgeon looks at your knots. "Weak," he says, "awfully weak." The nurse wants to know how much isuprel to put into 500 cc. of dextrose and water. "Well, how much have you been using on this patient?" "Usually 0.5 mg." "Hmmm, that should be okay." You don't have the guts to ask whether isuprel is the same as isoprotemol. Would she like to know about the thalamic radiations of the ventral nuclei of the cerebellum? No, and rightly, for it wouldn't help a single person in the ICU. What a way to live.

These thoughts were very much with me as I walked through the swinging doors of the ICU, as usual hesitating in wonderment at this strange mixture of science fiction and stark reality. Weird instruments hung from the walls and ceiling, adorned with their thousand buttons and switches and oscilloscope screens. Sonarlike beeps mingled symphonically with the rhythmic dick-clack of the respirators and the muffled sobs of a mother hunched over a bed in one corner. Moving and flickering as they stood guard over life, these machines often seemed more alive than the patients, who lay immobile, covered with bulky mummy like dressings and connected by plastic tubes to dusters of bottles that hung from the tops of poles. The mixture formed an alien and mysterious environment.

Nonmedical people react strongly to the ICU. It is the solid, physical incarnation of their fears about death and of the hospital as a place of death. Cancer, for instance, is certainly the most feared disease of our time, but unless you are the victim or a close relative or friend, it hardly exists outside hospitals. In the ICU, cancer hangs in the air like a sickening, primeval smog. If you work there a lot, you can easily forget that the hospital is a place where life begins as well as ends. But babies are not born in this room, and most people, with reason, associate it with the ominous, the unknown, and the final, where life hangs by its fingertips.

Although the normal human being does not enjoy a visit to the hospital, once he is in the ICU it holds him with its magnetic fascination, despite the morbidity, or perhaps because of it. His eyes dart around absorbing the fantasy, building monuments in imagination to the abstract power of medicine. Medicine must be powerful indeed, with all those machines. Otherwise, why have them? An observer, however, always senses the undercurrent of fear that mingles with the visitor's respectful awe, catching him in the conflict of wanting to be there and wanting to flee at the same time.

I felt the same ambivalence, for a different reason. I knew that most of the machines did almost nothing. Some of the smallest ones, though unimpressive to look at, did all the work. Those little green respirators, for insistence, clicking and clacking as they breathed for the people who needed them, were worth all the others put together. The complicated ones, with their screens and electronic blips, were not doing anything unless they were being watched. Medical school had taught me how to read these oscilloscopes. I knew that an upward sweep on the screen indicated millions of sodium ions rushing into the muscle cells of the heart. Then came a bump on the screen as the cells contracted while the cytoplasmic organelles worked like crazy to pump the ions back into the extracellular fluid. Fantastic to think about; but this scientific wizardry was only half the job. On the basis of these curves and sweeps, a doctor still had to make the diagnosis and then a prescription. That’s what pulled me apart, wanting to be there because I could learn a lot in a short time, yet always terrified that I wouldn't know what to do when total responsibility fell on me because I was the only doctor around.

In fact, my fear had already been justified several times — for instance, during my first night on call as an intern, when I was paged to deal with a hemorrhage in the ICU. Rushing upstairs, I had reassured myself with the fact that localized pressure would stop any bleeding. Then, entering the room, I had seen him and stopped in my tracks. Blood was pouring out of both sides of his mouth, drowning him in a red river, a continual bloody gush. It wasn't vomitus; it was pure blood. Terrified, I had just stood there watching, dumfounded, while his eyes pleaded for help. Later I was told that nothing could have been done. The cancer had eaten through the pulmonary vein. But all that mattered to me was that I had been lost, empty-headed, and immobilized. For nights afterward I had relived that scene, and now I had an obsession about being able to do something, even if it wouldn't help the patient.

Mrs. Takura was propped up in a corner bed. She was almost eighty, and her head was wreathed with fine white hair. A Sengstaken tube hung out of her left nostril, firmly held by a piece of sponge rubber that wrinkled and distorted her nose. A few drops of blood had dried in one corner of her mouth. The Sengstaken tube is about a quarter of an inch in diameter, and it is a rough one. Inside this large tube are three smaller ones, called "lumens." Two of the lumens have balloons attached, one inside the tube in a short lumen and one on the end in a long lumen. In order for the Sengstaken tube to work, the patient must swallow all this apparatus, never an easy task, and especially hard when the patient is vomiting blood, as is usually the case. Once the tube is down, the balloon on the bottom of the tube, in the stomach, is inflated to roughly the size of a large orange; this anchors everything in place. About halfway up is the second balloon; when inflated it takes the shape of a hot dog nestling inside the lower esophagus. The third lumen, small but long, simply dangles in the stomach for use in evacuating unwanted fluids, like blood. The point of the whole thing is to stop esophageal bleeding through pressure exerted on the walls of the esophagus by the hot-dog balloon.

Only once before, in medical school, had I treated a patient who needed a Sengstaken tube. His problem was alcoholism, which had caused severe cirrhosis and, eventually, liver failure. Mrs. Takura wasn't an alcoholic, of course — her problem sprang from an earlier case of hepatitis, years before — but their cases had a common aspect. A damaged liver impedes the passage of blood, so that pressure gradually rises in the blood vessels leading to the liver and then backs up, causing the veins to the esophagus to dilate and, in extreme cases, to break. At this point the patient vomits copious amounts of blood. Although I had treated the alcoholic for only a day or two, I vividly remembered trying to help him swallow those balloons. When he couldn't do it he had been taken to surgery, and he never made it back to the ward.

Portal hypertension with bleeding esophageal varices was a serious affair, but so far we had been able to stabilize Mrs. Takura's by getting the tube down her. And she was scheduled to be operated on in eight hours or so.

She didn't look Oriental, despite her name and her abundant good cheer and inner calm, traits that I was beginning to see in all Orientals. Every time we talked she was lucid and alert, knowing just what was happening and speaking very quietly. I think she would have calmly discussed her geraniums in the middle of a typhoon. When she asked me how I was, as she always did, the answer seemed important to her. We got along well. Besides, I thought she would recover. You get that feeling with some patients, just an irrational hunch. Sometimes it works out.

Once, a few hours after her admission, the doctors had tried to remove the Sengstaken tube, but this had resulted in recurrent heavy bleeding and sent her into shock before the tube could be replaced. Since I had been off duty that night, I missed the blood and drama; she did scare me badly the next morning, however, when her blood pressure suddenly dropped to 80/50 and her pulse shot up to 130 per minute. Somehow, I had been collected enough to order and administer more blood, realizing that the steady bleeding had finally affected her pressure. When the blood pressure came up again nicely, my spirits rose with it Cause, effect, cure. This should have given me a bit of lasting confidence, but, curiously, believing that a right decision lay behind every situation only made me more nervous. To give the blood had been a right decision, but a simple one; next time it might be different.

Tonight, Mrs. Takura was pleasant and calm, as usual. I checked her blood pressure and the balloon pressures, and generally messed around trying to justify my being there, although I really only wanted to talk to her. "So, are you ready for your little operation?" "Yes, Doctor, if you are ready, I'm ready." That was a shocker. I felt sure she meant "you" in the collective sense, the whole surgical service. She couldn't have meant me. I was nowhere near being ready, despite the fact that I did know a good bit about the operation, at least the theory of it. I could talk for twenty minutes on portal-pressure gradients, on the various benefits and disadvantages of the surgical approach by forming a portal-vein-to-inferior-venacava anastomosis, end to end or end to side. I could even remember the diagrams of the splenorenal union — that was end to side. The whole idea was to relieve the blood pressure in the esophagus by connecting the liver venous system, where the pressure had risen and caused the bleeding, to a vein where the pressure was still normal, like the interior vena cava, or the left renal vein. Also lodged in my memory were the comparative mortality figures for these various procedures, but I didn't want to think about that. How can you look at a patient and think 20-per-cent mortality?

"We're ready, Mrs. Takura." I leaned hard on the "we," when in fact I wanted to say "they," for I had never even watched one of these operations, called a portal caval shunt. Theoretically, it was fantastic. Nothing excited the professors so much as talking about those pressure changes and hooking up this with that. Once they got started, they particularly enjoyed rattling on about obscure articles written by Harry Byplane of Umpdydump University (Harry was always a very good friend, of course), which showed that some article by George Littlechump at Dumpdydump University had been wrong in assuming the intralobular hepatic vein pressure gradients with the portal interlobular plexus weren't important. That was it right there, the kind of stuff you got a lot of on medical-school ward rounds. To win the game, you had to quote the most obscure article about some pressure gradient (they especially liked pressure or pH gradients) saying that Bobble Jones had shown conclusively (any doubt was disaster) that in a series of seventy-seven patients (an exact number, even if fictional, was necessary), all seventy-seven died if they went to the hospital. It didn't much matter what you said at the end as long as you got in enough numbers and gradients and personal references to the author; then you were golden, and rocketed to the front of the class. That was the big leagues: "Well, Peters, you've really done it now." What about Mrs. Takura? Forget the patient, man, we're talking about hydrogen ions in the blood, that's pH, with a little p and a big H.

I can remember a time we were all clustered around this one bed during medical-school teaching rounds. The short white coats were students, as anyone could tell. The short white coats and white pants marked interns and residents. And then, at the pinnacle, there were those long, heavily starched white coats — a washday dream, they were, so white they made even the bed sheets look gray. Need I say who wore those coats?

Somebody had mentioned the name of the patient's disease, and we were off and running on an intricate discussion of pH, sodium ions, and glucose pumps, with articles from Houston, California, and Sweden. Names flew back and forth in a kind of academic Ping-Pong game. Who would get in the last name, the latest change? We were nearly breathless with anticipation when someone noticed that we were standing by the wrong bed. The patient in front of us did not have the disease under debate. That had ended the game without a winner, and we had quietly moved on to the next bed. What the hell difference it made I couldn't fathom, since we hadn't had time even to look at the patient. Maybe everybody felt shy about discussing one disease in the presence of another.

"Try to get some sleep, Mrs. Takura. Everything will be all right." I glanced over my shoulder to see if the coast was clear. The nurses hadn't paid much attention to me, mostly because they were busy with a man in the opposite corner. He was wired up to an EKG monitor that showed a very irregular heartbeat.

The woman was still sobbing quietly by the bed of her heavily bandaged teen-age boy. He had a head injury, the result of an auto accident; the poor fellow never regained consciousness. I headed for the door, pulled it open, and went out. Day changed to night. The bright lights, the sound of the machines, the bustle of the nurses were suddenly cut off as the door shut behind me.

I was back in the hushed dark air of the hospital corridor. To my left, a nurse sat at her station, her face silhouetted by the light directly in front of her. Everything else melted off into darkness. I turned into a completely black corridor. All I had to do was turn to the right, go down the stairs, and cross the courtyard to my quarters. There was still time to get some sleep.

Suddenly a light flashed behind me, and a voice shouted, "An arrest, Doctor. There's an arrest. Come quickly!" As I turned around, the light evaporated, leaving scintillating blotches in the center of my visual field. Berlin blockade, Cuban missile crisis, Tonkin Gulf: crisis, all right, but not so close together or close to home. To me, this was a red alert, the type of catastrophe I dreaded most. My first thought was that I would be not only the first doctor to arrive, but also, since it was the middle of the night, perhaps the only one. Given a choice, I would have fled in the opposite direction, not worrying whether I was a coward or a realist. But there I was, running toward the patient, almost a cliche of the young intern dashing down a dark corridor with his stethoscope thrashing wildly in his tightly gripped fingers.

You've seen it all on television and movie screens, and it's thrilling — isn't it? — rather like the bugle call and the cavalry charge in the nick of time. But what is he thinking, this intern? It depends on where he's running. If it's pitch-black, he's trying to get there in one piece. Beyond that, it depends on how long he has been an intern. If not long, just a couple of weeks, then he's running scared — terrified, to be more exact. He doesn't want to be the first person to arrive.

Now he's there, a little out of breath but physically intact. His mind is another thing; what little information he owned appropriate to the situation has suddenly been drained out of his cerebrum by the shock of responsibility. Don't bother to learn drug names or dosages, the pharmacology professors insisted, just learn concepts. How do you tell a nurse to draw up 10 cc. of concept for a dying patient?

As I pushed open the ICU door, the weird world enveloped me again, and of course I found myself the only doctor there, quite alone with two nurses beside the bed of the man with the irregular EKG. While my mouth formed an inaudible obscenity, my fingers involuntarily clutched the side railing of the bed as if using it for support. I was no longer the television intern, but a real one, complete with inexperience and terror. Who would support me if this man died? The nurses? The medical-school professors? The attendings? The hospital? Most important, I had not yet learned to forgive my own mistakes.

Looking back at the door, I hoped against the odds that a resident would suddenly appear; it came home to me why many brilliant and dedicated students go all the way through medical school and then, facing internship, change course and switch to research or some paramedical field. Anything must be better than internship. Something's wrong here. Why can't the intern know something useful when he runs into the ICU during the first couple of weeks? And why don't the attendings back him up? Even the helpful ones are mostly no better than quietly aggressive. They seem to be saying, "We waded through all this shit. Now, goddamn it, you do it, too."

Well, I was doing it, here and now in the ICU, with no chance of any help, but this time I got lucky. The EKG monitor displayed on the oscilloscope showed a wildly erratic electrical impulse, like the scribbles of an irritated child. As its beeping sound rose higher and higher, to an extremely rapid staccato, I realized that the patient had slipped into ventricular fibrillation; his heart muscle was just a quivering, uncoordinated mass. Now I knew what to do; I would "shock" him.

Actually, the decision was not so much mine as the nurses'. Always a step ahead, they had the defibrillator charged up and one of them was holding the greased paddles out to me.

"What's it charged to?" I asked, not really caring, but needing the control the question gave me.

"Full charge," answered the nurse with the paddles.

I put one of them on his chest, right over the sternum, and the other along the left side of the thorax. Oddly, he hadn't stopped breathing completely. Nor was he unconscious. The only sign of distress besides his gasping respiration was a sort of dazed look, as if the breath had been knocked out of him.

I pressed the button on top of the paddle handle. His whole body stiffened violently, and his hands shot into the air and down. The EKG blip was driven off the oscilloscope screen by the sudden tremendous electrical discharge, but it came right back, looking normal. I was reassured when the beep reappeared, too, suggesting a normal pulse rate, and the man took a deep breath. Everything seemed fine for about ten seconds. Then he stopped breathing, and right away the pulses went to zero, while the EKG continued along with the blip at a normal rate. That was crazy. EKG blips and no pulses was a combination not in the textbooks. My mind played a huge indoor tennis match, with concepts flying back and forth— electrical activity, electrical activity, but no beat, no pulse. "Get a laryngoscope and an endotracheal tube." One of the nurses already had them in her hands. He had to have oxygen. Oxygen and carbon dioxide had to move, and for that we had to insert an endotracheal tube and breathe for him.

The tube is put down by means of a long, thin flashlight affair called a laryngoscope. This instrument has a blade on the end of it, six inches or so long, that is used to raise the base of the tongue and bring into view the entrance to the trachea, where the tube must go. As the blade slides into the throat, you try to locate the lid that covers the trachea during swallowing — the epiglottis. All this time you are standing behind the patient, pulling his head far back, fighting through extraneous material like blood, mucus, or vomitus. Once you see the epiglottis, you slide the instrument past it, down a little farther, and pull up. With luck, you'll then be looking past the trachea at the vocal cords, which are creamy white, in contrast to the red mucosa of the pharynx.

That’s the ideal situation. In practice, you must often push this way and that on the throat with your free hand, looking for the trachea, and sometimes you never do find it. And even when you do, your troubles are still not over, because sliding the tube down can be devilishly hard. The precious hole between the vocal cords will be obscured at the last second by the rubber tube. Nothing to do but push it in blind. Too often your dead reckoning leads the tube into the esophagus, so that when you try to ventilate the patient — force air into him — his stomach blows up instead of his lungs. And all the while there is usually someone else pounding on the man's chest, and the laryngoscope is clanking against his teeth or jumping out of his mouth, and the whole area may be filling rapidly with fluid of one sort or another. Putting down an endotracheal tube was, to me, a subject fit for nightmares.

But there was no one else around to do it, so I pulled the man's bed out and got behind his head with the laryngoscope. "What's his basic problem?" I asked hastily, pulling his head back.

"He doesn't follow his pacemaker all the time," one of the nurses said.

Suddenly it made more sense. "What’s he been on? What's in that bottle?" I said, motioning to the IV bottle. "Isuprel," came the answer, and I told them to speed it up. I knew that Isuprel helped the heart with its contraction and was especially useful in cases where the heart wouldn't contract on its own.

"How fast?"

How fast? I hadn't the slightest idea. "Let it run." I couldn't think of anything better to say. His head was back now, and the laryngoscope far down into his throat, but I couldn't see the vocal cords. "Get me an amp. of bicarbonate." As one of the nurses vanished from the periphery of my vision, I realized that at last I had thought of something on my own. Then the vocal cords appeared. Their white contours stood out against the surrounding red like the gates to a subterranean chamber. For once I managed to get the tube into the trachea without too much of a struggle.

But no sooner had I slipped the tube in than the patient reached up and pulled it out. I was indignant, just for a second, until I realized he was breathing again. A strong, full pulse showed in his wrist. The nurse appeared with the bicarbonate. Stupidly, I wanted to give that stuff now, because I had thought about it and the nurses hadn't, and especially because I knew a lot about electrolytes and pH and ions. But I wondered what the effect would be on the calcium level. Both calcium and potassium combined with the pH in a tricky fashion. I was in danger of overthinking and getting all balled up, so I decided to save the bicarbonate; no sense rocking the boat.

Suddenly an anesthetist burst panting through the door, and another intern, followed by a resident, and another resident. All of them looked sleepy. One had no socks on, and there were pillow creases on the side of his head. The crowd continued to swell as another resident rushed in. This was about the time I liked to arrive, when everything was under control and decisions could be by committee. Actually, I was beginning to calm down, although my own pulse was still racing. The newly arrived house staff settled down on the counter and chairs. One of them leafed through the chart, while another called the private attending. I stayed beside the patient, who had started to talk. His name was Smith.

"Thank you Doctor. I'm all right now, I think."

"Yes, all your signs are good. We're glad we could help you." Our eyes locked, his showing more trust than I thought I deserved, and mine trying not to give away my inner uncertainty. The Isuprel was still running into him like crazy, and I didn't know whether to slow it down or not. Let the others carry the ball for a while. Mr. Smith wanted to talk.

"This is the third time for me, I mean the third time my heart has decided not to follow my pacemaker. When it happens, I don't have time to think, but afterward, like now, it all falls into a pattern. First, my throat tightens up, and then suddenly I can't breathe, nothing at all, and then everything goes gray and shadowy." I was listening hard, but only half comprehending. It was incredible to be talking with him when a few minutes ago he hadn't been there.

"A shadow, that's the best word I can think of, but the shadow doesn't pass. It goes deeper into blackness, until no light is left in the world." He stopped abruptly. "But do you know the worst part, Doctor?" I shook my head, not wanting to interrupt him. "The worst part is coming out of it, because it happens so slowly; not like going down, which is quick. First, I have these wild, chaotic dreams. No sense to them that I can find, until finally — it seems forever — the room and the bed and the people come into the dream and eventually take over. I can't explain why, but the last thing to come back is an awareness of myself, who and where I am, and the hurt. My chest feels caved in, as if I'm smothering from lack of air, especially if there's a tube in my throat."

"That must be why you pulled the tube out. Have you had many operations?" I asked.

"Enough to fill a book. Appendix, gall bladder…"

I interrupted him. "Do you remember what it was like to be put under anesthesia? Have you ever had ether?" That was one experience I remembered vividly, although it was a long time ago, when I was four or five. Back then, everybody had his tonsils out, and I remembered my terror as the ether mask was put over my face, the room began to fade, and an unbearable buzzing sounded in my ears. Then concentric circles moving faster and faster until they collapsed into a bright red center; then nothing, until I awoke vomiting.

"My appendectomy was in 1944," said Mr. Smith, thinking back, "while I was in the Navy, and I believe it was ether."

"Was that anything like the feeling you get when your heart stops? What about waking up?"

"No, not at all. The anesthesia is somehow pleasant, nothing like struggling with my heart — it seems literally like a struggle to keep it from jumping out of my chest, keep it under control. I can't remember waking up from those operations, but when my heart starts up again it is like a thousand unending nightmares."

He reached up and touched my hand, which rested on the bed railing. "God, I hope it doesn't happen again. You see, I can't be sure anybody will be there to help. You know, Doctor, there's another strange thing — this time I felt I was watching my own body from someplace outside of myself, as if I was standing at the foot of my own bed."

"Have you had that feeling before?" I asked, curious now; feeling outside oneself is a symptom of schizophrenia.

"Never. It was a unique sensation."

A unique sensation. A unique sensation. This man was telling me about dying, but the way he told it made death into a living process, something you could study in a textbook. Without that defibrillator, of course, he would have been dead, and with him all those thoughts. Tonight the line between life and death had hardly existed for three people — for him, for Marsha Potts, and for the old man with cancer. I was having trouble thinking about life and death at the same time, but I was happy this man wasn't dead, because he was so nice. What a stupid thought. Anyway, I couldn't imagine him dead. No matter what had happened he wouldn't have died, because he was alive right at that moment.

Does that make sense? It did to me. Who was I to think that I could have changed fate? Being alive and talking and thinking is so different from being dead and immobile that the transition seemed impossible now. It had been so simple, just a zap with the defibrillator, like slapping someone on the back to stop a cough, or running for a glass of water. Maybe he hadn't been fibrillating; maybe he would have come out of it on his own. He had before. I would never know.

The medical resident and another intern were still there, talking and adjusting the plastic tubes, scratching their heads and holding the EKG strips. They seemed happy and involved. As I went out I looked over at Mrs. Takura, who smiled broadly and waved with her free hand.

The strange nether world of the ICU vanished again as I turned down the corridor and descended the stairs. All of life seemed asleep. I thought of those nights in medical school back east when I had struggled to my apartment from the hospital through all that winter had to offer. Ironically, calm, star-filled nights like this one were even harder, so lonely you wanted to swear. In Hawaii almost every night was clear, blazing with thousands of stars and cooled by a gentle wind.

The thought of Jan back in my room kept me going. At times like this, when the medical tensions were beginning to evaporate, all I could think about was escaping the loneliness, being near someone alive and healthy, talking to her and loving her. A few times in medical school a girl had waited in my room while I went off to do something. That had always made it nice to come back. But too often she would just grunt a little in her sleep as I slid in beside her.

That "something" my medical-school peers and I found ourselves doing at odd hours of the morning was almost always a lab routine. The need for blood counts and Bence-Jones protein analyses seemed to occur to the residents primarily after midnight. So hundreds of times we had ended up spending the wee hours in what you might call the bowels of the medical ship, counting tiny blood cells, which grew even tinier with the passage of time. Meanwhile, the resident on the bridge was steering the patient through, frequently complaining about the slowness of his blood counters in the hold. The truth about blood counts is that if you've done one you've pretty much done them all. The point of diminishing returns on the learning curve is reached quickly, particularly at 3:00 a.m., when your mind tends to dwell on getting back to your room and, perhaps, to the young lady.

In one twenty-four-hour period I had done twenty-seven blood counts, a personal record, though by no means a hospital record. My last few, in the small hours, were, of course, no better than half-educated guesses. Thus it went in the big leagues, where you were trained for a cost of $4,000 a year, to be a lab technician. All of us had worked up fantastic scenarios wherein we threw the urine in the resident's face and told him to jam the bottle up his ass, or we went on a sit-down strike in the cafeteria. None of these scenes existed outside our imaginations, because, to tell the truth, we were quite intimidated. As the professors never tired of pointing out, others were standing in line to wear our little white coats. What, in fact, happened was that late at night, when you felt pissed off and exploited, you cut a comer here and there and invented a plausible result. But this happened infrequently, and only late a night.

But worst of all was later, not having anyone to listen. The whole world seemed asleep and quite indifferent to your conviction that medical education was shitty and irrelevant. So you hurried back to your room, to the sleepy girl, grateful, finally, for her warm body.

Quite a few students got married at the beginning of medical school. I suppose they were not so lonely, having the omni-present warm body. And the first two years were fine — courses during the day and hitting the books at night. They probably had a ball. But it was different when the blood counts came those last two years, and all the other Mickey Mouse in the middle of the night. Gradually, I think, some just gave up trying to communicate the frustration. The warm body wasn't enough. In any case, a lot of them weren't married any more when we finally got that piece of paper saying we were Doctors of Medicine. Actually, we had been champion blood counters, Doctors of Concept and Laboratory Trivia. Not one of us had known what dose of isuprel would save a life.

When I opened my door, I couldn't decide whether to make a lot of noise or be quiet. The kinder instincts won, and as the light from the hall flooded in I quickly rolled around the door and shut it. I took off my shoes. The room was perfectly silent, and so dark after the fluorescent lighting in the hall that I couldn't have moved around without knowing the position of the furniture. Some furniture! Of course, the hospital bed I slept on did have interesting characteristics. It could be cranked up into such a comfortable position for reading textbooks that I never managed to get through more than one or two paragraphs before falling asleep.

The rest of the furniture included an easy chair as hard as stone, a bookcase, and a desk designed for a small child. If I put both elbows on it, there was no room for the book, especially one of those five-pound, thirty-five-dollar jobs so popular with today's medical publishers. As I moved about in the dark, the only potentially serious obstacle was the surfboard I had hung from the ceiling. Gradually, as my sight adjusted, I could see the outline of the window and the bed, and I put my hand down on the covers, running it back and forth, faster each time, until I was sure she had left. Sitting on the edge of the bed, I rationalized that I was exhausted anyway, and she probably wouldn't have wanted to talk. It was past two, and I was exhausted; I really was.

The phone rang three more times before morning. The first two weren't important enough for me to go, just nurses with questions about some order and about a patient who wanted a laxative. On the matter of laxatives, I have made a small independent study. The study proves conclusively that five out of six nurses are ten times more likely to ask for a laxative order between midnight and 6:00 a.m. than at any other time of the day. As for the reasons, they are difficult to figure out, hinging perhaps on a Freudian interpretation of the nursing profession's anal hang-ups. In any case, I felt it was a near-criminal act to wake me up for a laxative order.

Each time the phone rang, I'd sit bolt upright as a shot of adrenaline whizzed through my veins. By the time I got the phone to my ear, my heart was pounding. Even if I didn't have to leave my room, it would take me about thirty minutes after each call before I calmed down enough to fall back to sleep. On an earlier evening, answering from a dead sleep, all I could hear was distant mumbling. "Speak louder," I had shouted, closing my eyes tightly and concentrating, barely able to make out the remote words. They had been telling me that I was speaking into the wrong end of the telephone.

The third call was at the opposite end of the spectrum from my fear of not knowing what to do. I could handle it for sure; so could a four-year-old child. Mrs. So-and-So had "fallen" out of bed. Patients don't usually hurt themselves falling out of bed — they're too loose, and, besides, the nurses know what to do. None of that mattered to the hospital administration. As long as they "fell" out of bed, the intern had to go say hello, no matter what time it was.

So I got up feeling — how to explain it? — well, if s not nausea, although you feel sick to your stomach, and if s not a high fever, though your forehead would fry an egg. The best nomenclature is a description. You feel just as you might expect to feel at being startled awake at 4:00 a.m. after about two hours' sleep during which you were awakened each time you sank off — having finally lain down after working for almost twenty hours, emotionally exhausted, physically, too — to hold the hand of someone who "fell" out of bed unhurt. Actually, most of them just sank to the floor on the way to the bathroom. But regardless of how they got there, even if they were twenty feet from the bed, the nurses always called it a fall, and up you went, in the observance of an absurd legality.

This formalism is even more absurd when one realizes that a hospital is otherwise dependent upon these same nurses to determine a patient's physical state and to call the doctor if need be. But for some inexplicable reason they cannot be depended upon to see if a patient has hurt himself sinking to the floor. Yet if s more, more than something useless and arbitrary you must do. About half your time since third-year medical school has been spent in pursuit of the useless and the arbitrary, which are justified by the diaphanous explanation that they are a necessary part of being a medical student or intern and becoming a doctor. Bullshit. This sort of thing is simply hazing and harassment, a kind of initiation rite into the American Medical Association. The system works, too; God, how it works! Behold the medical profession, molded to perfection, brainwashed, narrowly programmed, right wing in its politics, and fully dedicated to the pursuit of money.

These thoughts rumbled chaotically through my head as I went to the elevator and hit the button hard, half hoping to break the whole contraption. Returning to the hospital, down those sleepy corridors toward distant points of light, I tried not to wake up completely.

I once told a friend who was not in medicine the various reasons I got called out of my bed at 4:30 a.m. He didn't believe them. It was too disquieting for him; it shattered his colorful image of the intern awakened suddenly, all eager in white, flashing down the corridors, up the stairs by threes and fours, to save a life. Here was the real me, feeling shitty and stumbling down a hall swearing under my breath, on my way to say, How are you, patient?… Fine, Doctor… That's wonderful…Have a good rest, and please don't fall out of bed again.

When the phone rang again it was daylight, five-forty-five. Feet over onto the floor, sit up sideways, use my hands to push up. That slightly sick feeling again, and a momentary dizziness until the cold floor knocks it out of me. Over to the sink, hands on its sides, lean on it for a second. In the mirror my eyes are like aerial views of hot lava running into a muddy lake. The only reason the bags under them don't meet the corners of my mouth is that I can't smile. Ah, a trickle of water meanders out of the faucet. Holding on with one hand, I raise a few drops to my face.

Nothing about this morning was particularly noteworthy or different. It was just a morning, like other mornings. In two weeks I had worked up such a deficit of sleep that even when I did get six hours straight I felt the same way. The razor blade, much sharper than I was, left several points of blood on my throat. Mixing with the water on my face, it seemed like a lot of blood and, combined with my eyes and the dark under them, made me look like a Mafia heavy.

After thirty seconds or so I felt together enough to dress. Stethoscope, little flashlight, several different-colored pens, notebook, comb, watch, wallet, belt, shoes — on through the mental check list. Make sure socks are the same color. Mustn't spoil the tone of the place. One last visual sweep around the room to make sure there wasn't something else, some piece of paper, a book. Satisfied, I left, descended in the elevator, and stepped out into the morning air.

It had always been a point with me to walk around in front of the hospital on my way to the cafeteria. Somehow it lifted my spirits. This morning the sky was a pale faraway blue dotted with small clouds, half bathed in the east in golden tones of red; toward the west the colors faded off into pink and violet. The grass sparkled, still damp from the night air, even the trees sparkled, and birds were everywhere, producing an incredible din. Two types of birds predominated, the mynas, who strutted about gesturing awkwardly and making unharmonious, scolding squawks, and the less noticeable doves, moving more slowly, almost politely, some of them seeming to bob up and down as they fanned out their tail feathers and cooed in melodious voices. I liked that short morning walk. It was only a few hundred feet, but it made me feel happy.

Six o'clock in the morning is not my idea of the perfect time for a big breakfast, particularly after a sleepless night. But I forced myself to eat, stuffing the food into my mouth and relying heavily on water to take it down. By experience, I knew that if I didn't eat I'd be hungry in an hour or so, when it would be impossible to get food. Besides, I missed lunch about half the time because of the operating schedule. Another meal might not come my way for eight or ten hours.

After breakfast, I had about thirty minutes to see my patients before rounds started at six-forty-five. It was important to have everything in order before then, to know all the latest changes. The ICU was first. I never minded going there in the morning, or anytime during daylight, for that matter. Having other doctors around diminished that feeling of being alone on a high wire. Mrs. Takura was sleeping peacefully after her preoperative medication; the tube hung still in her nostril, wrinkling her nose from the tension. Pulse, urine output, blood pressure, breathing rate, temperature, electrolytes, BUN, protime, proteins, bilirubin… all the recent tests were back and recorded. Pausing to write a note about her status in the continuation sheet, I hoped she was ready.

Back in one corner Mr. Smith's machines were still beeping away, showing an EKG that looked pretty normal, although I was no ace at reading them, especially from the oscilloscope. He was sleeping, too. I went down to the wards.

On the ward, the name of the game was numbers and variety rather than crisis. I had several dozen patients, representing as many different types of people and problems. Most of them had had their surgery and were progressing well at various stages from postoperative, through having stitches out, to discharge. The length of their drains was usually a good indication of how many days had elapsed since they'd left the operating table. Drains are a somewhat awkward but quite necessary part of surgical practice. Planted deep with the wound at the end of the operation, they serve as an outlet for any unwanted fluid and help to keep down infection. The idea is to pull the drain out, inch by inch, beginning on the second postoperative day, thereby letting the wound heal slowly from the inside out.

Patients never understand these drains. To them, the dangling pieces of pale rubber are a source of endless conversation and discomfort, mostly mental. Mr. Sperry was two days postoperative for gastric ulcer, and it was time to begin pulling his drain. Grabbing it with a clamp, I gave the tube a good tug. But it held fast, just stretching a bit, so that it looked somewhat like a Chinese noodle. From his sitting position, propped up on two pillows, Mr. Sperry watched in dismayed fascination, his eyes as big as almond cookies and his hands gripping the sheets. Pulling at it again, I began to wonder if the drain had accidentally been stitched into the wound when gradually it let go and moved out a couple of inches. A bit of serosanguineous fluid escaped with the drain and was quickly soaked up with gauze.

"Doctor, did you have to do that?"

"Well, you don't want to go home with this drain hanging out, do you?"

"No."

I put a safety pin through the drain just above the skin to keep the tube from dropping back into the wound and then, with sterile scissors, I cut off the excess tubing. It was important to follow the right order in this simple procedure. Once, before I knew better, I had cut the drain off prior to placing the safety pin. The patient had been holding his breath all the while, and when he finally inhaled, the drain disappeared into his abdomen. Visions of a new operation crashed in my head, but fortunately a resident had retrieved the drain after taking out three skin sutures and fishing around with some forceps.

"Why don't you put me to sleep when you pull it?" Mr. Sperry looked at me, questioning.

"Mr. Sperry, putting you to sleep is not as easy as you think it is. Besides, anesthesia always carries a risk, but there's no risk in pulling out your drain."

"Yes, but then I wouldn't know about it."

"Did it really hurt when I pulled your drain?"

"A little, and it felt funny inside, like I was coming apart."

"You're not coming apart, Mr. Sperry. "You're doing great."

"Did you have to pull so hard?" he pressed.

"Look, Mr. Sperry, tomorrow I'll put these gloves on you, give you the clamp, and you can pull it out. How's that?" I knew that would get a response.

"No, no, I didn't mean that I wanted to do it."

Actually, I knew what he meant. After an operation I had once had on my legs, I felt the doctor was too rough when he took the stitches out. But I hadn't wanted to take them out myself. It's good for a doctor to be a patient now and then — makes him more responsive to all the patient's irrational fears. The solution is to tell the patient everything you are doing, even the simple things, because often it is what you take for granted that scares the patient the most.

"Mr. Sperry, you can move around as much as you like. In fact, movement is good for you. You are not going to pop open. This drain is the normal procedure. It lets out any bad juices while you heal. The safety pin is just to keep it from going back inside your abdomen."

All was well with Mr. Sperry, although I had surely given him something to talk about for the rest of the day: how the cruel doctor had yanked his drain and caused the wound to open and bleed.

That was the ward routine: checking drains, changing dressings, answering questions, looking at temperature graphs. Although Marsha Potts was not my patient, I paused in front of her door almost instinctively. She looked worse now, with the daylight exposing her jaundiced color and the skin on her face so tight and drawn that her teeth were bared in a perpetual grin. She was in terrible shape; we were doing all we could, but it would not be enough.

Outside her room, where the grass came right up to the building, the birds paid no attention as they squawked and chattered over bits of toast tossed to them by the mobile patients.

Now, at seven o'clock, the ward had come alive, suddenly filled with breakfast trays and clanging IV poles as people made their way to the bathroom. Nurses scurried here and there, carrying pans, needles, ointments, and pills. Swept into this world, I no longer felt tired, at least as long as I stayed on my feet. There was an exhilaration to the routine; it seemed to say, "No one can die here, everything is under control." In the midst of all this bright efficiency, Roso was out cold from his Sparine. I had to shake him several times to get any response at all. But once half-awake he agreed he was more strong, Doktoor, before sinking back into sleep.

A lab technician asked me to help her draw some blood from a patient with bad veins. She had tried three times without success. Certainly I'd try, and willingly, because it was a source of great comfort to me having these technicians to draw blood in the morning. To nondoctors it might seem a small point, but medical students resented spending most of their time before morning rounds trying to milk blood out of patients; by the time rounds started they hadn't been able to see any of their patients and were therefore ignorant of their latest condition. When the questions started coming—"What’s this patient's hematocrit, Peters?" — you had to guess, because you hadn't had a chance to look at the chart, either. But it must not sound like a guess. Snap back, without hesitation, "Thirty-seven!" as though you'd stake your life on it. It was not a matter of honesty. Better to play the game than to tempt disaster by saying you didn't know, whatever the reason. No one cared whether you had done those twenty-seven blood counts except if you didn't do them. So you shot back thirty-seven so quickly that half the time the professor would pass on without thinking. But if he paused, you were in trouble, unless you could distract him by referring to a recent article bearing on the disease. Of course, if he checked the chart, you lost totally, unless by wild chance the hematocrit was, indeed, thirty-seven; otherwise, you said somewhat lamely that you had another patient in mind. This would bring about the last, fatal pause as the professor leafed through the chart, looking for another question.

"What about the bilirubin, Peters?"

Now you were really up against the wall, faced with an all-or-nothing gamble. If your bilirubin guess was wrong, too, the professor's suspicion that you were lax on patient care would spread like ripples through the hospital. But in the happy event that you were right, you were returned to a state of grace and moved on to the next patient to watch another student get his interrogation. Bilirubin is different from hematocrit in that everyone's hematocrit varies a good deal, whereas the bilirubin value is usually pretty much the same in everybody, except in liver and blood cases. So you decided to gamble, saying, "It was about one, sir." In medical school most of us learned to play the game; if you played it well, you won more than you lost.

In Hawaii, the technicians had lifted this blood burden, and I didn't mind helping them occasionally. Besides, I was pretty good at it. I should have been, after having drawn several thousand blood samples in medical school. We students had started by drawing each other's blood, which was generally a snap, although some of us made it look pretty difficult. Even this exercise had not been without its dramatic moments. One time, after vigorously palpating the arm vein of another second-year student, I had it standing out like a cheap cigar. The tourniquet had been on for about four minutes while I built up my courage, and when I finally pushed the needle in, my friend just disappeared. It all happened so fast. I went directly from concentrating on the needle breaking the skin to staring at a needle and no arm. My "patient" was spread out on the floor in a dead faint. We had all dreaded those practice sessions, but they were easier than having each student draw blood from himself.

I'll never forget the first time I drew blood from an actual patient. It happened early in third year, when we students were beginning ward medicine. As bad luck would have it, our first day on the ward had coincided with a shift change among the interns and residents. To the new residents, the opportunity was irresistible. They decided to check the diagnoses of all the patients, and for this they needed proof — cold facts, incontrovertible laboratory evidence. As a result, we students had to draw about a pint of blood from every patient assigned to us. My first patient, poor fellow, was a chronic alcoholic with advanced liver cirrhosis. His surface veins had disappeared years ago, and I had to stick him twelve times, groping around inside his arm with the needle, feeling each needle point break through unknown inner structures with a sudden, almost audible popping release. Finally, I had had the good sense to give up and be instructed by the intern on how to get the needle into the large femoral vein in the groin, a procedure known as a femoral stick.

Now the laboratory technician was having much the same problem with a Mr. Schmidt, whom I palpated for the usual arm veins as she handed me a syringe. It was obvious why she hadn't been able to get any blood: I couldn't feel a single decent vein in his arm. So I did a femoral stick, and it was over in a flash.

Farther along the ward I came to Mr. Polski, who was a problem for me mainly because I had failed to achieve any real rapport with him. He had diabetes, very poor peripheral circulation, and a deep infection of the right foot. About a week previously we had done a lumbar sympathectomy, cutting the nerves that were responsible for contracting the walls of the blood vessels of his lower legs. But he was showing very little improvement. Because of the pain, he insisted on hanging his leg over the side of the bed, and that merely inhibited what meager circulation he had. At first I had tried the friendly approach, explaining carefully what happened when he let the leg hang over the side. Regardless, every morning when I appeared, there it was hanging down. Switching tactics, I had pretended to be angry, yelling in feigned rage — which didn't change the situation except to make him like me even less. The foot, now black and gangrenous, was scheduled for amputation.

I nodded my head to Mrs. Tang, an elderly Chinese lady with a cancer growing inside her mouth. She couldn't talk, so we just nodded. The cancer was so big that it had dissolved some teeth and the bone of the jaw on the left side, becoming finally an uncontrollable, fungating mass that occasionally broke through the side of her throat. She was like many older Chinese people who thought of a hospital only as a place of death and would not come to us until the very end. There was little we could do for Mrs. Tang but try some X-ray therapy. The cancer got bigger every day, and somehow Mrs. Tang every day seemed less real — perhaps because she couldn't talk, or maybe because she was so resigned.

There were others: a lymph-node biopsy, a breast biopsy, two hernia repairs. I greeted each of them, passing from bed to bed, using their names — I knew them all by now. I even knew the families of many of the patients who had been with us quite a while. The other intern and a handful of residents arrived, including the chief resident, and morning rounds began. This was a rapid affair; we probably looked like a bunch of myna birds, moving awkwardly and quickly, almost stepping on one another in our haste, as we went from bed to bed. The haste was necessary since we now had only half an hour until the first scheduled operation. No articles were discussed; we didn't do much more than just count heads to make sure everybody was still there. Gastrectomy, five days postop, going smoothly. Hernia, three days postop, probable discharge. Varicose veins, three days postop, also probable discharge. Gastric ulcer, X rays complete, scheduled for surgery. Did the X ray show the ulcer? Yes. Good.

In the next ward, we stood in the middle and twirled slowly on our heels. Mass lesion, mediastinum, aortogram pending. I ran through a staccato capsule description on each of my patients. The other intern did the same. There were four such wards, and we finished the last case in the fourth ward exactly seventeen minutes after starting.

"Peters, you do another cutdown on Potts while we go to the ICU and pediatrics." The little troop disappeared around the corner, and I turned toward Marsha Potts's room, confused and irritated, silently protesting. She wasn't even my patient. I knew I had been chosen because I didn't have any surgery until eight, instead of the usual seven-thirty, but even so I didn't want to get involved with her again, after fooling around with that venous pressure setup the night before. Moreover, a cutdown could be tricky. I hadn't done many of them. But mainly it was just so damn unpleasant in there. Still, Marsha Potts needed a cut-down because she needed intravenous fluid and food; with no more superficial veins that we could use for her IV, we had to cut down on a deeper vein.

As I entered that room, the cheerful morning bustle faded away. Even the bird sounds became inaudible to me, although of course they were still there. The smell was almost overpowering, so pungent and revolting it made the air seem heavy. It was the hot smell of rotting tissue mixed with the sweet, syrupy smell of scented talcum powder being used in a vain attempt to counteract the stench. The talcum powder only made it worse for me. Trying not to look at the poor woman's face, I put on three surgical masks to fend off the smell, but the layers made it hard to breathe and my diaphragm struggled to draw in the thick air. I didn't want to touch too many things in there. Death seemed spread on everything, almost contagious.

I pulled up the sheet from the bottom and bared her right foot. There were open ulcerations on the underside of her leg and the back of her heel. In fact there were sores all over her body, wherever it touched anything. After focusing a bright light on the medial aspect of her ankle, I pulled on the rubber gloves and opened the sterile cutdown tray.

The knife slipped through her skin with zero resistance. She was a little edematous on the foot, so that clear fluid rather than blood began to run from the wound. I was lucky to find the vein right away, and lucky I hadn't accidentally cut it. After making a little nick in the wall of the vein, I slid the catheter easily inside it, first try, as drops of sweat appeared on my forehead from the heat of the bright light. Using silk, I tied the catheter in place and closed the little wound, watching the IV run freely. With my foot I pushed the tray away, snapped off the gloves, and walked rapidly out toward the sunlight and the birds.

Washing my hands, I felt a deep disgust with myself, and I didn't know exactly why. She was a human being; I was supposed to help her. But the situation and her condition revolted me so much I had trouble accepting the responsibility. Where was my compassion; where was it going?

My first scrub was at eight, a cholecystectomy, or gall-bladder removal, with a private surgeon. My patient, Mrs. Takura, was scheduled for another operating room, to follow a ganglion removal; her operation should begin about nine, barring complications with the ganglion. Obviously I was going to be late for Mrs. Takura, but that was typical. The intern is a kind of pawn in the medical game; he is the first line of defense, sacrificed without remorse, disposable in the end, but needed, it seems, in the middle.

I pushed into the surgeons' locker room and began to put on a pale green scrub suit. It was so cramped in there that everybody always got shoved around a little, in a good-natured way. In fact, the sense of equality and the recognition of everybody as a person made scrubbing there a pleasure. Back in med school, the students and house staff had dressed in a completely different area set off by doors and a separate stairway from the sanctum sanctorum of the attendings' dressing quarters. It was almost as though a surgeon's image would crumble if you saw him in nature's state.

One med-school attending was so nasty that students actually shook while presenting their cases. A friend of mine — an excellent doctor, though inclined to stage fright — once had a complete lapse of memory at a bedside as he started to run through the facts in front of this attending. I knew he had the case down cold, but he could not get it out. "This woman presents an… uh… uh…" His face flushed and his pulses hammered at the sides of his neck. The attending could have eased the situation by suggesting that we come back to the case later, or even by giving a key word from the chart to bump the student's memory chain. Not a chance. He had flown into a rage, shouting in wonderment that a person so stupid could have gotten into medical school and ordering the student out of his sight until he knew his patients well enough to present them. Not all the attendings were like that, but a significant number were, even, sometimes, the chief of the service. Naturally, after one of those episodes, rapport between student and patient was in bad repair when it came time to draw blood the following morning. As time goes on, many details of medical school will blend and merge into generality, but not, I think, the scenes of rant and frenzy staged by overbearing surgeons. Some of them behaved so violently that it almost seemed as if they hated medical students; and yet these men were our mentors, our teachers and models.

After the green gown, I put on canvas boots and plodded down the long surgical corridor. Some of the OK doors were closed, and as I passed their small windows I could glimpse Ku Klux Klan-like groups clustered in the center of the room. Other doors were open, some with cases going on, others empty with anticipation. Dozens of nurses moved about, highly organized and busy, many of them looking quite pretty — a high achievement for anyone in one of those shapeless suits, with her hair tucked under a scrub hat. Others, however, might have done well at defensive tackle for the New York Giants, playing without equipment and just scaring the opponent into submission. Everybody said good morning; it was a friendly place.

When I moved up to the sink to scrub for the gallbladder operation, the surgeon and a resident were already there. The resident was Oriental, small, silent, and respectful. I smiled to myself, thinking of my friend Carno's description of the resident as being so small he had to run around in the shower to get wet. The smile started an itch under my mask. Uncanny how that always happened. Always after scrubbing came the itch, usually along the side of my nose or at the corner of my forehead. Of course, I couldn't scratch it until the operation was over and we broke scrub. Twisting my face and wrinkling my forehead occasionally brought minor relief. But the itch remained, fluctuating with my degree of concentration on what I was doing. For me, it was the most annoying part of the OR — aside from the retractors.

"Your name's Peters, huh? Where you from?

Where'd you go to school? Oh, one of the big boys from back east, huh?"

There it was, reverse prejudice. It seemed crazy now that one of my strongest motivations for applying to medical school had been the idea of becoming a member of a highly educated fraternity, a group whose dedication and training put it beyond the trivialities and pettiness of everyday society. Needless to say, I no longer labored under that delusion; it had been riddled early in medical school. Nevertheless, the competition to get in was so keen that if you made it to one of the top few medical schools, it almost invariably meant mat you had really whizzed through college, usually with straight A's. Therefore, the guys who had to settle for their fifth or sixth choice of medical school usually felt like victims of a system in which performance was gauged by the harsh and immutable reality of the transcript. They thought the ivory-tower types looked upon them as second-class citizens. It was all nonsense. Everybody came out on the other side of that huge medical machine looking and thinking exactly the same, and with the same license to practice medicine. In fact, it was the sameness of these men that frightened me, not their differences, which were superficial. I had begun to suspect of late that the machine was producing a lopsided product.

Scrubbing is an invariable, monotonous, ten-minute routine. First under the nails, then a general wash, then the brush. Each surface in turn up to the elbow, then each finger. Start again. Back and forth.

The scrubbing done, I backed through the door, ass first — the perfect symbol of the intern's position — my hands raised in surrender and submission. That’s too theatrical. Actually, I was resigned by now. After all, it had been my own decision to go into medicine; no Romeo had ever panted harder after his Juliet. Too bad she had turned out to be such a bitch. These pseudophilosophic ramblings bore no fruit, changed nothing, but they did help to pass those interminable hours in the OR.

Towel, gown, then gloves, from a rather perfunctory nurse whose eyes I couldn't catch, and the routine was complete. We draped the patient while the surgeon, who was part Hawaiian, and the anesthesiologist, an Oriental, maintained a half-intelligible conversation in pidgin English.

"I go Vegas next week. You want go?" It was the anesthesiologist, looking blankly over the other screen.

"What, you think I that kind gambler?"

"You surgeon, you dat kind gambler." "Fuck you, pake. At least I ain't no fly-by-night gas passer."

"Ha! No gas, no work for you, kanaka."

I was on the right side of the patient, between the surgeon and the anesthesiologist, so that such priceless wisdom and Hawaiian linguistic exotica had to go right by me. The resident stood on the other side, inscrutable.

With everything ready, the surgeon picked up a knife and made the skin incision under the right rib cage. About halfway through the cut, everybody realized that the patient wasn't anesthetized deeply enough. In fact, he was twitching and moving about as if he had a generalized, unbearable itch. The surgeon and the anesthesiologist simultaneously gave nervous little laughs, the surgeon's a bit cynical, because he actually wanted to tell the anesthesiologist he didn't know what the hell he was doing. I don't know why the anesthesiologist laughed, except maybe to fend off the surgeon's broken-record sarcasm. Surgeons are not known for their tact or their love of anesthesiologists.

"Hey, brudda, whatcha madder wich ya? You saving da kind gas for the next patient? Geevum, man, geevum."

The anesthesiologist didn't say anything, and the surgeon continued, "Looks like we going to do this case with no help from the gas passer."

I was unavoidably a kind of referee in this verbal pugilism, literally squashed against the draped anesthesia screen by the surgeon. Not until they were finally inside the belly was I handed the all-too-familiar handle of a retractor, the intern's joy and raison d'etre. There are thousands of different kinds of retractors, but they all do the same thing: hold back the edges of the wound and the other organs so the surgeon can get at his target.

The surgeon positioned one of the retractors to his liking, motioned for me to take it, and told me to lift up rather than pull back. Well, I'd lift up for about two or three minutes, and then I'd pull back. From where I was standing, my leverage on the retractor handle was negative. Two or three minutes was my limit. "Lift up, goddamnit. Here, let me show you." The surgeon took the retractor out of my hands. "Like this." Amid further comments on my ineptitude, he lifted on the retractor for about two seconds before giving the handle back to me, whereupon I lifted up for two or three minutes and then pulled back. It was unavoidable. Show me the man who can lift up rather than pull back through a five-hour cholecystectomy, and I'll follow him to the ends of the earth.

Cholecystectomy is simply the medical name for the removal of a gall bladder. The gall bladder is tucked far up under the liver, and the intern is needed to pull back the liver and the upper portion of the incision so that the surgeon, with the help of the resident, can take it out. The gall bladder is a pretty unreliable organ, and, therefore, removing it is one of the most frequent surgical procedures. Of all the memory aids I'd learned in medical school, I best remembered the one about the average gall-bladder patient: the four fs—fat, female, forty, and flatulent.

Throughout the operation, my arms were more or less under the surgeon's left arm. He was pivoted away from me, presenting his back, which totally obscured the incision, somewhere over his shoulder. When the anesthesiologist switched on his portable radio and began glancing through a newspaper, and the surgeon began alternately humming and singing, both out of tune, the scene came less and less to resemble the tense silence of medical school — except for those outbursts of displeasure by the surgeon. They were the same.

"Okay, Peters, take a look." I peered over into the incision, a red oozing hole with surgical tapes holding back the abdominal organs. There was the gall bladder, the cystic duct, the common duct, the… "Okay, that's enough. Don't want to spoil you." The surgeon moved back, muscling me out, chuckling with the anesthesiologist. The operating room is a feudal world, with an absolute hierarchy and value system, in which the surgeon is the divine and almighty king, the anesthesiologist his sycophantic prince, and the intern his serf, supposedly grateful for any small scrap of recognition — a look inside or perhaps even the chance to tie a knot or two. That glimpse into the wound had been my reward for being there holding the retractors and watching either the surgeon's back or the hands of the wall clock as they crept slowly around.

The atmosphere was congenial enough, however, until the surgeon asked for the operative cholangio-gram, an X-ray study, to make sure he had the common duct well cleaned of gallbladder stones. This could be determined by injecting an opaque dye into the ducts and then X-raying the area. Any remaining stones would stand out.

When no X-ray technician appeared magically at the snap of his finger — all were busy on other cases — the surgeon cursed and waved his scalpel about, threatening dire reprisals. The nurses were immune to this display, as was the anesthesiologist, whose radio continued to drum out its patter of music and news. This familiar scene was played just about every time the need arose for a mid-operation X ray.

A technician finally came and took the shot, returning in a few minutes with a foggy blur, which the surgeon pronounced the most inept attempt since Roentgen himself. Did he want another taken? No! There is much to learn about the surgeon. I was sure, on reflection, that he wanted that X ray because he had read about it in some journal and thought it would look good on the operative record. The practical effect of the X ray was at best neutral — the way he utilized it, at any rate.

The next day a radiologist would struggle with the X ray, trying to figure out which end should be up and why the hemostat showed in the middle of the ductal system. His report would be sheer guesswork. The unhappy ending of this episode would come later, when the surgeon said something sarcastic to the radiologist, who would smile wryly and reply that if the surgeons could organize themselves a little, radiology might be able to do something. In truth, the surgeons are often at war with everyone— with radiology, pathology, anesthesiology, the operating schedule, residents, nurses, interns — constantly surrounded, they feel, by an ungrateful and inept staff. In a word, many of them are quite paranoid.

Once the retracting had been completed, I prefaced a request to leave with a brief explanation about Mrs. Takura and was excused from the rest of the cholecystectomy. As I stepped out of the operating room into the corridor, the surgeon was still deep in his complaint about X-ray and the anesthesiologist still absorbed in his newspaper.

The work had already started on Mrs. Takura when I began scrubbing the second time. I could see the chief surgical resident and the first-year resident, Carno, busily inserting subcutaneous clamps. Carno and I had come to Hawaii at the same time, for the same reason — to get away from the pressure and have a little fun. In the first few days we had hit it off pretty well, and had even considered getting an apartment together. But now our schedules made it hard to get together.

Friendship among medical people is difficult and elusive, much harder than in college. There is so little time for it. Everyone tends to draw more and more inward, become almost autistic, even when free. In the later years of medical school, the on-call schedules are so different that you can't count on anybody showing up for dinner or a party. Sometimes I couldn't even count on myself. I'd often make plans and then feel too washed out to carry them through.

Also, there was the unavoidable competition. It had settled on us from our very first day, like the spores of a fungus, beginning with the premise that medicine was at its zenith in the research-oriented university center. That was where the "good guys" ended up. To get there, you first had to have a residency at a university center, and for that you needed an internship in one of a handful of princely hospitals. We had been told right off that the top four or five in the class would be asked to stay on as interns, the golden ticket to advance one more giant step. Pressure! There were about 130 of us, all good students in college, and all stumbling around in a haze, sopping up facts as fast as we could and accepting the value system that told us we had to stay on the top. The alternative, too horrible to contemplate, was that we would FAIL and end up in a small-town general practice. That was made to sound bad, really bad, like going from the executive suite to the mail room.

It didn't make any difference if you did well; everyone in the group could do that. After all, we were horses trained to run, and we ran like hell. The real point was to do better than the next guy. That didn't create a congenial environment for friendship, especially when you were short of time, and the time you did have you invariably wanted to spend with a girl.

The system affected that, too, especially during the last couple of years. At first, being a medical student gave you a certain mystique at cocktail parties— everybody thought you were sure to make it into the big money someday. But gradually, since your schedule was so screwed up, you couldn't count on being anywhere at the right time, and you came to be considered a bad risk. All those lovelies from Smith and Wellesley, the ones you were used to, drifted away to more fertile ground. So we had turned to the girls who were there, the ones with the crazy schedules just like ours. And they turned to us. The hospital was full of girls — technicians, instructors, nurses, nursing students — many of them damn nice, and most of them conveniently available.

As our training forced us into the mold, we withdrew into ourselves and into the artificial world of the medical school and the hospital. The change was imperceptible, almost unconscious, but steady; once on the escalator leading to the ivory tower, we stayed on it, intellectually. Even though I'd come to Hawaii, I hadn't split totally. Never would. I still had a foot in the door back east; at least, I hoped so. I wasn't a rebel or a revolutionary, just a little worried about where I was going.

Right now I was going into the OR with Mrs. Takura, backing in again with my hands up, ready to be gowned and gloved. They were just getting into the abdomen, and the chief resident motioned me to his left side. After I had squeezed into my position between him and the anesthesia screen, he handed over the legendary retractors and we settled, in, this time for eight hours.

It was hard to recognize nice old Mrs. Takura. Instead of being her usual agreeable and considerate self, she was bleeding all over the place. She had had a cholecystectomy several years back, and it was difficult operating through all the adhesions and fibrous tissue. About two hours into the operation, we took time out to plug a little puncture in the bowel, and then a strong "bleeder" that was squirting on Carno's chest. As her blood pressure sagged, full bottles of blood replaced the empty ones. It was a tough, long procedure, but the chief resident seemed to be doing a good job. Any levity that might have existed earlier disappeared as fatigue crept over us.

Although you would never know it from watching television, humor plays a big part in the operating room. To be sure, it is often grisly, and often at the expense of an unwitting and innocent patient. Most surgeons can regale an operating team for hours with bizarre and off-color tales from the past. With my limited experience, and therefore a limited repertoire, I was mostly silent during these performances, but just before getting serious about Mrs. Takura, when everybody was still feeling good, I ventured a story that was a favorite in my medical school.

It seems that an enormously obese lady had once appeared at the hospital during a time when the OR was covered only by two interns and a resident. She complained of an agonizing abdominal pain. Elbow deep in fatty tissue, the three examined her, conferred, re-examined, and conferred again, unable to agree on a diagnosis. Finally those who thought she had a hot appendix won out, and up the lady went to the OR, where she was literally draped all over the table. Hearing of the action, a small band of six or seven others had gathered by the time the resident began cutting down through the layers of fat toward the peritoneal cavity. After repositioning the retractors several times, as he moved in deeper and deeper, he suddenly stopped and had the overhead light readjusted. Then he asked for a pair of tongs, and while everyone watched in anticipation, he brought up through the lady a piece of white cloth. A stunned silence fell over the assemblage until, simultaneously, everyone realized that the resident had cut all the way through to the operating table. The patient's abdomen, being so large, had skewed off to the left, causing the resident to miss the abdominal cavity entirely.

But the laughter from that story had long since drifted away. We labored now inside Mrs. Takura, and the muscles in my hands and arms were numb from maintaining tension on the retractors in that awkward position hour after hour. As lunch-rime approached and receded, my stomach growled in protest, a counterpoint to the itch on my nose. My bladder was so full I didn't dare lean against the operating table. Time crept on. I seldom saw into the wound, although I could tell what was happening from the surgeon's comments. Fastidiously the vessels were sewn together — a side-to-side anastomosis — and the final suture was placed and run down with tired fingers. When I was at last relieved of the retractors, I couldn't even open my fists; they stayed clenched until I bent the fingers back one by one and soaked them in warm water.

Although it was almost four o'clock, we were not through. We still had to close. Like all the others, I was tired, hungry, and uncomfortable in every way. Suture after suture, wire, silk, wire, slowly working up the long incision, starting from the bottom and working with rapid ties, the gaping portion very slowly but progressively drawing closed until the last fascial suture. Placed. Then the skin. By the time we snapped off our gloves at the finish it was past five — the beginning of my glorious night off.

I urinated, wrote all the postoperative orders, changed my clothes, and had some dinner, in that order. As I walked across to the dining room, I felt as if I'd been run over by a herd of wild elephants in heat. I was exhausted and, much worse, deeply frustrated. I had been assisting in surgery for nine straight hours. Eight of them had been the most important hours of Mrs. Takura's life; yet I felt no sense of accomplishment. I had simply endured, and I was probably the one person they could have done without. Sure, they needed the retraction, but a catatonic schizophrenic would have sufficed. Interns are eager to work hard, even to sacrifice — above all, to be useful and to display their special talents — in order to learn. I felt none of these satisfactions, only an empty bitterness and exhaustion.

After supper, even though I was not on call, the usual ward work was still to be done, and I moved perfunctorily through a series of dressings, drains, and sutures. I rewrote IV orders, looked over laboratory reports, and did a history, physical, and preoperative preparation on one new patient, a hernia. Roso's hiccups had started again as he came out of his hibernation with the Sparine. Anything I wanted to ignore I did so by leaning on my tiredness, rationalizing. I avoided even looking into Marsha Potts's room.

Sleep was impossible, though I had been without it for most of twenty-four hours. Besides, I wanted to go somewhere away from the hospital, to talk with somebody. My confused and angry thoughts were rocketing around in my head too much for me to deal with alone. Carno couldn't be located anyplace; probably he was with his Japanese girl friend. But Jan, thank God, was there and available. She wanted to go for a drive, perhaps a swim. She wanted to do anything I wanted to do.

We drove eastward, moving toward the silvery violet of the evening. The road took us up over the Pali to the windward side of the island, gradually climbing and opening out the view of the colors from the setting sun on the expanding panorama of ocean behind us. The scene had a poetry that kept us silent until we were through the tunnel and out in the shadow again, in Kailua. There we found a beach where we were alone. My head gradually cleared of hostile thoughts, and the prison of the day, with its creeping clock and stiff fingers, seemed far away as I floated in the shallow water, letting the small exhausted waves rock me with their surge. Later we lay on a blanket and watched the stars come out.

Wanting to hear Jan talk, I asked her questions about herself, her family, her likes and dislikes, her favorite books. All at once I wanted to know all about her, and to hear her tell it in her small, soft voice. She grew weary of this after a time and asked me about my day.

"I spent all day in surgery."

"You did?"

"Nine hours."

"Wow, that’s wonderful! What did you do?"

"Nothing."

"Nothing?"

"Well, practically nothing. I mean I was the retractor, holding back the wound edge and the liver so that the real doctors could operate."

"You're silly," she said. "That was important and you know it."

"Yes, it was important. But the problem is that anybody could have done it, anybody at all."

"I don't believe it."

"Yeah, I know you don't believe it. Neither does anybody else. No one thinks that anybody but an intern can take an intern's place. But let me tell you, in that operating room, no one could have done the nurse's job except another nurse, ditto the anesthesiologist and the surgeon. But me? Anybody! The guy off the street. Anybody at all."

"But you have to learn."

"You hit the problem on the head. The intern is frozen in one spot, eternally retracting. They call it learning — that's the rationalization — but if s a hoax. You learn enough about retracting after one day. You don't need a year. There's so much to learn, but why at this snail's pace? You feel so damn exploited! They ought to hire people to retract, and put the intern over there tying knots and watching the surgeon work."

"Can you tie good knots already?" she asked.

That stopped me. I could remember telling her that I wasn't very good with knots, but still, her comment seemed discouragingly off the mark. It indicated that I wasn't getting through to her and it was useless to try. Even so, I felt better, almost as if my own thoughts had focused. I told her no, I couldn't tie very good knots, but I'd probably learn if they gave me the job.

She was getting to me again, turning me on. We ended up running through the shallow water. She was so beautiful, so full of life, I wanted to yell with joy. We kissed and held each other close, rolled up in the blanket. I was wild for her, and knew that we were going to make love, and that she wanted to as much as I did. But she felt obliged to talk some more first, and tell me some personal things about herself. For instance, that she had made love to only one other boy, but that he had tricked her because it turned out that he hadn't really loved her. This went on for five minutes or so, slowly turning me off again, and I decided that making love was probably a bad idea, after all. She couldn't believe this, and wanted to know why. The real reason, my inner frustration, would not have satisfied her. Instead, I told her that I loved the sheen in her hair and her sense of life but I didn't know if I loved her yet. That pleased her so much she almost made me change my mind again. Driving back to the hospital, I got her to sing "Where Have All the Flowers Gone?" over and over again, and I felt at peace.

"You think you didn't do anything today, but you did," she said, suddenly turning toward me.

"What was that?" I asked.

"Well, you saved Mrs. Takura's life. I mean, you helped, even if you thought that you should have been doing something else."

I had to admit her point, a very nice point, which I had almost forgotten. For Mrs. Takura I would stand holding a retractor for weeks.

Back at the hospital I jumped into my whites and dashed over to the ICU to see how she was doing. Her bed was empty. I looked at the nurse, questioning, holding back the thought.

"She's dead. She died about an hour ago."

"She's what? Mrs. Takura?"

"She's dead. She died about an hour ago."

As I stumbled back to my room, my thoughts piled up, tumbling over into tears, draining me of every thought except that the day had been a horrid abortion, unredeemed even by the act of love. In bed, I fell into a troubled sleep.