The Year of the Intern

Day 172

My ears were trained to separate its sound. Somewhere off in the distance I could hear the unmistakable high-pitched undulations building and cycling, growing progressively louder as it drew near. The clock said 9:15—a.m. I was seated behind the counter of the emergency room — waiting.

For some people, even those closer to the ambulance than I, the siren would be inaudible, mixed with the general background noise. Others, aware of their good health, or unaware of their bad, would be content to let the siren diminish, melting away into the subconscious, intermingling with the noise of cars, radios, voices. For them it was a distant thing. It belonged to someone else.

For me it invariably got louder and louder, because I was the intern assigned to the emergency room— the ER to those who knew and loved it. My duties in the ER could be subsumed under the title of official hospital welcomer to all who came. And come they did — the young and the old, the sleepless, the depressed, the nervous, occasionally even the injured and the sick. There I worked, often feverishly; I frequently ate; I occasionally sat. But, always waiting for the dreaded ambulance, I almost never slept.

Its sound meant trouble, and I was not ready for trouble, nor did I believe I ever would be. Although I had been assigned to the ER for more than a month, and had been an intern for almost half a year now, my most prevalent emotional state was still one of fear. Fear that I would be presented with a problem I couldn't handle and would screw it up. Ironically, I had been plunged into this new environment, one that demanded radically different medical choices, just when I was beginning to develop a certain degree of confidence on the wards and in the OR. Except for a group of highly capable nurses, I was on my own in the ER, solely responsible for what happened. It was not so bad during the day, when other doctors were around — the house staff was only a few seconds away — but at night five minutes, maybe even ten, might pass before anyone else from the house staff arrived. So things could be crucial. Sometimes my hand was forced.

Even the schedule in the ER was different. On duty twenty-four hours, off twenty-four. That doesn't sound so bad until you do it for a solid week. If your work week starts at eight on Sunday morning, by eight Wednesday morning you have already worked forty-eight hours, with another forty-eight to go. The result is that after two weeks your system is in total rebellion: you have headaches, loose bowels, and a slight tremor. The human body is geared to work only so long and then sleep, not go for twenty-four hours straight. Most organs of the body, particularly the glands, must rest; their function actually changes in a time-honored way over a twenty-four-hour period, whether the whole body sleeps or not. So after sixteen hours on duty your glands have more or less gone to sleep, but the same decisions are there to be made, with the same consequences. Life is no sturdier at 4:00 a.m. than it is at 12:00 noon. In fact, some studies suggest that it is frailer. Your patience hardly exists, everything is a struggle, the slightest hindrance becomes a major irritation….

The siren approached, very near now. I listened hopefully for the end of the build-up and the receding Doppler effect that we occasionally got as an ambulance sped off to one of the smaller hospitals nearby. Not this time. I couldn't see it, but I could tell from the way the siren suddenly trailed off that it had entered the hospital grounds. Within seconds it was backing up toward the landing, and I was there to greet it.

Through the small rear windows I could make out the chaotic resuscitation efforts of the ambulance crew. One of the attendants was giving closed-chest cardiac massage by compressing the patient's breastbone; another was trying vainly to keep an oxygen mask on the face. As the ambulance stopped I reached out and twisted open the door. A few passers-by paused and looked over their shoulders. To them the event was closed. The ambulance had arrived, the doctor was waiting with an assortment of strange and miraculous instruments at hand, all was saved. For me it was just the beginning. I was glad that no one could see into my mind as I tried to prepare for what was to come.

"Bring him inside to Room A," I yelled to the crew as they slowed their resuscitative efforts. I helped lift the stretcher out and roll it fast through the short hallway, asking how long it had been since the patient had made any respiratory attempts, any sign of movement or life.

"He hasn't, and we got to him about ten minutes ago."

He was a bearded man of about fifty, and so large it took all of us to lift him onto the examining table. Seconds stretched into what felt like hours as the necessity for making a decision drilled into me — the kind of decision that isn't much discussed outside hospitals. I must either call a cardiac arrest or declare this simply a case of DOA — dead on arrival. Surely it was unfair to demand such a decision based on what I could remember from a textbook! Still, it had to be made, and made fast.

What would happen if I called a cardiac arrest? Six weeks earlier, we had restored a man to life after only eight minutes of clinical death. He lay now in the ICU, a vegetable, alive in a legal sense but dead in every other way. Seeing that man day after day, I had come to feel that in giving him the half life technology made possible we had somehow deprived him of dignity. For six weeks the body had functioned — the heart beating, the lung mechanically pumping, the eyes dilated and empty; and his relatives were being drawn out to the limit of their emotional and financial reserves. Whose hand will dare to pull the plug on the machine that breathes, whose will cut off the IV, whose mind relax the attention necessary to maintain a proper ionic concentration in the blood stream so that the heart can beat on forever without the brain? No one wants to kill the grain of hope that lingers in even the most objective mind.

But there is the problem of the bed. It is needed for others — people who perhaps are more alive, and yet will be just as dead if deprived of the resources of the ICU. It comes down to a decision based on subtle, undefined gradations of life versus death. It isn't a matter of black or white, but of varying shades of gray. What does it really mean to be alive? A perplexing question, the answer to which evades a mind numbed with fatigue.

Where does the exhausted intern look for guidance in these moments? To college, where sterile concepts of truth, religion, and philosophy invariably lead to an automatic acceptance of life as the opposite of death? No help there. To medical school? Perhaps, but in the ivory tower the complexities of the Schwartzman reaction and the sequence of amino-acid cycles have pushed aside the fundamental questions. Nor will there be any help from an attending physician. He always remains silent, perhaps perplexed, but hardened by repetition. And the relative or friend standing by? What would he say if you meekly put forward the proposition that there may be halfway points between life and death? Alas, he cannot think beyond the poor soul that is, or was Uncle Charlie. Unassisted, then, the intern gropes in side himself and makes arbitrary decisions, depending on how tired he is, whether if s morning or night, whether he is in love or lonely. And then he tries to forget them, which is easy if he is tired; and, because he's always tired, he always forgets — except that later the memory may surface from his unconscious. Angry and uncertain, he has once more been tested and found unprepared…

Paradoxically, even with six people around me I was alone, standing there next to the nonbreathing hulk of the bearded man. His extremities were cold, but his chest was quite warm; he had no pulse, no respiration, dilated fixed pupils. One of the ambulance attendants kept talking, telling me what he had heard from the neighbor who had been with the man. The man had called his doctor after an asthma attack that morning, but it had gotten worse — so bad, in fact, that he started toward the ER, driving with a neighbor. In mid trip he had experienced an attack of acute dyspnea, an inability to breathe. He had stopped the car, jumped out, staggered a few steps, and collapsed. The neighbor had run for help and the ambulance was called.

"DOA," I said firmly trying not to show doubt. In fact, my mind was a jumble of loosely connected thoughts racing around in search of a pattern. Strangely, in the ER mornings are an intern's most vulnerable time. Despite the surface refreshment of a night's sleep, his decision-making abilities are undercut by the deep exhaustion of the twenty-four-hour cycle. His experience is insufficient for him to make critical decisions with the certainty not of rational thought, but of pure reflex. One takes for granted the old aphorism that familiarity breeds blind acceptance. And so it is. Very often, in the beginning of his career, the intern is faced with a situation in which his mind is clear enough to think, yet he can find no answers. As with the schizophrenic who cannot handle an overabundance of sensory input, information remains unassociated in his mind. So the intern absorbs these experiences that rush in upon him; they hang around his mind in a loose conglomerate until he is tired enough to relegate them to his unconscious, and eventually he does reach a point at which experience brings familiarity, and familiarity brings acceptance without thought. By then a large part of his humanity has dropped away….

All this mental activity happened in milliseconds. I didn't stand pondering and uncertain while the bearded man lay there. From the time I opened the back of the ambulance to the time he was pronounced DOA, less than thirty seconds elapsed. But it seemed much longer, and it affected me for hours. I did have one thing to be thankful about. My training had advanced far enough so that I would not be popping back in to feel for a pulse.

The central, cutting question remained: why should I be allowed to make such a decision? I felt somehow an accomplice of evil, an agent in this man's death. It's true that if I hadn't done so, someone else would have pronounced him dead; I was not necessary to the drama. That’s easy enough to say if you're not involved, but I couldn't dismiss the matter so quickly. I had made the decision without which the bearded man would not have been technically dead at this moment. We'd have had him all wired up by now, and we would have been pushing on his chest, breathing for him, keeping him legally alive. So I felt that, because I had cut off this possibility, I was the one responsible for his being dead.

Had I been too hasty in calling him DOA, in taking the easy way out? As soon as I said it, all the medical doors clanged shut. Had the decision gone the other way, in favor of an attempted resuscitation, my first move would have been to insert an endotracheal tube so that we could breathe for him. I had always found this a very difficult task. Maybe I had pronounced him DOA partly to save myself the trouble. Or maybe it was because I knew all the beds up in ICU were full, and figured that even if we did manage to resuscitate him, he'd only be another vegetable anyway. I now think these are questions without answers, but at the time they were driving me crazy. In that state, I walked out into the hallway to face the wife and child. The wife was tall and thin, almost gaunt, with dark, deep-set eyes. She wore sandals and some sort of floor-length granny dress. Up against its ample folds, really wrapped in it, was a little girl of about seven.

The situation was right out of a prime-time television program—"The Interns" or "The Young Doctors" — ingredients for either a dramatic or a terribly sentimental confrontation. The reality, again, was nothing Ben Casey would have recognized. Facing the dreadfully concerned and frightened wife and child was neither dramatic nor sentimental, only one more hurdle for me to jump. Perhaps an omniscient third party would have read more into it. I was hardly that. I knew what had happened in the room behind the curtains, but I had no idea what these people were thinking, what they needed to hear. Worst of all, I was hopelessly swamped in my own crazy thoughts about death and responsibility, about what might have been. I wanted to beg them to hear my lectures on the Krebs cycle or some other medical elegancy. How poorly medical school had prepared me for this. "Just get the concepts, Peters. The rest will come." The rest — death — you learned about by trial and error, and finally, gratefully, you did fall back on the comfortable stock phrases of television.

"I'm very sorry. We did all we could, but your husband has passed away," I said softly. The banal words rolled out, seeming good enough, really quite satisfactory under the circumstances. Perhaps I had a future in television. The only bothersome part was that business about doing all we could; we hadn't done anything. What I said, however, was only a stupid self-serving hypocrisy. It would pass. Wife and child simply stood there, frozen, as I turned and walked away.

Thank God no other patient was waiting to be seen. I signed the sheet of paper making it official that I was the reason the bearded fellow was dead, and then I went quickly into the doctors' room, slamming the door behind me. In the process I jarred off the wall a picture a drug firm had given us of a bunch of Incas opening up some poor devil's skull; but the Playboy calendar opposite only rustled a little in protest, and Miss December hardly seemed disturbed. I sank into an enormous old leather chair. It was a large room, with blank walls except for the Inca picture and Miss December. A low, crowded bookcase stood at one end, and a small bed and a lamp at the other. The chair I sat in faced the pale green wall that was supporting Miss December. I longed for my mind to become as empty as that room, and as placid.

Miss December helped; in fact, she had me mesmerized. What did Playboy have against body hair? Aside from the required abundance on top of her head, Miss December was as smooth as a piece of marble — no hair around her breasts, under her arms, or on her legs, and apparently none between her legs, either, although that was difficult to tell for sure because of the artfully draped Christmas stocking. Maybe Playboy was misjudging a good part of its market. I didn't think pubic hair was so bad. In fact, remembering the night before, I decided that Joyce Kanishiro's pubic hair was one of her most appealing features. No offense meant — if s just that she had very pretty pubic hair, and a lot of it. When she was naked, you saw it no matter what position she was in. I thought it would be hard to put Joyce on a Playboy calendar.

Miss December, Joyce, and the esthetics of body hair couldn't drive the bearded man entirely out of my mind. It certainly wasn't the first time death had confronted me in the ER. In fact, on my very first day on ER service, when I trembled to see even a patient with mild asthma, an ambulance had pulled in, its siren trailing off, and disgorged a twenty-year-old boy on whom the ambulance crew had been performing artificial respiration and cardiac compression. I had stood on the landing virtually wringing my hands and hoping that someone would call a doctor. This was ludicrous. I was the person they had been racing to, running red lights, risking life and limb.

I had looked down at the boy and seen that his left eye was evulsed. Its distorted pupil looked off into nowhere. What on earth could I do with that eye? Actually, I didn't have long to think about it, because the boy wasn't breathing and his heart had stopped. The crew rapidly informed me that he had not made the slightest movement since they picked him up, in response to a call from a neighbor. As they rolled him onto the examining table, I glimpsed a wound in the back of his head. I tried to get a better look at it, but my view was blocked by little pieces of brain oozing out of a hole about an inch in diameter, and I suddenly realized that he had been shot, that a bullet had gone through the left eye and out the back of the head. The nurses and ambulance crew stood by, panting from their efforts, while I went through my routine. It was sheer nonsense to fuss with my stethoscope — nothing would make any difference — but for lack of another strategy I put it on his chest. All I heard were my own thoughts, wondering what to do next. The intern is always expected to do several things, yet this boy was so dead he was practically cold.

"He's dead," I had said finally, after feeling for pulses.

"You mean DOA, Doctor? No arrest, is that right?" That was right, dead on arrival, The medical jargon was reassuring; it made me feel secure. That boy with the hole in his head had been very different from the bearded man. Sure, the hole had scared me half to death, and I had been greatly relieved to be rid of the responsibility of figuring out what to do with that eye. The main point, however, was that he had had a big hole right through his head that preempted any action by me; hence, I had felt little responsibility. On the other hand, even now, without the sheet that covered him, the bearded man would look quite normal, as if in a deep sleep. That's the thing about death from asthma. You don't find much even at an autopsy, unless the victim has had a massive heart attack.

Sitting in the doctors' room, I tried to picture Joyce Kanishiro in the center fold of Playboy. That would be something. She even had a few black hairs around her nipples. They'd have to touch up the photo a bit.

Joyce was a laboratory technician with a strange schedule like mine. That was no problem, but she did have one gigantic drawback: her roommate was always at home. Every time I took Joyce back to her apartment, the first few times we went out, her roommate was there eating apples and watching television. There was a bedroom, but it was never opportune for us to go into it. Anyhow, the roommate, a confirmed night person, would probably have still been there staring at the test pattern when we came out at 5:00 a.m. After a few nights of situation comedies followed by the late news and the late movie, I knew Joyce and I would have to change the locale.

My reverie about Joyce was interrupted by another memory, an episode that had taken place in the late afternoon some two weeks after I started ER duty. The same routine — siren/ red flashing lights — and this fellow had looked normal, too. As the attendants unloaded him and rushed him inside, they told me he had fallen fifteen stories onto a parked car. Had he moved? No. Tried to breathe? No. But he looked normal, quite peaceful, somewhat like the bearded man only a lot younger. How long did it take to get him here? About fifteen minutes. They always exaggerated on the low side, to forestall criticism. With an ophthalmoscope, I looked into the fellow's eyes, focusing until I saw the blood vessels. Concentrating on the veins, I made out clumps that could only represent blood clots. "DOA," I said. "No arrest." I had been pretty upset about that case, too, although falling fifteen stories onto a parked car was generally conclusive.

Then the family had started arriving, in spurts— not the immediate family, at first, but cousins and uncles, even neighbors. It seemed that the man — his name was Romero — had lost his footing while painting the outside of a building. After the nurses called his wife to tell her that Romero was in critical condition, word of the accident had spread quickly, and by the time Mrs. Romero arrived the place was jammed with people demanding to know how he was and waiting to see him. As I informed Mrs. Romero of the death in my best quiet and confidential tones, she raised her hands to heaven and began to wail. Taking their cue from her, the rest of the crowd began wailing, too. For an hour or so from that moment I witnessed the most incredible and frightening performance by the Romeros and their friends as they, continued to drift in and engulf the ER. They beat the walls, tore their hair, screamed, cried, fought with each other, and finally began to break up the waiting-room furniture. I had no time to brood over the metaphysical implications of the case, being much too busy protecting myself and the rest of the staff. Interns have been killed in the ER That’s no joke.

Later I had seen in the pathologist's autopsy report that Romero's aorta was severed. That made me feel a little better. But I knew that the pathologist would probably find nothing so plainly wrong with the bearded man.

Dozing and musing in the old leather chair, I played with such thoughts and memories while Miss December's gigantic, almost hilarious breasts seemed to grow even larger. Joyce didn't have breasts like that. We had moved to my room to avoid the TV addict, and I vaguely remembered waking up at four-thirty that very morning as she left via the back door before anybody else was up in the quarters. It was her idea; I couldn't have cared less. But that was how we got away from Miss Apples and TV. It was a great schedule. During my twenty-four hours off, I surfed in the afternoon, read in the evenings, and then about eleven, after her work, Joyce would arrive and we'd go to bed. She was an athletic girl, who liked to bounce all over the place. She had great endurance, really insatiable. When she was around I didn't think about anything else.

But the hospital bed in my room made a hell of a lot of noise, and it was pretty small. When Joyce got up to leave at four-thirty or so, it always felt delicious to expand all over it, luxuriating in the spaciousness. For a while I had gotten up with her — it seemed the courteous thing — and waved as she went down the stairs and drove away. But lately I had just propped up on one elbow, watching her dress. She didn't seem to mind. This morning she had come over to the bed, all starchy white, and kissed me lightly. I said we'd get together soon. She was an okay playmate.

When the phone rang to wake me up three hours later, such a short time had elapsed that I half expected to see Joyce still standing there. I must have fallen asleep before she got out the door.

Saturday, busiest day of the week in the ER, 7:30 a.m. Even though I had been in bed for eight hours, I felt physically bankrupt and out of phase. It was that twenty-four-hour baloney. I had followed my usual routine, which started when I balanced against the sink and studied my bloodshot eyes and ended with my arrival at the ER at one minute after eight, as always. Strangely, despite a general tendency toward tardiness, I always managed to arrive promptly at the ER to relieve my colleague, who would slink off gratefully with blood-spattered clothing and drooping eyelids.

Until the arrival of the bearded man this had been a relatively quiet Saturday morning, with no big problems, only the usual procession of people who had dropped a steam iron on their toes or fallen through a plate-glass window. Everything had been handled quickly.

A half hour had come between me and the bearded man, and obviously nothing untoward had happened outside the doctors' room, else I would not have been allowed to sit there musing. My watch showed 10:00 a.m. I knew it was only a matter of time!

After a perfunctory knock, a nurse entered to say that a few patients were waiting. Feeling almost relieved at being tugged from my reverie, I went back into the daylight and took the "boards" the nurse had prepared. My hat is off to these nurses. They routinely escorted each patient into the examining room, took all the administrative detail, the blood pressure, and even the temperature if they thought it was necessary. In other words, they screened the patients very well. Not that they decided whom I should see, because I had to see everyone, but they did try to establish priorities if the place was busy, or to give me a little peace occasionally if it wasn't. Whenever a new intern arrived, I guess the nurses were tempted to handle everything alone, because most of the stuff that came in really didn't rate as an emergency.

But I was the intern and in charge, dressed in white coat, white pants, and white shoes, stethoscope tucked and folded into my left pocket in a very particular way, equipped with several colored pens, a penlight, a reflex hammer, a combined ophthalmo-otoscope, and four years of medical school— apparently ready for anything. In fact, really, only for the ailments I had already seen and dealt with. Considering that the variety of bodily ills approaches infinity, I wasn't ready at all. My inadequacy was like a shadow that fell away only when the place was jammed with crying babies and suturing to be done. After about ten hours, I usually got so tired that even if there were no patients I couldn't think. So the morning was toughest, just getting through to the afternoon; the rest seemed to take care of itself.

The first of the two new patients were a surfer who had been hit in the head with a board, leaving a two-inch cut over his left eye. He was oriented and alert, with normal vision. In fact, he was fine except for the laceration. I called his private doctor, who, predictably, told me to go ahead and sew it up. That was the way it worked. The patients came in, and I saw them and then called the private physician. If they had no doctor, we picked one of them, provided, of course, they had the means to pay. Otherwise they were considered staff patients, and I or one of the residents would take responsibility for treating them. "Suture it up" was the invariable reply from private doctors on these laceration cases. During the first few days I often speculated as to whether the private doctors then billed their patients for the suture, although we weren't encouraged to investigate that.

Actually, I was now rather good at knot tying and suturing, by virtue of having forced my way into several operations, including three hernias, a couple of hemorrhoids, an appendectomy, and a vein stripping. Mostly, though, I had gone on holding those damn retractors and, occasionally, cutting off warts.

Cutting off warts is an intern's reward for behaving himself; if s about on a par with hemorrhoid removal, although hemorrhoids are rather higher on the ladder. We had taken off dozens of warts in medical school, during dermatology, since the procedure was essentially without risk and well beneath a surgeon's dignity. My first Hawaiian wart had come with the Supercharger, a surgeon nicknamed for his matchless slow-motion incompetence. We scrubbed together on a simple breast biopsy, which is normally a thirty-minute job, unless you find a malignancy.

Not so with the Supercharger. He rooted around for an hour or so before sending off a little wedge of mangled tissue to pathology. I stood by hoping that the tissue was benign — luckily it was — and then the Supercharger closed the wound. Being an assistant on a breast biopsy is not a thrilling procedure under any circumstances; this one was made worse for me because I hadn't done anything, not even retract. When the Supercharger finished tying the last knot, he had stepped back, snapped off his gloves, and magnanimously informed me that I could now remove the wart from the wrist, which I dutifully did — to the accompaniment of a lot of bad advice from the Supercharger, who couldn't understand why I wasn't more grateful.

My next operation, however, had been more involved; in fact, it had almost wiped me out. It was a vein stripping, and the surgeon was a private M.D. I had never scrubbed with before. As we washed our hands he told me that he expected me to do a careful job on my side. I blinked a little, knowing he had mistaken me for a resident, but I let the misconception stand. When I answered that I would try to do a good job, he told me trying wasn't enough, and that I'd either do it right or not at all. I didn't have the guts to tell him that I had never done a vein stripping before. I had seen several of them, but only from behind retractor handles; besides, I wanted to try it.

Needing to follow the surgeon's lead, I delayed beginning until he was well under way. The patient was a woman of about forty-five, with bad varicose veins. Having been assigned to the case only a few minutes before it started, I hadn't seen the patient beforehand, so I had to guess what her veins looked like when she was standing. Although I knew the theory, I wasn't quite up to the practice. It was like having read all about swimming, knowing the names of the strokes and the movements, having watched other people swim, and then getting thrown into deep water. My job was to make an incision in the groin, find the superficial vein called the saphenous vein, and tie off all the little tributaries. Then I was to move down to the ankle, make another incision, isolate the same saphenous vein there, and prepare it for the stripper. The stripper was simply a piece of wire, which I would thread up through the vein to the groin; after tying the end of the stripper to the vein, I would pull both stripper and vein out through the incision in the groin. That was what I was supposed to do, and I knew it by heart; I'd read about it, watched it, and thought about it.

Almost without pressure, the supersharp scalpel cut smoothly through the skin in the groin region. I began to dissect with the scissors, but I couldn't control them very well. I changed and used a hemostat clamp, not to clamp a vessel, but to bluntly separate the tissues by opening the clamp after I pushed it into the fat. That method caused less bleeding, and I began to make some headway, going deeper into the thick layers of fat. Down there, deep in the groin, I saw nothing I recognized, nothing; it was like feeling around in the dark — until I stumbled on to a vein. I had no idea which vein it was, but, by slowly cleaning around it, I was able to follow along it to a larger one, which I hoped was the femoral vein. If I was right about that, then the first vein I had encountered was the coveted saphenous vein, but I wasn't sure. I was all thumbs, dropping the instruments once or twice, altogether nervous about my role. After all, what would the surgeon say if I told him I hadn't operated before except to put in cutdowns for IV's and remove warts? I thought about asking him if I had the right vein, but such a confession of ignorance would only have gotten me removed from further participation.

At any rate, I plunged on, hoping I'd found the saphenous vein and not a nerve. The job grew progressively more difficult. In fact, it was a mess. I pushed and pulled on the vein, trying to strip it out, bluntly spreading the hemostat, dabbing blood with a gauze sponge to keep the field clear. Several times the vein broke and blood spread, but I somehow managed to stop it with a hemostat after a few wild stabs in the dark. There was some consolation in this bleeding, because it proved that the structure I had isolated was indeed a blood vessel.

Perhaps the hardest part was trying to get a tie around the hemostats that I had placed deep in the wound to stop the bleeding. Putting the silk around the tip of the hemostat was easy enough, but trying to maintain tension on the first throw seemed all but impossible. Then, when I released the hemostat, the tie I had just made would pop off and the bleeding would start again. All in all, from a technical standpoint I might as well have been butchering a hog. I glanced self-consciously over at the surgeon from time to time, but he seemed oblivious to my trials and intent on his side, where all was under control.

What a way to learn, I had thought. But it seemed the only way. If he had known I was a novice at vein stripping, he wouldn't have let me do it. It was as simple as that. So I pushed on, finally freeing up all the tributaries to the saphenous vein. Even with the tributaries isolated, I was nervous about cutting the vein in two, an irrevocable act. So I went to the ankle and made a cut, locating the saphenous vein easily there because it was the same one I had used doing IV cutdowns. I threaded a stripper up inside the vein and pushed it out through the inguinal incision. After tying the vein to the stripper at the ankle, and using a bit of force, I pulled the whole thing up through the leg, ripping out the vein. A spurt of blood, a sharp crunchy sound, and the vein came out, all shriveled up at the end of the stripper. The surgeon had long since finished the other side and disappeared for coffee, leaving me to sew up the whole job. I never heard anything dire about the day's results, so I assume that the lady was none the worse for my debut.

Despite my having sewed hundreds of incisions in the OR, the first few emergency-room lacerations had been major affairs for me. For one thing, in the ER almost every patient is awake and sharply observant. On my first ER day, when the nurse asked me what kind of suture I wanted, she might as well have asked me for the population of Madagascar. In the OR, the surgeon stipulates what kind of suture material he wants for the skin before the case starts; you merely take what the nurse gives you, even if the surgeon has already departed, the room. But in the ER I was faced with a variety of choices — nylon, silk, Mersilene, catgut — which came in all sorts of thicknesses. The nurse wasn't trying to put me down; she just wanted to be told. "What sutures will you be using, Doctor?" I had no idea. "I'll take the usual, Nurse." "The usual, Doctor?" Obviously, there was no usual. "Uh, nylon," I tried.

"What size?"

"Four-O," I told her, wondering what I was ordering.

Needless to say, I quickly learned about sutures, and also about suturing, but always by trial and error. On the first case, I put in too many stitches, and on the second case, I came to the end of the laceration with too much skin on the top. Slowly but surely I learned the little tricks, like excising beveled edges, and even fancy stuff, like small Z-plasties to change the axis of a laceration in order to reduce scarring. I came to enjoy suturing quite a bit, because it was a clear problem with a neat, clean solution that I quickly enough learned to provide. It made me feel useful, a rare and cherished sensation.

All that learning was behind me now. The surfer was waiting, a sheet over his head. Through the little window at the site of the laceration, I began to clean and anesthetize the area with xylocaine. After trimming the edges slightly, I poised the needle with the attached nylon suture about midway from either end of the laceration and back a few millimeters from one edge. Guided by a rolling motion of my wrist, the needle pierced the skin, traversed the laceration, and emerged on the opposite side. I withdrew it with the needle holder. Then, barely catching the edges of the wound with the needle, I brought the suture back to the original side and tied it, not tight, but just a little loose so that the swelling of the wound would bring the edges together. Four more sutures finished the job.

The other patient was a somewhat mysterious twenty-year-old girl who appeared chronically ill. She admitted to having been diagnosed and treated for systemic lupus erythematosus. The name alone sounds forbidding, and, indeed, lupus is a serious disease. It was one of the diseases we had discussed ad nauseam in medical school because, being so rare and ill-understood, it was good for a lot of academic speculation. So I didn't feel entirely unprepared— except that she was complaining of abdominal pain, which wasn't a common symptom for someone with lupus. Trying to connect the two in my mind, I palpated her abdomen and asked questions about her condition, which either she or her mother answered. Then, needing to think, I went back to the desk-counter in the center of the ER and racked my brains for some association between her pain and her basic disease. While I was trying to come up with a suitably exotic lab test, mother and daughter walked by, said that the pain was gone, thanked me, and went out the door. So much for my challenging diagnostic mystery, and one of the few ER cases that four years in medical school had prepared me for.

At that point, Almost came rushing in and practically collapsed in front of me, putting his forehead on the counter, panting and wheezing. His real name was Fogarty, but we called him Almost because he invariably held off until the very last moment before coming into the ER to be treated for his asthma. It was like waiting until you ran out of gas so that you could coast into the filling station. The nurses led him, blue and heaving, into one of the rooms while I prepared some aminophylline. I had seen Almost several times, beginning with my second day on ER duty. From medical school I knew quite a lot about asthma in terms of pulmonic pressure gradients, pH changes, smooth muscle function, and allergic phenomena, and I even knew about the drugs that were useful — epinephrine, aminophylline, bicarbonate, THAM, and steroids. But I hadn't known a thing about dosages. So, the first time, while Almost was in another room puffing on the positive-pressure breathing machine, I ran into the staff room and looked it up in a paperback. Anything to avoid asking the nurses. Actually, from ward cases I had an idea of what and how much to give a reclining patient. But this guy was walking around, not lying in bed, and that makes a big difference. You cannot use the same amounts. To ask the nurses something else would have demoralized me. Anyway, old Almost and I had gotten used to each other, and an amino-phylline IV did the trick, as usual.

While the ER sometimes got so crowded that patients sat on the floor or stood against the walls, it was more usual to have a steady stream over the twenty-four-hour period, amounting, perhaps, to 120 or so on weekdays and twice that on Saturdays. It was now about 10:30 a.m. The stream had started to run, and I was on my feet, moving quickly from one room to the next, calling the private M.D.'s, not really thinking too much, almost unaware of the omnipresent fear of the next big case.

One chart read "Chief complaint, depressed." Thirty-seven-year-old lady. As I walked into the room she lit a cigarette, cupping her hands around the match as if in a great wind. Throwing her head back with the cigarette precariously perched in the corner of her mouth, she looked at me blankly.

"I'm sorry, ma'am, you can't smoke in here. Those green metal bottles are filled with oxygen."

"All right, all right." Obviously irritated, she ground the cigarette relentlessly in a small stainless-steel dish accidentally left on the examining table. She was silent now. When the cigarette was totally destroyed, she looked up and stared aggressively into my eyes, about ready to explode, I thought.

"Your name is Carol Narkin, is that correct?"

"That’s right. Are you the only doctor here?" She wanted to get at me.

"Yes, the only one here now. But we'll call your doctor, too. His name is Laine, it says here on the chart."

"That’s right, and a damn good doctor, too," she said defensively.

"Have you seen him recently?" I was trying to calm her down with routine questions, working around to why she had come to the ER.

"Don't get smart with me."

"I'm sorry, Miss Narkin, I must ask a few questions."

"Well, I'm not answering any more. Just call my doctor." Angrily she looked away.

"Miss Narkin, what am I to say to your doctor?" She didn't budge. "Miss Narkin?"

Clearly, I couldn't help her, and so I walked out, thinking I'd go back after the next patient. Why had she come here? There was no point in calling her doctor without being able to give him some sort of report. When I returned to see her after a few minutes, she was gone. That was typical of ER work— brief, inconclusive encounters and a lot of wasted time.

Next the nurse pressed five charts into my hand and pointed a bit sheepishly into the next room, where I was confronted by an entire family — mother, father, and three kids — standing there waiting to be treated.

The mother spoke. "Doctor, we came because Johnny here has a temperature and a cough."

I looked at the chart. "Temperature 99."

"And as long as we were here, I thought you wouldn't mind looking at these spots on Nancy's tongue. Show the doctor your tongue, Nancy. Arid Billy fell at school last week. See his knee, see that scrape? Well, it's been keeping him at home, and he needs a note. And George, he's my husband, he has to have a doctor sign his welfare statement because of his back condition, since he doesn't work and since we just came from California. And I've been having trouble with my bowels for the last three or four weeks."

I stared at the faces. The husband didn't meet my eyes, and the kids were busy climbing on the examining table, but the mother was loving it, looking at me excitedly. My first impulse was to throw them out. They should have been at the clinic, anyway, not the ER. We weren't set up for routine outpatient care. But if I indulged my temper, I was sure the mother would complain to the hospital administrator that I had failed to see them in their hour of need. The administrator would report to the attendings in charge of the teaching service, and I would end up getting shit on. That was how much you could count on support.

Besides, it was still morning; bright sun flashed through the windows, and I felt pretty good. Why spoil it? So, instead of getting angry, I looked perfunctorily at the spots and the scrape, and gave them a few pills. But I drew the line at the welfare paper. I couldn't tell anything about a bad back with the resources of the ER; and lots of times I'd treat these guys and see them running around on motor scooters the following day.

The next patient, a drunk called Morris, was also a frequent visitor to the ER. His chart read "Intoxicated, multiple bruises"; the description fit. Apparently the man had fallen down a flight of stairs, as was his habit. When I entered the room, he propped himself up on his elbows with great difficulty, his eyelids half covering his pupils, and bellowed, "I don't want an intern, I want a doctor!" Incredible how such remarks could sink into the tenderest recesses of my brain and cause such havoc. That stupid drunk really hurt my feelings. He made me aware again that I often had to run to the review book for a dosage, that I was scared most of the time, that I had spent four years memorizing a million facts and didn't seem to know anything. With him, I couldn't hold myself back. "Shut up, you drunk old fart!" I shouted.

"I'm not drunk!"

"Any more comments like that and I'll throw you out of here on your head."

"I'm not drunk. I haven't had a drink in years."

"You're so drunk you can't even keep your eyes open."

"I am not." He practically rolled off the examining table trying to point his finger at me.

"You are so." Our level of communication was not high. We continued the childish exchange while I examined him roughly, actually bending my reflex hammer as I pressed it against his Achilles tendons but proving he had tactile sense in his lower extremities. I ended up sending him to X-ray, more to get rid of him for a while than to get films of the bones under his bruises.

About that time of the late morning, the number of patients coming in began to exceed the number going out. A bunch of screaming babies arrived together, as if by conspiracy, and were distributed to various rooms. I really didn't enjoy treating babies. It was rather like my conception of veterinary medicine— zero communication with the patient. Half the time I was forced to ignore the child and try to make some sense out of the mother. Moreover, I found it nearly impossible to hear anything through a stethoscope on the chest of a screaming two-year-old. The usual problems were colds, diarrhea, and vomiting— nothing serious. These kids seemed to anticipate my arrival, saving up so that they could either urinate or defecate while I was examining them.

That Saturday morning was no exception. Children were all over everything, up to their usual tricks. The first baby had had a discharge coming out of its right ear for several days, which the mother thought was Pablum, but she became suspicious when the discharge continued even after she changed the baby's diet. From the general hygiene of the two of them, I thought possibly it was Pablum, but it turned out to be pus. The baby had a roaring infection in both middle ears, behind the eardrums. The right drum had ruptured, causing the discharge; the left drum was still intact, bulging outward from the pressure behind it. It would have been proper to make a little hole in the left drum to release the pus, but I didn't know how to do that, and when I talked to the private doctor, he only wanted me to treat with drugs— penicillin, as usual, and gantrisin, a sulfa drug. When I emphasized the seriousness of the unruptured left eardrum, he cut me off, saying he would see the child Monday morning. Dutifully, I wrote the prescription for the penicillin and the gantrisin.

The next baby had not been eating well for a week. Some emergency. The next one had diarrhea, but only once. It seemed incredible to me that a mother would rush her child to the hospital after a loose bowel movement, but one soon learns that nothing is incredible in the ER. A few other children had colds and stuffy noses and mild temperature elevations.

In order to be thorough, I had to look in every ear, down every throat. This work was often more like wrestling than medicine. Children, even young ones, are surprisingly strong, and although I always entreated the mother to hold the child's arms against its head during the examination, she'd invariably let go and the child would grab for the otoscope, pulling it away and bringing with it a little drop of blood from the ear canal. That made everyone joyous and confident, naturally, but I'd try again, peering into the little hole in the contorting, screaming infant. If any of them had really high temperatures, 104 or over, I'd ask the mothers to give them tepid sponge baths. That morning we had two such cases going. All in all, the ER was sometimes like a pediatric clinic. Of course, there were occasional emergencies, but not as often as the public thinks. Mostly the problems were trivial, stuff that should have been treated in the clinic.

When the odd and horrible thing did happen, the whole staff would become somber and withdrawn for several hours. One morning, a small, dark lady had come in quietly, carrying a small baby in a pink blanket. At the time I hadn't paid any attention to her, being busy with someone else. A nurse took a clean chart and disappeared with the mother. A few seconds later, she reappeared on the run, saying that I should see the child immediately. When I entered the room, the child was still swathed in the pink blanket. Opening it and pulling it back, I saw a blue-black baby, its abdomen swollen to twice normal size and hard as a stone. I couldn't be sure how long it had been dead, but I guessed for about a day. The mother sat in the corner, not moving. We didn't talk; there was nothing to say. I had just looked at the baby, marked the chart, and walked out.

About once a week a pair of hysterical parents charged into the ER with a convulsing child. The child was usually pretty young, and the first time I saw one of those I almost passed out from anxiety. This little girl was about two years old. She lay doubled up, with her arms pressed against her chest; saliva and blood drooled from her mouth, and her whole body shook with rhythmic, synchronous, convulsive jerks. As usual in such cases, the child was out of control of both her urine and her feces. Still terrified, but relieved because the doctor was there, the parents put the girl down on the table. Since they were too hysterical to be of any help, I asked them to wait outside. I also wanted to avoid their judgment of my action — or inaction — for, in truth, I didn't know what to do. Then one of those great nurses bailed me out by handing me a syringe and offering to hold the child while I tried to find a vein. Suddenly I remembered: amobarbital IV. The next problem was getting the needle into the vein. Even on a quiet, resting child, finding a vein can be difficult. On one who's convulsing, it can approach the impossible. How much drug to inject was another dilemma, but I thought I'd just give a little and test the reaction. Finally getting into a vein, after several abortive probes, I gave a squirt, and the child's convulsions suddenly slowed down and then stopped; her breathing stayed strong, thank goodness. My terror of convulsing children decreased somewhat after that experience, especially after I learned to use Valium, or paraldehyde and phenobarbital intramuscularly. But the first time it could have gone either way.

An even bigger scare concerning children had occurred with a seemingly routine case. It served to reinforce my fear that an ordinary situation would deteriorate before my eyes, leaving me helpless. The boy was about six years old, a cute little guy, brought to the scary ER by his overly solicitous parents. He wasn't feeling too well — that was apparent, because he had vomited three times and had other telltale symptoms adding up to the flu syndrome. For the parents' sake as much as the child's, I treated him with an antiemetic drug called Compazine, something I'd used successfully hundreds of time after operations. However, this time I got one of those adverse side reactions you read about at the bottom of the manufacturer's product information sheet — the type of episode the drug detail men don't like to talk about and doctors seldom see. Two minutes or so after the injection the child went into a convulsion, his eyes rolled back, he couldn't sit up unaided, and he developed an obvious rhythmical tremor. The parents were aghast, especially since I had been explaining to them the boy was not very sick. I frantically sedated the child with a little phenobarbital. While I was at it, I probably should have given some to the parents, too, and taken a little myself. I ended up having to admit the child to the hospital. Needless to say, the parents had not been very pleased by this performance, nor had I.

So the early hours of Saturday passed, a combination of glorified pediatric clinic, suturing factory, and occasional true crisis. The few suturing jobs had been routine and rapid. My only disturbing problem had been that bearded fellow, but the hours and the tedium dulled it sufficiently so that the day became a typical one of generalized monotony punctuated by infrequent but memorable moments of terror and uncertainty.

I was actually beginning to like the quick, uninvolved routine of the ER. No patient required such deep attention as to make a real claim on my emotions. I could remember when it had been different, six months ago, back at the beginning of my internship. Mrs. Takura, for instance, had gotten to me. We had become friends; her long operation, throughout which I held the retractors, unable even to see her wound, had been a physical and emotional trauma. When I finally got away from her operation, out to the beach with Jan, I had been secure in my intuition that Mrs. Takura would pull through. Returning to find her dead had been the final, backbreaking straw in my disenchantment with what was happening to me as an intern. I had blown up at the system — at petty day-to-day harassment, the retractors, the lack of teaching, and the constant, nagging fear of failure. It had taken me a long time to get over Mrs. Takura, and, finally, I hadn't so much accepted her fate as merely put it aside, vowing not to get emotionally involved again. It became easier, then, not to let patients get inside me. I began to think of them in hard, clinical terms, as so many hemorrhoids, appendixes, or gastric ulcers.

Roso had also been a trial. Unlike the short time with Mrs. Takura, my rapport with him had developed over several months. I even gave him a haircut, after he had been with us so long that his hair was a shabby mane flowing halfway down his back. He didn't have any money, so I offered to cut it if he wanted me to. He was delighted; perched high on a stool in the sunlight of the alcove by the ward, he seemed proud to be alive. Everybody thought it was the worst haircut they had ever seen.

Roso had always smiled, even when he felt terrible, which was most of the time. In fact, he had nearly every complication I had ever read about, and a few that were not even in the medical literature. His vomiting and hiccups had persisted until another operation became imperative. I was in my familiar position, both hands clenched around pieces of metal and looking at the back of the chief resident for six and a half hours while Roso's Billroth I was converted to a Billroth II; his stomach pouch was now attached to the small intestine at a point about ten inches farther down than usual. It was hoped that this procedure would end Roso's troubles, because the obstruction in his digestive system that was causing them was at the very connection between the stomach and the intestine that had been made in the first operation. But even after this second operation everything on his chart hovered near critical; his course was like a sine wave. Hiccups, vomiting, weight loss, and several horrendous episodes of upper gastrointestinal bleeding kept me busy— especially those bleeding episodes. A week after the Billroth II, Roso vomited up pure blood and rapidly sank into shock. I stayed with him several nights in a row, continuously irrigating his stomach with iced saline, and pulling out the nasogastric tube when it got clogged and pushing it back in. He hung on, somehow, through our mistakes and my miscalculations, and through his own relentless, troubled course.

After the bleeding, nothing would go through his stomach until I was lucky enough to pass a nasogastric tube down through the anastomosis and into his small intestine. Using that as a start, I fed him directly into the intestine with special stuff. Some stayed down — but he got diarrhea. Then one day he sneezed out the nasogastric tube. I had him on intravenous feedings off and on for four months, balancing sodium and potassium and magnesium ions. He developed a wound infection, inflammation of his leg veins, a touch of pneumonia, and a urine infection. Then we became aware of an abscess under his diaphragm, which was causing the hiccups; back to surgery again. Somehow he managed not only to live through all this, but actually to recover. It took me four hours to do his discharge summary; his chart weighed five pounds — five pounds of my own writing, frequently stained with blood, mucus, and vomitus. When he left the hospital, I was happy to see him alive and vastly relieved to have him gone. His case and my attachment to it had been almost too much to bear on top of everything else. At times during his bleeds, administering the iced saline and seeing to his tube, I had begun to wonder if I had set him up as a challenge just because everybody said he wouldn't make it. Maybe I didn't give a damn about him, was just using him to prove to myself that I could handle a tough case. Eventually, though, I stopped examining my motivations and began to treat my patients as hernias, or whatever they had; it was infinitely less wearing. The ER was easy on a brooder. You were always too busy or too tired or too scared to think….

Eleven forty-five in the morning. I was about to go to lunch when a rather pale young woman in her early twenties walked in with two girl friends. After a hushed consultation with the nurse, the pale one followed her into one of the examining rooms. The other two sat down and nervously lit cigarettes. The sound of a New York accent drifted out of the examining room as I wrote the last sentence on a baby's chart and put it in the "Finished" basket. Eager to get away for lunch, I pushed into the room where the nurse had taken the girl. The chart indicated vaginal bleeding for two days, clots that morning. The girl took out a cigarette.

"Please, no smoking here, Miss."

"I'm sorry." She carefully put the cigarette back and looked at me, then away. She was of average build, and dressed in a short-sleeved blouse and a miniskirt. With some color in her face, she would have been pretty. Her conversation suggested no more than a high-school education.

"How many days have you been bleeding?"

"Three," she said. "Ever since I had the D and C." We were both nervous. Wondering if my uncertainty showed, I tried to stand motionless and appear knowledgeable.

"Why did you have a D and C?"

"I don't know. The doctor said I had to have it, so I had it, okay?" She feigned irritation.

"Where was it, here or in New York?"

"New York."

"Then you came here right away?"

"Yeah," she said. She really had an accent. The fact that she had come to Hawaii so soon was off center. A six-thousand-mile trip directly after a D and C was not standard medical procedure.

"Was it done by a professional person?" I asked.

"Of course. Whaddaya mean, by a professional person? Who else?"

What to do? If she had had an abortion — and I was pretty sure of it — I knew I would have some difficulty getting a private M.D. Also, I remembered all too well from medical school a string of girls in endotoxin shock from infections caused by bad D and C's. It can happen so fast; the kidneys give up and blood pressure disappears. However, this girl's blood pressure was obviously all right for the moment. In fact, she was functioning well in all respects, except that she was quite jumpy and a little pale. I wondered if she was trying to follow my thoughts. She need not have worried. I didn't care how she had gotten into her condition, only how to get her out of it. My chances of discovering the exact cause of her bleeding were pretty small. She'd probably have to have another D and C. In that case, I would try to locate a private gynecologist, but few of them cared to get mixed up in such an affair — picking up someone else's pieces, so to speak. One way or another, a pelvic examination was in my future, and that was the last thing I wanted right before lunch.

The memory of my first pelvic floated across my consciousness. It had been during a second-year medical-school course in physical diagnosis. I had had no preconceptions, which was fortunate, because my patient was quite a hefty lady. She was a clinic patient in for a regular checkup. At first I didn't think my arm was long enough to reach the uterus, and the guy after me claimed he lost his watch— although he found it later in the bag where we threw the gloves. At the time, we had not yet been through obstetrics or gynecology, and reaching into the lady was strangely unsettling. But after a hundred or so, a pelvic examination is a routine like any other. The only problem is finding the cervix — which might seem absurd, because it's always there. But when there's a lot of blood and dots, the job can be hard, particularly if the patient is uncooperative. Moreover, you don't want to hurt the patient by fumbling around. So it pays to take a few minutes extra and do a good job. But not before lunch.

"How long had you been pregnant?" I suddenly asked the girl from New York.

"What?" She was sputtering again, in obvious surprise. Since it was important for me to know, I let the question hang in silence. "Six weeks," she said finally.

"And was it a doctor or someone else?"

"A doctor in New York," came the resigned answer.

"Well, we'll do what we can for you," I said, and she nodded in relief.

Leaving the room, I told the nurse to get her ready for a pelvic. In a matter of minutes the nurse reappeared to say that everything was ready, and when I walked back in the patient was draped and waiting nervously in the stirrups, with her skirt rumpled around her waist. As I prepared to insert the speculum, I couldn't help recalling a night six weeks before when I had been waked up by a nurse saying that she couldn't catheterize an elderly patient with a full bladder because she couldn't find the right hole. I had gotten up and been halfway over to the hospital before the ridiculousness of the situation hit me. If the nurse couldn't find it, how could I? But I did, after a while; it was just a matter of persistence.

It was the same with finding this cervix. Persistence. Surrounded by blood and clots, which I cleared away as best I could, the cervix suddenly popped into view. The orifice was closed, and no new blood appeared when I dabbed it with a sponge stick. I pushed down on the abdomen, to the girl's great discomfort, and got nothing. Then I noticed a small tear, bleeding very slowly, on the posterior aspect of the cervix. Almost surely that was the problem. I cauterized it with silver nitrate, called a gynecologist, explained things, and walked over to lunch with a unique feeling of accomplishment. Miraculously, I was still hungry.

Lunch was a rapid affair; fifteen minutes of stuffing down two sandwiches and a pint of milk amid careless banter of surfing, surgery, and sex. Nothing serious — there wasn't time for it. I made some tentative plans with Hastings to go surfing late the following afternoon about four-thirty. Carno was eating at a distant table; except for seeing each other at the hospital, we rarely got together any more. I also talked with Jan Stevens for a few minutes. I hadn't seen much of her lately, although during July and August, early in my internship, we had had quite a spree, culminating in an unusual weekend trip to Kauai.

The first day, Saturday, had been great. We stocked the car with beer, cold cuts, and cheese, and drove to the big Kauai canyon. On the way, the road rose and fell among the clouds, moving us in and out of quick rain squalls as the sugar-cane fields rolled by on either side. The canyon was even more expansive and spectacular than we had expected. I found a lookout for us, and Jan turned the groceries into sandwiches. I asked her not to talk — a necessary precaution, because as our relationship had developed so had her desire to communicate. The view was wonderful, what with rainfall, waterfalls, and rainbows sparkling in the corners of the steep valleys that branched off from the main canyon. I was totally at peace.

By late afternoon we had driven to the end of the road on the northern shore, right at the beginning of the Napali coast. In a secluded grove of evergreen trees, I put up our borrowed pup tent, and as the sun prepared to set among the puffy little clouds along the horizon, we swam naked in the still waters within the protective reef. It didn't matter that there were campers in full view at the other end of the beach — although I wondered why they were so near the water, rather than where we were, on higher ground among the pines.

Somewhat self-consciously we ran up to the car. I pulled on a pair of white jeans and Jan wriggled into a nylon windbreaker. Even another meal of cold cuts and beer couldn't destroy the atmosphere. Night descended rapidly, with the sound of breaking surf on the reef mingling with the soft whisper of the breeze through the evergreen trees above us. The night creatures began their eerie symphony, increasing in intensity until they dominated even the sound of the surf. The western sky was just a smudge of red. Jan looked beautiful in the half-light, and the idea of her in nothing but that nylon windbreaker seemed fantastically sexy. In fact, I was delirious with the sensuality of the moment.

Naked once again, we returned to the beach. As we slid into the water the full Hawaiian moon floated over a ridge of trees; the scene was so perfect it seemed unreal. I couldn't stand it a second more. Holding hands, we ran back to the tent and fell together on the blankets. I wanted to devour her, to capture the moment in my mind.

Slowly and reluctantly, from the depths of this wet embrace, I became aware of the whine of mosquitoes. In our desire to make love, we tried to ignore them at first, but they began to bite as well as whine. No passion could have resisted that onslaught. In dreadful seconds the whole sensual atmosphere disintegrated, ending with Jan's departure to the shelter of our Volkswagen. Still shaking with desire, I resolved to stick it out in the tent rather than sleep crammed into a car built for midgets. I rolled up in one of the blankets so that just my nose and mouth were vulnerable. Even so, the mosquitoes bit me so relentlessly that my face began to swell, and finally I surrendered, trudging back to the car accompanied by a swarm of mosquitoes who seemed as unfulfilled as I was.

I knocked on the window, and Jan sat up, wide-eyed, opening the door with relief when she recognized me. I stumbled in wearily and told her to go back to sleep. After smashing the mosquitoes that had come in with me, I somehow fell asleep myself, under the steering wheel, in a contorted ball. In about two hours I awoke sweating. The temperature and humidity had risen to Turkish-bath levels; the moisture was so thick it had condensed on all the windows. Opening a side window, I felt a cool rush of air and about fifty mosquitoes come into the car. That was that. I started the engine, told Jan to relax, and drove out to the main road and back toward Lihue, until I found an elevated spot with a good wind, where I managed to doze until the sun came up. My breakfast was bread and cheese mixed with ants and sand and washed down with warm beer, all eaten off the hood of the car. Then I woke Jan up and we drove back to town.

Somehow Jan and I had drifted apart after that. Not that I blamed her for the weekend. It was more because she began heckling me a lot, especially after we started sleeping together, wanting to know if I loved her, and why not, and what was I thinking about. I loved her sometimes, in a way that was hard to explain; as for what I was thinking, most of the time we were together my mind just drifted. Anyway, I couldn't cope with her questions. It had simply become convenient to let the whole thing slide back into casual friendship. But it was nice seeing her in the cafeteria. She was still a great-looking girl.

The ER had completely changed in the fifteen or twenty minutes I took for lunch. A new group of people stood waiting, and eight fresh charts were waiting in the basket. Obviously no real emergencies were at hand, or the nurses would have called me immediately. Just more routine stuff. One of the new people was a chronic visitor to the ER, in for his usual shot of xylocaine to ease an alleged back disorder. His arrivals were so frequent and predictable that the nurses always had a needle full of xylocaine ready and waiting for me on the tray next to the patient. Kid Xylocaine, as we called him, had developed a certain expertise about his condition, and this was his time to shine, as he directed me where to insert the needle, how to insert it, and how much to give. Feeling somewhat victimized by this ritual, I nevertheless did what he wanted; he sighed with apparent relief and left.

Walking next into Room B, I was greeted once again by my drunk friend Morris, who had returned at last from the X-ray department. Flopped on an examining table and secured by a wide restraining belt, Morris held a large manila envelope filled with fresh X rays. He greeted me. "All I ever get is a goddamn intern. I don't know why I come here any more."

Lunch had made me mellow and somehow able to ignore this prattle as I took the X rays out of the envelope and began to hold them up, one at a time, against the light of the window. I didn't expect to find anything of consequence, except perhaps in the upper left arm, which was badly discolored. Earlier, when I lifted and rotated the arm, Morris had rewarded me with a stream of obscenity. Something might be amiss there. I went through the whole stack of X rays — left knee, right knee, pelvis, right wrist, left elbow, left foot — on and on, without finding anything for the left arm and shoulder. Not there. Nothing to do but have the nurse return Morris to radiology. "They're going to love you up there, Doctor Peters," said the nurse. "He terrorized the X-ray department all morning and used up two boxes of film."

"That doesn't surprise me," I said, picking up a handful of new charts and heading for Room C.

The afternoon babies were much like the morning babies, suffering mostly from colds and diarrhea. One had to be sponged for a temperature of 104.2, and another, about four years old, needed suturing for a laceration on his chin. Suturing children is very, very difficult. Their terror at being brought to a hospital, often bleeding and in pain, is only made worse by the papooselike contraption they are strapped into to keep them still. Not even the papoose could immobilize this boy's chin; it was like hitting a moving target. The worst part for him was being under the sheet with the hole in it. After the sting of the xylocaine, he didn't feel much of anything but pressure and slight pulling. Yet he screamed just the same, and hated it all the way. So did I.

A thirty-two-year-old man in another room had a catalogue of complaints, beginning with a dry throat and proceeding down the body. His real aim was to be admitted as a hospital patient, and when he realized that the dry throat hadn't impressed me very much, his trouble shifted to a right-side chest pain. To test his reaction, I finally told him the hospital was already overcrowded, whereupon he stormed out in a rage, complaining that when you really needed a hospital it was always full.

The afternoon drifted by in a carelessly busy way. By now I had seen about sixty patients, par for the course, with no more than the usual sweat. But Saturday night was approaching, and that always meant trouble. Two older men with asthma walked in together, and the nurses put them into separate rooms with the positive-pressure breathing machines. The gentleman in Room C was wheezing away, his bony chest held at almost full inspiration, his back straight, hands on his knees. I asked him if he smoked. No, he answered, he hadn't smoked in years. Reaching down, I slowly pulled the pack of Camels out of his shirt pocket, his eyes following my hand until he saw the cigarettes. When he looked up at me, the expression on his face, even in his suffering, was so comical yet warmly human that I couldn't help smiling. It was like catching a small boy in a piece of silly mischief. Much of the emergency room's appeal lay in its lavish display of the variety and folly of humankind.

Old friends kept turning up. Another drunk, well known to us, stumbled in, complaining of a fall over a rocking chair that had left him with a chronic leg ulcer! I had seen the same ulcer a few weeks before when the drunk was a ward patient — an eventful time for all of us. Despite rigorous security measures, he had stayed drunk for days on end, and his discharge was probably hastened when the chief resident found him behind the blood bank with two bottles of Old Crow and a female patient. This time I bandaged his ulcer and told him to come back to the clinic on Monday.

Between the drunks and the crying babies with colds, an ambulance pulled up unannounced, without siren or flashing red light. That meant it wasn't much of an emergency. When the stretcher was unloaded, it revealed a thin lady of about fifty dressed in dirty, ragged clothes. I followed one of the nurses, who was saying they couldn't get any response from this patient. And neither could I. The lady just stared at the ceiling, breathing heavily. She had a small laceration in the hairline of her forehead, but it wasn't even suturable. She seemed fully conscious, and yet she was totally immobile. I began a neurological exam, testing first her pupils and then her reflexes. No bad signs. But when I tried to do the Babinski test, by lightly scraping the bottom of her foot with a key, she practically hit the ceiling, screaming that there wasn't anything wrong with her feet, it was her head that hurt, and why was I fooling with her feet? She jumped off the examining table and disappeared down the hall, with a nurse in hot pursuit. Finally, we called the hospital administration and the police, who ended up dragging her away still screaming that she was all right.

Down in Room F was an elderly gentleman who had run out of his diuretic, or water-eliminating, pills and whose legs were swollen with excessive fluid. He turned out to be one of those people with a remarkable talent for talking continuously and apparently sensibly without saying anything at all. A torrent of words rolled out as I tried to examine him. He spoke of his extrasensory perception and of the many times he had been able to use it, especially in communicating with his wife, who had died several years previously. Against my will I paused to listen while he described how he could take a bottle of water and distill it into his own model of the universe. In fact, he thought the earth was one small portion of one molecule of some gigantic object from another universe in another dimension. A little dazed, I gave him a supply of pills, told him to stay off his feet for a while, and took up the next chart.

It was important to listen to these patients, despite the craziness and trivia. Every so often their ramblings were significant Once in the medical-school hospital a man had checked in to the ER complaining that he had eaten several shot glasses, without the usual complement of bread. The resident and intern began to escort him out the door, with the suggestion that he return in the morning, when the psychiatry department was staffed. Seeing their disbelief, the man grabbed at the intern's pocket, coming away with a test tube and a wooden throat swab, both of which he quickly chewed up and swallowed while the house staff watched in paralyzed disbelief. They turned him around, then, and led him back to the examining room, softly suggesting that he stay overnight. In the X ray, his abdomen had looked like a bag of crushed marbles.

"Goddamn hospital. I'm never coming here again. Next time I'll go to St. Mary's." This was from the ubiquitous Morris, as he was rolled by on an examining table. Evidently he was to haunt me all day long, although I took some hope from the fact that now he appeared to be holding the X ray of his upper left arm. Perhaps I could get rid of him, after all.

"Doctor, a call for you on 84," said one of the nurses.

I already had the receiver to my ear, listening to a busy signal from my third effort to reach a Dr. Wilson, one of whose patients had come in suffering from a urinary-tract infection. Feeling frustrated, I pushed the burton for 84.

"Dr. Peters."

"Doctor, my boy has a terrible headache, and I can't find my doctor. I don't know what to do." Her story hung in my head, blending with the din of crying babies in the background. We didn't need another aspirin case, but there was no way for me to tell her not to come. Reluctantly I answered, "If you are convinced that the boy is ill, then by all means bring him to the emergency room."

"Doctor, a call on 83." I told the nurse to put it on hold while I redialed Dr. Wilson, steeling myself for another busy signal. Instead, there was a ring and Dr. Wilson answered. "Dr. Wilson, I have a patient of yours here, a Mrs. Kimora."

"Mrs. Kimora? I don't think I know her. Are you sure she's one of my patients?"

"Well, she says so, Dr. Wilson." It frequently happened that doctors couldn't remember their patients' names. Perhaps a description of her problem would jog his memory, and it seemed to as I went on. "She has a urinary-tract infection, with heavy burning on urination, and her temperature—"

"Give her some gantrisin and send her to my office on Monday," he said, interrupting me.

I paused, fighting an urge to hang up. Why didn't he want to hear about the case — her temperature, urinalysis, blood count? "How about a culture?" I asked.

"Sure, get a culture."

"Okay," I pushed 83 to take the call on hold.

"Doctor," a voice wailed on the other end, "I just had a bowel movement and there's blood in it?"

"Was it bright red on the toilet paper?"

"Yes." We established that her hemorrhoids were the probable cause of the bleeding and that she wouldn't have to come in to the emergency room, just see her physician on Monday. With a sigh of relief and profuse thanks she hung up. The nurse was holding another call, on 84, but this sort of thing could go on indefinitely, and I ignored it. Instead, I went back to Mrs. Kimora and explained very carefully about the gantrisin, that she would have to take two of the pills four times a day. A nurse took the urine for culture.

Now for Morris. Immobile on the table and apparently somewhat less drunk than before, he greeted me with his usual cheer. "I wanna get outa here." At least we agreed on that. Taking up the next X rays I held them against the light and saw immediately, with great disappointment, that he had a sharp fracture halfway between his elbow and his shoulder, as if he had taken a good karate chop. He would be with us a while longer.

"Mr. Morris, you have a broken arm." I looked at him sternly.

"I do not," he countered. "You don't know what you're doing."

Wanting to avoid another yes-you-do-no-I-don't series, I retreated and rapidly wrote an order commending Morris into the hands of the orthopedic resident. The nurse called the switchboard operator and put the resident on page.

By midafternoon I was barely keeping abreast of he crowds. About 4:00 p.m. we were briefly overwhelmed by a bunch of surfers with lacerated scalps, cut fingers, and deep coral cuts. The surf was up! The babies seemed unending, crying in every corner, with their temperatures, diarrhea, and vomiting. I was suturing madly, sending people to X-ray, and desperately trying to look into the ears of totally uncooperative children. One mother came in quite frantic, saying her baby had fallen down a third-floor rubbish chute with the garbage. I was tempted to inquire exactly how that had happened. But instead of asking any questions, I examined the child, and removed onion rings from his ear lobes and coffee grounds from his hair. Amazingly, he was quite intact. But I sent him to X-ray because his right arm appeared to be a little tender, and it did turn out that he had a greenstick fracture of the right humerus— about the least you could expect after falling three stories into a pile of garbage.

Meanwhile, the X rays were piling up, all different kinds, from skulls to feet. I was the first to admit I wasn't much good at reading these things. But that was the system — the intern read the X rays at night and on weekends. It didn't make any difference that we were badly trained for the job; we had to do it as best we could. Knowing my lack of qualifications, I was always fearful of missing something important— especially after the humbling experience with the toe. That incident had occurred one other Saturday night, when a girl came hobbling in on the arm of her boyfriend. She had stubbed her toe. When I sent her up for an X ray, her friend went along. About an hour later, in the middle of pandemonium, I looked at the X rays, mostly at the metatarsals, and told them that they were apparently negative and— The friend interrupted quietly to say that when he saw the film he thought there was a fracture. I paused and gulped. "You did?" Back at the X-ray view box, he pointed out a line in the middle phalanx of the third toe that was definitely suspicious and could have been— indeed, was — a fracture. So it goes in on-the-job training!

Morris was now conveniently stashed away in the orthopedic room, out of earshot. The orthopedic resident had responded to his page, examined Morris and his reams of X rays, and disappeared, after trying unsuccessfully to reach the on-call staff orthopedic attending. Morris would stay in the orthopedic room until the attending was contacted. So Morris was an albatross still to be carried, but he wasn't around my neck any more. I forgot about him.

Around five-thirty the whiplash injuries started trickling in. That was standard whenever traffic got heavy and cars began piling into one another out on the freeways. Anyone claiming a whiplash injury needed a careful palpation of the neck, a thorough neurological exam, and a cervical spine X ray before his doctor could be called. All these X rays looked frightfully the same, and when I slipped one of them on the gigantic view box in the middle of the ER I felt as transparently vulnerable as the negative of itself. Moreover, the patients were always there, peering anxiously over my shoulder while I read their films. I only hoped they were impressed with my wizardry at making so much out of those smudgy black, white, and gray pictures of bones and tissue. It was mostly for their sake that I generally faked a thorough analysis, lingering a little longer than necessary over some part of the negative. Actually, anything I could diagnose had to be pretty far out of line or clearly broken in two, which took about ten seconds to determine. Anything else was a lucky hit. But you couldn't let the home team down, so I would gaze knowingly at the negatives, mumbling to myself and making notes, while the patient fidgeted, expecting the worst.

As the clock slid around to six, our traffic unaccountably fell off, giving me a short respite. I even began to get a little ahead, and after I dug a large fishhook out of a middle-aged man, no one else was waiting. The ER was suddenly peaceful; outside, the golden afternoon sun cast a long shadow of violet across the parking lot. This was the calm before the storm, a temporary armistice between battles. Feeling tired and lonely — surprisingly lonely, with so many people around — I ambled over to dinner. On the way I passed a few people waiting for rides home. Those who had come from the ER nodded pleasantly and smiled; I smiled back, glad to have the unusual second contact and hoping I had done right by them. Interacting with the patients outside the hospital made all of us seem more real and took away some of the fear that dogged us as we came to expect disaster in every movement of the clock.

Sitting down was a luxurious experience. I stretched my feet out under the table onto a chair opposite. Joyce came along and sat by me, which was pleasant, although we didn't have much to say to each other. She was full of laboratory gossip and blood counts, which threatened to give me indigestion; nor did I want to discuss the ER. I ate rapidly, knowing that each bite might be my last for the night. At least that part of television's view of medicine is dead right. We ended up talking about surfing with another intern, named Joe Burnett, from Idaho.

Every intern needs an outlet, a safety valve; surfing was mine. It provided the perfect detachment and escape. Not only was the environment different in sound, sight, and feeling; on top of a decent wave, struggling and concentrating to make the shore, no other thought was possible. As the months passed and my addiction to surfing grew, I began to understand why people follow the sun in search of the perfect wave. I suppose it's healthier than drugs and alcohol, but its grip is just as strong, and a bad move can kill you. Hawaii does not publicize that last fact very widely.

But never mind that. Even if the waves weren't good, beauty was all around. And who could tell? — any minute a big one might rise up to challenge you. Surfing is its own thing, basically unlike any other sport, although it superficially resembles snow skiing. The difference is that in skiing the mountain stays still; on a wave everything moves — you, the mountain, the board, the air around you — and when you fall off your board in a big wave you have no say about where you go. All you know is you weren't meant to be there. So Joe and I talked about surfing, excitedly describing little episodes, our hands and feet motioning and moving, telling how the waves curled, how we got locked in or wiped out, everything. And I forgot about the ER.

Curiously, surfing is not a sociable sport except when you are away from the water talking about it. Out there on your board you hardly speak. You're part of a group of detached people held together by a bond of water, but you are unmindful of the others except to curse if someone drops in on your wave. Every wave you catch is somehow your wave, even though you don't go surfing alone. You always go with someone, but you don't talk.

The phone rang for me, and I had to break off with Joe; the ER was getting some business. It wasn't peaceful any more when I arrived. During my thirty minutes away, more babies had come in, crying with the usual complaints. A teen-aged girl complained of cramps. I asked her how much relief she had obtained with aspirin. She hadn't tried any aspirin yet. I gave her two. Another miracle cure worthy of four years of medical school. And the colds. There were several people with plain old garden-variety colds— runny nose, irritated throat, cough, the usual. Why they had to come to the ER was beyond my comprehension. Even though I had reached my third wind after dinner, any humor in the situation was going right by me unnoticed. People were waiting to be sutured, and I had to see those with runny noses.

One of the suturing jobs was a little out of the ordinary. A lady had cleanly sliced off the tip of her index finger with a carving knife. She had been swift enough to rescue the little piece, and after I soaked it for a while, I sewed it back in place with very thin silk. All this was done while the private M.D. gave explicit instructions over the telephone. Had I seriously expected him to come down and do it himself?

One of the back rooms held an elderly man who was troubled by back pain and inability to hold his urine. The latter symptom was clear enough from the smell in the room, which nearly overpowered me as I examined the man by degrees, ducking into the hall from time to time for fresh air. Bad smells were still my bete noire. I thought maybe he should be admitted to the hospital, since he had a urinary-tract infection and obviously couldn't take care of himself.

However, the first attending I called knew him and didn't want him as a patient. He told me to find another doctor. Seems that the old man was a notoriously bad patient, famous for disappearing from the hospital without being discharged, and always turning up again on weekends or in the middle of the night. The next doctor refused, too, and suggested yet another. Finally, after calling five M.D.'s, I got one to agree to take him as a patient, but as the nurses were preparing the man for admission they discovered he was a veteran. All my efforts on the phone flew out the window; now we had to ship him to a military hospital.

Passing by the entrance on my way to see another patient, I nearly bumped into a young woman of about twenty, clutching a poodle as she was propelled by a man not much older than she. She was screaming that she didn't want to talk to any goddamn doctor. That was fine with me; I proceeded into the room where I was going. But I had to see her anyway, eventually, and when I did she wouldn't say a word; it would have been easier to communicate with the poodle, still tightly clutched. I decided to let her sit a while, but that was a mistake, because a few minutes later she dashed down the hall and disappeared. I was too busy to take much notice — until the family psychiatrist arrived shortly thereafter with the girl's parents. It seems that the hospital had called the police when the girl was found outside pulling up flowers. I was a little surprised to see the psychiatrist — I always had so much trouble getting any of them to come in on weekends or after 4:00 p.m. I could count on having two or three psych patients on Saturday night, a bad time for them. Since I never got a psychiatrist to come around, I just did what I could to make the patients quiet and comfortable; but a light sedative and kind words don't do much for them.

"Doctor, 84," a nurse called to me from the main counter. I picked up the phone outside Room B and poked the 84 button.

"Peters, this is Sterling." Sterling was the orthopedic resident. "I finally got hold of Dr. Andrews, who's covering staff orthopedics this month, and he thinks that a hanging cast would do for Morris."

There was a pause. I began drawing interconnected circles on the scratch-pad by the phone. This bastard Sterling didn't intend to come down and put on a hanging cast, whatever the hell that was.

"Why don't you have a go, Peters? And if you have any trouble let me know, okay?"

"I've got about eight patients here I haven't even seen yet."

"Well, if he has to wait too long, call me back."

"For Christ's sake, Sterling, he's been here since ten o'clock this morning. Don't you call that long? I mean nine hours?"

"Aw, that's all right. Give him a chance to sober up."

Arguing with Sterling involved more effort and thought than I wanted to put into it, and, furthermore, it went against my new determination to keep my distance, not to get pissed off. "Okay, okay, I'll get to it as soon as I can." I hung up the phone, mentally mapping out the next half hour.

"Nurse, have the attendant draw up some warm water and get a supply of plaster ready down in the ortho room."

"What size plaster, Doctor?"

"Two- and three-inch, four rolls of each."

Putting on my most nonchalant air, I wandered into the doctors' room and quickly scanned the shelves for a book on orthopedics. Mercifully, I found one and turned rapidly to the index. There it was— cast, hanging, see page 138, which turned out to be a discussion of breaks and fractures of the proximal humerus, just what I was looking for. Despite my apprehension at being shoved into still another strange task, I was impressed by the ingenuity of the hanging cast, which did, in fact, work by a kind of traction. Rather than encasing the patient's whole arm and shoulder, the cast was placed only around the area just above and below the elbow, where its weight would pull downward on the fractured bone and ease it back into alignment. The whole arm was then pulled into the body by swathing the cast to the chest; this held the arm immobile but allowed movement in the shoulder. Amazing.

A nurse stuck her head in. "Doctor, there are nine patients waiting."

I knew that I would hear from the nurses if a real emergency arose; now was the time to get rid of Morris once and for all. After replacing the book, I headed toward the ortho room, somewhat better prepared to make a hanging cast than I had been five minutes before. As I entered the room, it became obvious why Morris had been easy to forget for the past hour or so. He lay on the examining table fast asleep, snoring lightly, cinched in place by a broad leather strap. Nor did he awake when I cranked him into a sitting position, holding his head to keep it from flopping over. Damn that Sterling; this was his job. I had heard the television blaring in the background while he was talking on the phone with me. After cutting Morris's left shirt sleeve off at the shoulder, I fashioned a piece of stockinet for the underside of the cast and slipped it on his arm, trying not to disturb the fracture.

"Doctor, there's a call on 83."

I didn't even answer the nurse, hoping that whatever it was would solve itself.

"Ohhhhh." Morris came to when I positioned his arm for the cast. "What are you doing to me?"

"Mr. Morris, you broke your arm falling down the stairs, and I'm putting a cast on it."

"But I don't—"

"Yes, you do! Now don't say another word." I hoped Sterling would ask me for a favor some day. After soaking the plaster rolls in water long enough for the bubbles to stop, I wrapped them around and around Morris's arm, building the cast up layer on layer. I made it big, almost an inch thick. Since it functioned by its weight, mine was going to work very well.

"Now just stay where you are, Mr. Morris. Don't move. Let it dry."

Reaching the main portion of the ER, I picked up 83, but no one was there. Good strategy. It was only seven-thirty; I was already eleven patients behind, and I knew it would get worse. Grabbing a handful of charts, I started off, glancing at the top one: "Skin rash."

Skin problems drew a blank in my mind no matter how many times I read and reread the descriptions of papulosquamous erythematous pruritic vesicular eruptions. The words lost all sense, twisting and turning in my memory so that if I saw a patient with anything other than acne or poison ivy I was lost. And there in front of me stood a man with a violent pruritic eczematous erythematous rash. I knew what it was, because a dermatologist had used those words to describe my sunburn after an Easter week in Miami during medical school. It meant itchy, wet, and red, but dermatologists preferred complicated scientific jargon. In fact, dermatology is the only branch of medicine still using Latin to any great extent — appropriate, in a way, since I couldn't see that the science had advanced very far since the days of alchemy. Although the terminology and the diagnosis of skin disorders were difficult, the treatment was simplicity itself. If the lesion was wet, you used a drying agent; if the lesion was dry, you kept it wet. If the patient got better, you continued what you were doing; otherwise you tried something else, ad infinitum.

The patient standing before me was a skinny, sallow-faced fellow with dark hair, bushy and unkempt. Looking at his hands and his arms, I couldn't think of a thing except how little I knew about dermatology. He didn't have a private doctor, which meant I would have to call one, and I wondered what I could say without sounding like an idiot.

I noticed that the rash was on the palms of his hands, too, and some distant bells began ringing in my mind. Only a few dermatological disorders occur on the palms of the hands. Syphilis is one. Hmmm. I was so involved with my own thoughts, I hardly heard the patient when he said that he had neurodermatitis and needed more tranquilizers. I was still trying to remember the exact list of those diseases that occur on the palms when his words suddenly scored in my consciousness. Neurodermatitis. With practice, I had developed an ability not to show surprise or gratitude when such sudden gifts of diagnosis were presented, and I continued to look at his arms knowingly until sufficient time had elapsed. It made me feel that my knowledge of dermatology at least equaled his when I guessed correctly, that he was on Librium. He was thankful to get some more.

As evening spread into night, my steps became labored and slow, and my fear mounted, giving rise in my imagination to a series of hopeless cases waiting to descend upon me. There was no pause in a continual stream of patients that kept me always five or six people behind. My suturing became more rapid, out of a combination of necessity and diminishing interest. Whenever I sutured, the people waiting stacked up, so I had to be fast, dispensing with trimming the edges and other fancy stuff. I was not haphazard, just less careful, and perhaps more easily satisfied. As, for instance, with the man who had a flap laceration on his arm. During the daytime I probably would have excised the flap and closed it as a linear cut. Now I just sewed it up, flap and all, hoping for the best.

In the eye-and-ear room a four-year-old boy sat forlornly on the examining table. His grandfather stood nearby. As I entered, the boy started to whimper, putting his arms to his grandfather, who held him while I read the chart. It said, "Foreign body, right ear." After talking quietly with the little guy for a few minutes, I convinced him to let me look in his ear. Far up in the canal I could see something black; it looked like a raisin or a small pebble.

Since the grandfather didn't know an ear, nose, and throat man, I picked one out of the M.D. roster, a Dr. Cushing, and gave him a call.

"Dr. Cushing, this is Dr. Peters at the ER. I have a four-year-old boy here with a foreign body in his ear.

"What's the family name, Peters?"

"Williams. The father's name is Harold Williams."

"Do they have health insurance?"

"What?"

"Do they have health insurance?"

"I haven't the slightest idea."

"Well, find out, my boy."

What a scene, I thought, retracing my steps into the eye-and-ear room. With a dozen people waiting, I've got to find out about the health insurance. No, the grandfather said, they were not insured.

"No, no insurance, Dr. Cushing."

'Then see if any of the adults are employed."

Once again I returned to the eye-and-ear room to quiz the concerned grandfather. Actually, I knew that this information gathering was easier than calling a dozen or so physicians until I found one who wasn't so concerned about getting paid; but it seemed gross and inhumane, just the same.

"Both the parents are employed, Dr. Cushing."

'Tine. Now, what is the problem?"

"Little David Williams has a foreign body in the ear, something black."

"Can you take it out, Peters?"

"I suppose so. I can try."

"Good. Send them to my office on Monday, and call me back if you have any trouble."

"Oh, Dr. Cushing."

"Yes?"

"I had a little girl in here this morning with infections in both middle ears." The Pablum child suddenly came back into my consciousness. "One drum was ruptured, and the other was bulging out. Should I have drained it?"

"Yes, probably."

"How do you do that?"

"Use a special instrument called a myringotomy knife. You merely make a tiny incision in the lower, posterior part of the eardrum. It's very simple, and the patient gets immediate relief."

"Thanks, Dr. Gushing."

"Not at all, Peters."

Thanks for nothing, Dr. Gushing. After all that nonsense, I had to go fumble for the foreign body myself. As for incising the eardrum, I decided that I should consider myself instructed on the procedure.

Back in the eye-and-ear room, I immobilized the boy and reached into his ear, trying to grab the black object. It came apart as I pulled the forceps back, and when I looked at what came out I didn't want to believe my eyes. It was the back leg of a cockroach. The little fellow was sobbing now as I dug out the cockroach piece by piece, feeling sorry for the boy and wanting to have it over and done with, nearly vomiting with revulsion. The last few pieces came out with a great gush of irrigation. The boy's crying gradually subsided, and I swabbed out the ear with disinfectant. He seemed all right, but I felt pretty faint.

Throughout the last of this procedure, a nurse had been fidgeting behind me. She now informed me, somewhat icily, that Morris was still waiting down in the ortho room. Sometimes these nurses bugged me nearly to death, especially at night. I did feel a bit guilty about Morris, though, because he had been with us for almost twelve hours now, and I suppose my guilt added to my animosity toward the nurse. Being deep in sleep, Morris couldn't have cared less. His cast was quite dry. Unfortunately, I had to wake him up in order to bind the cast to his body with an Ace bandage, and in so doing I came in for a little more verbal abuse, which seemed to me not quite up to Morris's usual standard. What bothered me a bit was whether Morris would be able to move his shoulder, with his left arm bound so closely to his chest. But I was doing it by the book, and the clinic would ball me out on Monday if anything was amiss. Returning to the main part of the ER, I told the fidgety nurse that Morris could go home, if she could find time between coffee breaks to give him a tetanus shot.

By ten o'clock the place was really hopping, jammed full of all manner of bodily ills. With the rise in clientele, I had fallen slightly further behind, perhaps by a dozen charts. Standing quietly in the middle of the main waiting room was a woman who wanted me to examine a small puncture wound on the bridge of her nose inflicted some eight hours earlier by a pair of pruning shears. Her name was Josephs. I didn't know why Mrs. Josephs had waited so long, but, in any case, her doctor had sent her to the ER for a tetanus injection. That was sound enough. However, the tetanus toxoid only helps the body to build immunity; furthermore, it is a slow worker. It seemed wise to supplement the tetanus shot with some premade antibodies for temporary protection, especially on a wound over eight hours old. We had just received a new shipment of a very good human-antibody serum called Hypertet, but I couldn't give it to Mrs. Josephs without first calling her physician, a Dr. Sung, who was well known for his sharp tongue and antiquated medicine. I dialed his number with trepidation.

"Dr. Sung, this is Dr. Peters at the ER. Mrs. Josephs is here, and I am about to give her the tetanus shot, but I feel she should have something to hold her until the shot takes effect."

"Yes, you're right, Peters. Make it a dose of horse antitoxin, and do it quickly, please. I don't want her to wait."

"We have a very good human tetanus-immune globulin called Hypertet, Dr. Sung. Wouldn't that be better than the horse serum? It's much faster, and besides—"

"Don't argue with me, Peters. You don't know everything. If I wanted Hypertet, I'd order it."

"But, Dr. Sung, if I use horse serum, there's a chance of allergy, and I'll have to skin-test her. All that takes time."

"Well, what the hell are you getting paid for? Now, get on it."

The sharp crack of the disconnection shot into my ear. Well, screw it. Old Dr. Sung was practicing very bad medicine, and someday it would catch up with him. Why should I get steamed up? Too bad about the Hypertet, though, all nicely packed and ready for injection. Ten to one the old bastard hadn't ever heard of it. So this is what we get paid for, I thought, grimly working through a long set of directions for sensitivity testing on the side of the horse-serum bottle while fifteen people waited outside.

But I didn't get very far with the horse serum. A siren, off in the distance, brought back the old fear. To my horror and disbelief, three ambulances pulled up simultaneously, and the crews jumped out and started unloading pieces of people, all victims of the same automobile wreck, putting them in rooms where others were already waiting. One smashed body would have been terrifying; five were simply overwhelming. While the nurses called upstairs for help from the house staff, I tried to do something, anything, before the situation immobilized me. One of the patients was a young boy with the side of his head crushed in. His breathing was extremely stertorous; at times it stopped altogether, only to resume seconds later. I started an IV, which the kid probably didn't need right off. But he would need one eventually, and I kept busy putting it in and getting some blood for type and cross match. Inserting an endotracheal tube came next, an automatic choice. Normally a very difficult procedure for me, this one was easy because the boy's lower jaw was so broken up that I could pull it away from his face. After sucking out his mouth and throat, bringing up bits of bone and a lot of blood, I put in the tube for him to breathe through. Surprisingly, his blood pressure was all right. I wanted to stay by the boy, even though there was nothing more for me to do for him just then, but the other patients were lying everywhere, crying for help — and, anyway, a neurosurgeon was on his way down. Later I heard that the boy had died a few minutes after leaving surgery. It bothered me for a while, until I rationalized that he had been virtually dead when I got to him.

Now, after all these months, it was easier for me not to get emotionally caught up in any one case. Other problems were waiting, demanding attention. The lady in the next room, for instance — she was critical, too. A huge area of skin and hair, running from her left ear to the top of her head, could be flapped back, revealing a network of multiple skull fractures, like a cracked hard-boiled egg ready to be peeled. The pupil on the left side was widely dilated. Where to begin? While I was looking at the skull, she suddenly vomited a pint or so of blood, which splattered off the table onto my pants and shoes. Thank goodness for the IV, providing some direction for my chaotic thoughts. I hurriedly got that going, at the same time sending up a blood sample for type and cross match to get some blood available for transfusion. Since she had vomited blood, I thought we might need eight units rather than the usual four, although her blood pressure was surprisingly strong. This matter of acceptable, even normal, blood pressure in the face of clear body failure had begun to bother me. All the books cited blood pressure as a prime and reliable indicator of general systemic function, but most of my experience seemed to be going against that rule. At any rate, I poked around at the woman's abdomen, trying to think where that blood might have come from.

Just then a nurse urgently called me into another room, where a man was barely breathing and, she thought, convulsing. Apparently hit in the stomach, he had been one of the drivers, I guessed. The nurse handed me some amobarbital to stop the convulsing, but before I could give it I realized that instead of convulsions, he had what some call the dry heaves, a kind of retching. He vomited a little, too, not blood but a stale-smelling alcohol that also managed to splash on my shoes. When Dr. Sung called back in the midst of all this wanting to know if I had given the horse serum yet, I was tempted to unload on him, but I just said no, we were busy.

A motorcycle had been involved in the same accident. The rider was virtually skinned alive. He had abrasions all over him except on his head. He was one of the few who actually wore a helmet. Every weekend had its quota of wiped-out easy riders. For sheer gore they were unmatched — so bad, in fact, that a standard hospital joke went around about the motorcycle patient who arrived at the hospital in several ambulances. Total body bruise, fracture, and abrasion was a better description for this one. If they could talk at all, those fellows would staunchly insist that a motorcycle wasn't so dangerous, because you got thrown free when you had an accident. But being thrown free at sixty miles an hour, onto concrete, on your head, and then getting run over didn't leave us much to work with. This one was not only totally abraded; his left lower leg was crushed as well. The two bones were hanging out at a forty-five-degree angle, with the foot attached only by some thread of sinew. Pants, socks, bits of sneaker, and asphalt were squashed into the wound.

Surprisingly, he was conscious, although dazed.

"Do you have any pain?"

"No, no pain. But I have something in my right eye."

God, with all that injury he was worried about a cinder in his eye. I took it out. His blood pressure was all right, the pulse a little high at 120. I started an IV and sent up a sample for type and cross match, arbitrarily picking five units of blood to be available. He apparently didn't need blood right away, but he obviously was facing some bone surgery. With a hemostat I tried to stop a little of the blood oozing out of the leg muscles, which were in plain view. It amazed me how little he bled.

I went back to the lady who had vomited up the blood and was relieved to find her blood pressure holding up well. Perhaps she had just swallowed the blood, I reasoned; after all, she was bleeding from both nostrils. Twenty minutes had passed since the ambulances pulled in, and some others from the house staff were there now, helping to stabilize the patients. I got X-ray to come down and shoot a group of heads and chests and other bones. No description could capture the uproar of that time. It was total chaos, as colds and diarrhea and babies and asthmatics mingled with broken bones and crushed heads. Nor did matters improve much when the attendings arrived and began ordering everyone about. The OR, alerted earlier, finally began to absorb the automobile-accident patients.

Dr. Sung called again, threatening to file a complaint with the hospital if I didn't get right on that horse serum. At that point I didn't give a damn about his horse serum, so I hung up on him. This brought him storming in about twenty minutes later, ready to give me hell, just as we were moving the last of the critically injured up to surgery. I stood there, covered with a mixture of blood and vomitus, vaguely hearing him rant. This lunatic could get me into real trouble, so I didn't say anything except to mention the Hypertet again, and how much quicker it would have been. That made him even madder, and he stomped out taking his patient with him. Sure enough, a written reprimand showed up in my box a few days later. So much for priorities.

By eleven the cyclone had passed, leaving the usual jumble of patients with lesser complaints, a much larger number than usual because of what had gone before. They were everywhere — inside, outside, sitting on the ambulance platform, on the floor, in chairs. I began to go from one room to another, half listening, performing like a tired machine. One man had fallen by his pool during a party, breaking his nose on the diving board as he went down and cutting his thumb on a gin-and-tonic glass. The nose was straight, so I left it alone. The laceration I sutured rapidly, after telling his private M. D. the sad story. Even he sounded drunk.

It was, in fact, a big night for drunks; most of them were suffering from minor cuts and bruises or premature hangovers, with nausea and vomiting. And the kids were still coming in, long after bedtime, with their diarrhea and runny noses and fevers. Occasionally I had one with a temperature of around 104, yet I wouldn't be able to find anything wrong. This made me very uncomfortable. As a human being you have an almost irresistible desire to treat; you are expected to treat. The parents almost invariably clamored for penicillin, but I had enough sense not to give in most of the time. To treat a symptom like fever without a firm diagnosis is bad medicine; and yet I often got only a fleeting and rather limited look at the eardrums or the throats of those miniature screamers. Sometimes I treated, sometimes not; always I went on half-educated guesses.

It went on being a typical Saturday night in the ER. The crowd thinned out about 1:00 a.m. From now on we would see less of the various things that drove people away from their TV sets during the evening to seek the sanctity of the ER — things like colds, diarrhea, and minor puncture wounds. In about an hour, the problems that were keeping them from falling asleep would begin to appear. The same ailments they had ignored all day and through the early evening would, of course, keep them awake, forcing them to the ER in the middle of the night to see the astute and understanding intern. Like itchy thighs. On another tour of duty, I had fallen asleep around 5:00 a.m. only to be awakened because some patient had itchy thighs.

Slightly after one an ambulance pulled up without its siren, and the crew unloaded a peaceful-looking girl in her early twenties who was in a deep sleep approaching coma. Ingestion. The usual, as I found out: twelve aspirins, two Seconals, three Libriums, and a handful of vitamin tablets. All of these drugs, except maybe the vitamins, could be dangerous — especially Seconal, a sleeping pill — but you had to take quite a few of them if you were really serious. Otherwise it was only a gesture, a childish cry for attention within the social fabric of the individual's life; the usual ingestion case is a young woman lost in the unreal world of True Romance magazine. I could be interested and sympathetic, but not in my state; I was so tired that any sense of empathy had long since dissolved into irritation. How could this stupid girl pull such a stunt so late on a Saturday night? Why couldn't she throw her little show on Tuesday morning?

As they always did, several members of the family and some friends arrived shortly after the ambulance. They stayed in the waiting room, nervously talking and smoking. I looked down at the girl sleeping on the table. Then, putting my hand on her chin, I forcibly shook her head and called her by her first name, Carol. The eyes opened slowly, so that only half the pupils were showing, and she whimpered, "Tommy."

"Tommy, shit." Irritation became anger as my exhaustion and hostility sought expression and won. I ordered some ipecac from the nurse and decided to pump her out. The pumping-out procedure was no bargain for either of us, but I wanted to make her remember the ER. Besides, I knew that when I called her private doctor he would ask what I had gotten out of her stomach.

An ingestion stomach tube is half an inch in diameter. After cranking her into a sitting position, I crammed one down her throat, through her left nostril. Her eyes suddenly shot open all the way as she retched and struggled to get free of the attendants holding her. She vomited a little around the tube as I pushed it farther down into her stomach, and then everything in her stomach came up, including an undissolved Seconal and a portion of one of the Librium capsules. When I pulled the tube out, what remained came with it. A few minutes later the ipecac took effect, causing her to vomit again and again, even though her stomach was empty. By now Tommy had joined the others in the waiting room. Perhaps he also wanted some ipecac, so as to play a full role in this melodramatic event.

After sending up a blood sample to see if the aspirin had changed the acidity of the blood, and finding out that it hadn't, I called Carol's doctor. I told him what she had taken and that, aside from being sleepy, she was all right now, nicely tranquilized.

"What did you get when you pumped her out?"

"One Seconal, bits of Librium, not much else."

"Fine, Peters, good work. Send her home, and tell her father to call me on Monday."

Soon after that Carol was taken home, in all her glory, covered with vomitus. I never questioned my harsh attitude toward her, not after eighteen hours in the ER, and, while I'm not proud of it now, that’s the way it was.

Back around midnight a new shift of nurses had come on. It was now two, and I was really sagging, but the new nurses were a clean and spirited bunch, displaying remarkable agility and garrulousness for that time of night. The contrast made me feel even lousier, like a silhouette. And the next patient didn't help. Her chart read, "Depressed, difficulty breathing."

As I walked into the room, my dismay was instantly confirmed by the sight of a lady in her late forties who was wearing a light blue negligee. She lay on the table, one hand pressed dramatically against her ample upper chest. Two other ladies stood nearby hysterically telling me and the nurse that their friend was unable to breathe. I could see from a distance that the lady was breathing very easily.

"Oh, Doctor," the lady whined, drawing out the word in a deep southern accent. "I cain't hardly breathe. You have to help me."

She smelled like week-old martinis. One of the hysterical ladies produced a prescription bottle. I looked at it. Seconal.

"Oh, those little red pills. I did take two. Was that all right?" The southern lady looked at me with fluttery eyelids; she was having a hell of a good time at two o'clock in the morning. I had a strong impulse to throw her neurotic ass out of the ER. That was a sure administrative bomb, however — perhaps even career suicide. Despite my disenchantment with the system, I hadn't come to that.

"Do you hear anything strange, Doctor?" I was forcing myself to listen to her chest, which was totally clear. "Oh, you're going to take my temperature and blood pressure," she said gleefully. "I do feel rather faint. I just cain't understand what's happening to me." On her arm went the blood-pressure cuff and into her mouth the thermometer, silencing her at last. I was glad of the opportunity to get away from her for a few minutes by calling the doctor who covered the hotel where she was staying. He said to give her Librium.

Back in her presence, I coaxed myself to be civil. "Madam, the hotel physician has suggested Librium for you."

"Librium, Doctor? Are those the little green and black pills? Well, I'm afraid I'm allergic to those. They make me so gassy, and sometimes," she said, sitting up now, moving into high gear, "sometimes if s so bad my hemorrhoids pop out." With this, we were fully launched into her extensive pill history and the dreadful details of her lower gastrointestinal tract. In the middle of her recital, a performance worthy of Blanche DuBois, I interrupted to say that perhaps orange Thorazine would do just as well.

"Orange Thorazine!" She virtually squealed with delight. "I've never had that! I just cain't thank you enough, Doctor. You've been so sweet." And out she went, chattering gaily with her friends about the wonders of medicine.

One of the nurses from a private ward appeared, limping slightly. She had fallen down a flight of stairs, with apparently no serious damage, but she had thought it best to have it checked. I agreed. Her name was Karen Christie, and nothing seemed wrong with her hip, but I suggested she have a pelvic X ray, anyway, to be perfectly sure. Hospitals are understandably sensitive to any threat of personal-injury claims on the part of the staff. When Miss Christie's X ray appeared fifteen minutes later, I snapped it up on the view box amid an assortment of skulls and broken bones. My eyes were a little blurry as I ran them over her femur, acetabulum, ilium, sacrum, and so on. All was normal. I almost missed the white coil toward the center, and when I did see it I couldn't figure out how the X-ray technician had managed to get such a strange artifact in his picture. Then it dawned on my sleepy mind that I was looking at an intrauterine contraceptive device, which served the double purpose of making Miss Christie a much more interesting case and lightening my mood for a moment.

Unfortunately, my sour humor returned with the next patient. He sat quietly sobbing because he had hurt his nose when the car he was riding in hit a fire hydrant. With no encouragement from me, he loquaciously told the whole story. He had been minding his own business when he got picked up by a lesbian, who turned out to be so upset with her roommate that she ran the two of them into the fire hydrant. I didn't ask what had happened to the lesbian, being grateful not to have her, too. I thought wryly, and unkindly, that this fellow was the fag end of the night in more ways than one. Putting up with him was almost more than I could tolerate in my state of zero compassion. All I was prepared to handle were simple medical problems — diagnosis and cure. This guy needs more. He refused to do anything but sit and cry, and ask for Uncle Henry. When Uncle Henry arrived, not even he could persuade the man that an X ray was not lethal. Finally, when Uncle Henry agreed to stay constantly by his side, they disappeared to X-ray. The film showed a broken nose, and his private physician admitted him to the hospital by phone. Somewhat later, a policeman arrived with the real story. It had been a simple punch-out in one of the local "gay" bars; the lesbian was imaginary.

Off in the distance, again I picked up the fateful sound of a siren, hoping it would pass us by. Instead, the ambulance screeched into the parking lot and backed quickly to the platform. I was in no shape for what I saw, the human wreckage of yet another automobile accident. The two girls on stretchers had obviously gone through the windshield. They were bloody from the waist up, with first-aid bandages covering their heads and faces. After the girls, two men stepped out of the ambulance under their own power, showing only minor bruises.

As I removed the bandages from one girl's face, a geyser of blood spurted straight up onto my face and chest. A textbook case of arterial bleeding, I thought, replacing the bandages. I put on a pair of sterile gloves and a mask and then jerked the bandages off suddenly, immediately pressing a piece of gauze into the wound, working my hand along a gaping laceration that ran from her forehead down between her eyes almost to her mouth. Bleeders were spurting little jets of blood in various directions. With great difficulty, I managed to get mosquito hemostats on the bleeders, but before I could tie them the girl ripped them off. She was drunk. For a minute or so we went through a cruel, gory routine, she taking the hemostats off as fast as I put them on. I won by dogged persistence, finally tying off the bleeding vessels, but of necessity leaving enough work to enrich a plastic surgeon. Meanwhile, a resident had arrived to work on the other girl. Then we discovered that the two girls were military dependents, and since they were stable — meaning they weren't going to die in the next hour — off they went to a military hospital. That left me with the two fellows, who were in relatively good shape. I cleaned their abrasions and mechanically sutured a couple of scalp lacerations without uttering a word.

By about three-thirty there was only one more patient to be seen, a baby sixteen months old. I was really dragging by then, and I don't remember much about the case except that the parents had brought the child in because he really hadn't been eating too well for the last week or so. Thinking I must have missed something, I had them repeat that several times. All the while the child was sitting there smiling and alert. With a touch of sarcasm, I asked if they didn't think their behavior was a little strange. Why strange, they wanted to know; they were worried. A slow burn came over me as I silently examined the perfectly normal baby, and then fled to the telephone to call their private doctor, who was equally irritated because I'd waked him up. That was absurd, too. The doctor was angry because his patient was bothering me at 3:30 a.m. I ended up turning everything over to the nurses, who sent them all home. I couldn't talk to them again.

After the child left I wandered out on the platform, peering blankly into the silent blackness. I felt nauseous and drained, but I knew from sore experience how much worse I would feel to be waked up for the inevitable next patient after sleeping for only fifteen or twenty minutes. All the nurses were busy with small jobs except one, who was having coffee. I felt strangely detached, as though my feet were not firmly on the ground, and thoroughly lonely. Even fear was gone, banished by exhaustion. If anything serious came in now, all I could do would be to try to keep it alive until a doctor arrived. Well, that was a useful function, of sorts. Of course, I would continue to do miracles with the drunks and the depressed and the kids who weren't eating too well — my true constituency.

Somewhere near and coming nearer, a Volkswagen's horn was beeping, disturbing the deceptive tranquility of the ER. As the beeping got louder, it began to remind me of the cartoon character called the Road Runner — an absurd association, but somehow appropriate to my mental state. Beep-beep. Maybe it was the Road Runner. Thirty seconds later fantasy was replaced by a VW that pulled up, still beeping, next to the platform. A man jumped out yelling that his wife was having a baby in the back seat. After calling for a nurse to bring a delivery kit, I ran down to the VW and opened the door on the right side. There in the back, sure enough, was a woman lying on her side, obviously in the last stages of labor. The light was very poor, obscuring the birth area; everything would have to be done by feel. As she started into another contraction, I felt the baby's head right on the perineum. The woman's panties were in the way, so I cut them off with some bandage scissors, and while she grunted through the contraction, I kept my hand on the baby's head to prevent it from popping out. After convincing her to roll over on her back, I pushed the front seats forward, and got one of her legs braced on the rear window and the other one draped over the driver's seat. My hands were moving by reflex now, leaving my mind to do absurd things, such as remember an old joke— what’s harder than getting a pregnant elephant into a Volkswagen? Getting the elephant pregnant in a Volkswagen. With the contraction over, I got the baby's head out slowly, rotated it, pulling it down to get one shoulder out and then up for the other shoulder, and suddenly I was holding a slippery mass. I almost dropped it trying to back out of the car. Thank God, just then the baby choked and started to cry. Not knowing what to do through all this, the father had been behaving oddly; he interrupted his audible anguish about the upholstery, which was pretty messy by now, to ask whether it was a boy or a girl. In the dark I couldn't tell. Must not be this guy's first child, I thought. I wanted to suck the newborn's mouth out with the bulb syringe, but the baby was too slippery to hold in one hand. Instead, I gave the infant to one of the nurses, with explicit instructions to keep it level with the mother, and, after putting on some clamps, I cut the cord. Then everyone— attendants, nurses, and father — helped lift the mother out of the car. The afterbirth came away without effort in the ER. I was amazed that there were no lacerations. The whole crew disappeared up to the obstetrics area.

That baby redeemed the night. Maybe they would name it after me. More likely they'd call it V.W.

I almost didn't even mind seeing the dirty drunk who had come in during the excitement of the birth. He had a scalp laceration, which I sewed up without anesthetizing it while he swore at me. Actually, he started to swear and swing at me as soon as I appeared. He was so drunk he was beyond feeling. After the last stitch, I went into the doctor's room and plopped down on the bed, instantly asleep.

That was 4:45; at 5:10 a nurse knocked and came in to say a patient was waiting to be seen. At first I was disoriented, literally unable to recall where I was and aware only of the hammering of my heart. In the twenty-five minutes between then and now, sleep, the great healer, had incapacitated me, leaving me dizzy and weak, with scintillations in the periphery of my visual field. These passed as I began to move around. Even so, my left eye refused to focus, and when I opened the door the light in the hall was like a thousand flash bulbs. I felt just about as shitty as I could feel and still function.

The patient, where was the patient? The chart in my hand said, "Abdominal pain, twelve hours." Jesus! That meant I had to record a complete history and probably wait for lab reports. I walked into the room and looked at the patient. About fourteen, soft silky hair of shoulder length, skinny, large nose. Mother sat over in a corner. The check list of questions for possible appendicitis is a long one, and I started in on it. When did the pain start? When did you first feel it? Did it move? Was it like indigestion cramps? Did it come and go or remain steady? Meanwhile, I casually felt the abdomen for sensitivity, through Bermuda shorts, reasonable apparel in Hawaii's climate — but underneath them was something odd, the distinct outline of a girdle? Crazy. Did you eat today? Tonight? Did you feel like vomiting? The stomach seemed soft. It could not have been very tender, for moving my hand over it evoked no sign of discomfort. Did you move your bowels? Was it normal? I took out my stethoscope. Has your urine been normal? I put the stethoscope in my ears and rested the bell of it on the abdomen, the patient's words filtering through the earplugs. Have you had trouble with abdominal pain before? Have you ever had an ulcer? For some reason I always left the questions about the menstrual cycle until last. It was just a small propriety. When was your last period? The answer came rather apologetically: "I'm a boy."

I looked at her — him — for a minute, my dull mind reeling. Long silky hair, loose purple velvet shirt. No, it was a blouse. Girdle! Putting my hand under the girdle, I lifted the whole works up, practically raising him off the table. No doubt about it, that was a penis. The mother just looked away. I was unprepared for such sudden reverses. It all seemed a huge, cruel joke. Here I was struggling to make some sophisticated intra-abdominal diagnosis, and I was wrong even on the sex. Anyway, he didn't have appendicitis or anything else terribly serious. Probably a simple case of abdominal cramps. I thought to myself, if I told him they were menstrual cramps he'd be pleased.

Being a slow learner, I immediately fell asleep again. Crash! The door came open and a delighted nurse informed me that I had a patient. The same process occurred, the same agonizing gauntlet of getting up and blinking and gradually clearing as I emerged into the light. This one was a dandy, a Sa-moan lady towing along her ailing mother, who couldn't speak a word of English. With so many languages in use around the islands, we were accustomed to working through translators, but in this case the daughter's English was not even a serviceable pidgin. Besides, the complaints were so numerous that every organ system seemed to be involved. She had pains here, pains there, headache, weakness, couldn't sleep, and generally felt crappy. Sounded like me.

Very carefully I asked the daughter if her mother had any burning sensation when she passed her urine, and was rewarded with a blank look. Rephrasing it, I asked if her mother had any pain when she made pee-pee, wee-wee, shishi, umm… my mind had run out of synonyms… when she makes water. I thought this brought a glimmer of understanding, so I put it together again. Does your mother have pain when she makes water? The answer was great, made me want to give up medicine entirely. She said she didn't know. The lexicon of English does not hold a word to describe my frustration. I said, for Christ's sake, ask her, then. So she asked her. Yes. That was how it went with every question. Slowly, and every answer was yes. She had burning on urination, frequency of urination, nausea, vomiting, vaginal discharge, diarrhea, constipation, chest pain, cough, headache…. Since the mother was quite emphatic about her chest pain, I tried to take an electrocardiogram, but the machine broke. When the birds started singing outside, it was as if they meant to attack me with their song; but of course they were only heralding the light. I was so tired I just didn't care about the old lady, about anything. In the firm conviction that she would not die within the next few hours, I gave her some Gelusil, which she liked enormously, and set up an appointment in the clinic. It was glorious morning by the time she left.

Before I could disappear into the doctors' room again, a baby and an old man came in simultaneously. The mother had dropped the baby on its arm, which was a little swollen, and the man had strained his back several days before. With the baby and the man up in X-ray, I fell asleep in a chair by the counter, smack in the center of the ER. When my relief came to take over, he let me sleep on. Forty-five minutes later I woke up feeling as bad as before, but knowing that this time I could go back to my own bed. Where are the television cameras now? I mused, trudging along home looking like a Jackson Pollock action painting made of dried mucus, vomit, and blood. It was a strange and wonderful feeling to take off my clothes and slide between the cool, slightly coarse sheets.

Thus my twenty-four hours off began. After more than a month of the ER routine, I was a mental and physical shamble. I became lucid around lunchtime, when I was waked by a combination of the birds, the sun, and hunger. A shave and shower made me feel somewhat human, and by the time I had walked over for lunch in the warm noonday sun, I was back in the real world again.

Following lunch, I succumbed to an imperative somewhere in me to get away from the hospital. More sleep would have been the prudent course, but I had discovered through experience that, no matter how tired I was, the general afternoon din around my quarters would keep me awake. So I put on my bathing trunks, loaded the surfboard on to my car, threw some medical books into the back seat, and took off for the beach.

It was a relief to drive out there and let the clutter of colors and movement capture my mind. People seemed to be everywhere, all of them strangely whole and healthy. In the hospital, one often feels that everybody in the world has diarrhea or a chest pain. But there they were, busily and happily walking around, laughter mixing with the physical activity, suntans, and brightly flashing bikinis. These people looked so normal. With my morose thoughts, I was somehow an outsider, not belonging. Too tired to swim or play volleyball, I propped myself up against the surfboard, facing the sun, and let the scene roll by.

I didn't try to talk to anybody and no one approached me, which was just as well. I was so full of the ER that I would quickly have turned off anybody in his right mind with my yammer about blood and broken bones. But that wouldn't be my real subject; my real subject would be me — my anger, exhaustion, and fear. Come on, now, I thought, too many dire and dramatic nouns; stop wallowing in self-pity. That's about all you've been doing lately, feeling sorry for yourself. So what if it's a crappy deal being an intern? Change it if you can, but stop feeling sorry for yourself. That doesn't help anybody, least of all you. I still wished, however, that our culture would take some of the pressure off by realizing that a white coat and a stethoscope do not confer wisdom. Much less instant nobility.

Well, screw it. I'd take a nap instead.

I fell asleep there in the sun by myself, in the middle of all that gaiety and laughter. Actually, this happened every afternoon I was off during the period of ER duty. Sleep in the morning, eat, sleep in the afternoon, eat. Do nothing for a while, then sleep, only to wake and find the twenty-four-hours-on cycle beginning again, wondering where the time had gone. When I awoke it was late afternoon; the people had thinned out and the sun was much weaker. No one bothered me as I continued to sit and look at the sun on the water. It was like watching a bonfire. Its activity seemed an excuse for my stillness and undirected thought. Not that I was unconscious; everything around me came into my mind — all movement, sound, and color. I just wasn't connecting.

Hastings had to wave his hand in front of my face a few times before I got him into perspective. Surf? Sure, why not, if I could get myself and my board down to the water. I felt immobile, as if the sun had sapped all my remaining strength. This was another part of the afternoon-off routine. Hastings would meet me down at the beach, quite late, and we'd surf, not talking to each other except to say a few words like "outside" if a large wave was coming. I didn't understand why we made such elaborate plans to meet and then ignored each other. But both of us liked it that way.

Paddling out was the high point of the day, a kind of catharsis. I felt my body and mind join again. I used my arms and feet to paddle, feeling the strength that was there and the touch of water under me, cool and gently moving. The expanse of the ocean, spreading to apparent infinity around me, made me feel small yet real, the true center. People vanished; their voices changed, became muted and distant as they were swept off by the waves. The setting sun turned the whole western sky into warm, soft oranges and reds reflecting millions of times from the surface of the water, like a Claude Monet painting. To the east, silver blues and violets began to appear among the pinks and faraway greens. Sailboats were dotted around haphazardly, little dabs of color against water and sky. The island rose up sharply from the water's edge, and sunlight cast contrasting shadows among the canyons, creating a texture as soft as velvet, making the soaring ridges fly like buttresses off a Gothic cathedral. Deep violet clouds hovered over the island, concealing the peaks, forming the prismatic reflections of rainbows in the shadows of the valleys. Whatever effect it may have on others, this beauty cradled me, drained all other thoughts and made me whole again.

The waves added to the atmosphere with their impetuosity and rhythm; one minute an organized vibration of harmonic motion, the next a swirling mass of senseless confusion. I caught one of the waves. I felt its power, the wind and the sound. Twisting as the board responded, I made my body work against the force to fall; speed and crucial milliseconds. Down the wave and then a twist of my torso, running my hand along the sheer wall of water and the crash and swirl, yet still standing, my feet on the board lost beneath a swirl of white foam. Finally the sudden kickout, with a violent but controlled backward twist, made me want to shout with the joy of being alive.

Darkness erased the scene slowly and drove us back to shore. Hastings went his way and I mine, to the hospital for a shower. Back in the geometric, sanitized world of clean floors, utilitarian showers, and fluorescent lights, I dressed and left the grounds again. Driving up Mount Tantalus, I pleasantly anticipated the night to come.

Her name was Nancy Shepard, and I had met her — how else? — through the hospital. Her father had been a gall-bladder patient whose progress I followed closely after assisting a private M.D. in the operation. Every time I changed his dressing, he had mentioned that he wanted me to meet his daughter, retelling how she had gone to Smith and spent a year at Boston University working on a master's degree in African history. In truth, I grew a little tired of hearing the stories, although I remained interested in meeting her. Finally, the day before her father left the hospital, she had appeared, and she was nice — very. In fact, she looked a little like another girl from Smith I had dated while I was in college. Anyway, we went to the beach a few times, which we both enjoyed. She could talk about almost anything; it was fun to be with someone educated and intelligent. A political-science major, she was fond of arguing heatedly over small points of government, especially about Africa. Despite a number of successful dates and my admiration for her, I stopped asking her out very often, mostly because of lethargy and lack of time. In fact, that night’s invitation to dinner had come out of the blue. Not that I didn't want to see Nancy. I just never got around to it — and by then Joyce had become pretty convenient.

The dinner was fine. Nancy's parents and two brothers were also there, all of them lively talkers. After coffee, Nancy and I wandered out into the large, verdant yard and began an argument about Jomo Kenyatta and Tanzania. Why had Africa failed to produce more Kenyattas? She was emotional on the subject; it was good to see her color rise as she warmed to the argument, making her even prettier.

But then she started asking me questions about medicine. Because she was really interested, not just passing the time, like so many, I worked hard to make her understand, answering as well as I could. Inevitably, she asked why I had gone into medicine. To this question an intern develops many answers. Most of them are evasive half-truths. But with her I decided to try for the whole truth.

"Well, Nancy, I don't think I'll ever know exactly. In the beginning I suppose I had some vague notion about helping people by entering a noble profession. But now that I have a lot of medicine behind me, I think I was attracted just as much by the idea that being a doctor would give me a sort of power that other people don't have — a power over people as well as disease. Few things mean more to Americans than good health, and those who have that to give, or claim to have it, are automatically authority figures in our society."

"What do you mean by power and authority?"

"Just that, I suppose. It's something like the power a medicine man holds in a primitive tribal society. He holds a high position only so far as he's able to play on the fears of his fellow tribesmen and make them think he can control nature. If s a kind of legitimate hoax — legitimate because he performs a more or less useful function, and a hoax because he doesn't really control anything but the tribal psychology. I think modern medicine is the lucky heir to that kind of psychological misconception. My patients don't fall prostrate before lightning and thunder, but they're sure as hell terrified by cancer and lots of other diseases they don't understand. When they come to the hospital, they are looking for a medicine man in more ways than one. Before I went into medical training, I was like any guy in the street. I mean I believed in the power of medicine to do almost anything, and I wanted that power, wanted to be looked up to as the agent of that power."

"But surely you mean the power to help people?" She still didn't understand.

"Sure, I can help people. Not as much as I'd like, and nowhere near what they hope for, but some. But that kind of power is severely limited. Medicine is still fairly primitive. We just don't know enough. It's the other kind of power, the more abstract kind, that I'm talking about. That's nearly unlimited. For example — I played a little football in high school, and one time a fellow broke his leg in practice. I was right next to him in the pileup, and I found myself there looking straight at him, wanting to do something, but totally helpless. When I thought about it later, what I remembered was the envy I felt toward the doctor. I know now that he didn't do much except say a few soothing words, administer a painkiller, and haul the guy away. But to me, to all of us, he was a kind of god. The more I thought about it, the more I wanted a piece of that power."

"But what about the idea you started with, of medicine as a noble profession, of just helping the boy with the broken leg. What happened to that?"

"It got all mixed up with the god idea. Anyway, I went on to college planning to become a doctor. Although a lot of new avenues opened up after that, no pressing alternative appeared. So I finally just drifted into medical school, not really having anything else in mind, wanting both kinds of power, and realizing I could have them in the medical profession, plus the social status and a reasonable income. Now mat I've more or less made it, all those abstract notions have fallen apart on me. I don't have much social status, no money at all, the god-power thing seems utterly empty, and as for the power over disease itself — I hope to heaven I never have to undergo any surgery. I know too much about the limitations of medicine."

I should have been sharp enough to notice the slight chill Nancy was giving off, but I didn't. She had been waiting for the "ever since I was a little boy" story so dear to television and other fictionalized accounts of medicine. But she had made me reach down into myself, searching for answers, and the little boy wasn't there.

"Then you don't feel you have any special quality that made you go into medicine? No vocation, so to speak?" She was still looking for Ben Casey.

"No, this is definitely not like the priesthood for me. The closest I can come to medicine being a vocation is that I did well in both science and the humanities in college, and medicine is a logical combination of the two."

"Well, you don't sound like you have the same motivations as the doctors I know." She was flaring up. And so was I.

"Just how many doctors do you know, Nancy? My whole world is made up of them. I live with them— interns, residents, attendings, the medical-school crowd — and I can tell you that, in general, what happened to me happened to them, and what I feel is pretty much what they feel, if you can get them to admit it."

"Well, I think it stinks."

"What stinks?"

"That our society has let you get this far. You're the wrong person to train as a doctor, because you don't care enough about helping other people."

"I just told you that I want to help people, and I do, but the whole thing is more complicated than that. Hell, I'm just like everybody else. I don't have one consuming goal that shuts everything else out. I want to live, too. Besides, a lot of the idealism I had was smothered in medical school. It's just not oriented that way."

"Don't you like being an intern?" she interjected.

"No, not really."

She was again surprised. "Why not?"

"Basically I feel so tired, really exhausted, all the time. And yet I lack any sense of real usefulness. I realize most of the things I do could be done by someone without the training I've had. Plus I'm constantly scared, thinking I'll screw something up and look like a fool. You see, medical school didn't seem to prepare me very well at all." By now, the resolution of that afternoon to keep my mouth shut had dissolved in the intensity of the moment.

"Well, I think that's understandable. Medical school can't do everything," she said.

"It might be understandable from a distance, but when you're right in the middle of it, you don't understand what’s happening to you. And when I do stop to think, and realize that the four years at medical school were mostly wasted as far as taking care of the patients is concerned, and that I'm being exploited under the guise of learning, the psychological burden is too heavy. I just get furious at the system— the way medical school and internship and medical practice are interconnected — and at the society that supports it."

"Being furious is hardly the best attitude for a doctor to have," she added with coolness.

"I couldn't agree with you more, and I wish the establishment realized that, too. Eventually, you reach a point where you don't give a damn. Sometimes, after getting called on a cardiac arrest in the middle of the night, I suddenly realize that I wish the guy would die so I could go back to bed. I mean that’s how tired and pissed off I get. In a sense, I've stopped thinking about patients as people, and of course that only adds to the guilt."

Looking over at her, I could see her ethics creaking under the strain of my words. But I went on blindly.

"I suppose this business of not thinking about patients as people is the hardest to explain. Maybe a few doctors can empathize indefinitely. But not me. I can't take it. To survive now, I want to know my patients only as gall bladders or hernias or ulcers. Of course, I include in that anything about them that directly affects their basic disease process, and I believe I am becoming a good doctor technically, but beyond that I don't want to get involved. My system is not geared for it. I had this one patient named Roso, and I got so tied up with him that when he was discharged I was more relieved he was gone than I was happy he was alive."

The silence was icy. I stared into the sky, purposely looking away from her. Then I went on.

"Another thing. Very important. As an intern, I'm exploited the same as an underdeveloped country operating under mercantilistic relations with a colonial power. For instance, all I do in the operating room ninety-nine per cent of the time is hold retractors, often for the sloppiest G.P., who shouldn't be doing surgery, anyway. I'm there to be used. Anything I learn is in spite of the system, not because of it. And if I don't do what I'm told, or make too many complaints about the medieval system — pouf! — out goes my chance to specialize in a good hospital. So when I say I'm scared about making a mistake, I'm worried not so much for the patient — although that's partly it — but because I might get the boot and end up in some hick town giving typhoid shots. That's medicine's equivalent of the living death.

"And besides, a lot of very real and serious problems come up, which no one tells us about or even offers any advice. Like the emergency-room question of when you should try to revive a patient and when you should just let him alone. As interns with no experience, we're totally vulnerable about such things. And this is not entirely a medical problem. What about the ethics involved? If the person is revived and becomes a brain-stem preparation — and that means he is taking up a sorely needed bed in the ICU — then you've deprived somebody else of the ICU bed, someone else who might have a better chance. That's a godlike decision. Medical school never taught me to play God. And then all—"

I had been rambling on, looking out through the dark trees, putting these thoughts together for the first time. In some ways I was talking only to myself, and when I turned and looked at Nancy she exploded, stopping me in the middle of a sentence.

"You're an unbelievable egotist!" she said.

"I don't think so. I just live in the real world."

'To me you're an egotist — cold, inhuman, unethical, immoral, and without empathy. And those are not traits I look for in a doctor." She could really lay it on when she wanted to.

"Look here, Nancy, what I've told you is the truth, and it's not just my truth. I'm a composite of most of the interns I know."

"Then the whole bunch of you ought to be thrown out."

"Right on, baby! If you feel so strongly about it, why don't you organize a sit-in at the ER? Compassion's a cheap commodity when you get eight hours of sleep a night. Most nights I get less than half that much. The rest of the time I spend checking Mrs. Pushbotton's itchy hemorrhoids. Don't you moralize at me from your easy chair."

And so it went, ending with both of us steaming with anger. I left after a halfhearted promise to call her sometime.

Back in my geometric, all-white room, I lay fuming, all keyed up, with less than nine hours before the ER holocaust was to begin again. Sleep was clearly out of the question. I called the lab, and Joyce answered. Could she come by at eleven? She said she would, and I felt better.