The Year of the Intern

Day 307

To an intern in medical practice during the latter half of the twentieth century, Alexander Graham Bell is the arch villain of all time. The blame, of course, must be spread a bit wider, to include not only the man who invented the telephone, but also the sadist who designed the ring. And then all those fellows working for Ma Bell who perpetuate the jangle— they're in it, too. How did hospitals function before the invention of the telephone? I often thought of myself, nowadays, as a mere extension of that little piece of black plastic. It was every bit as terrifying as the ambulance, and a good bit more sudden — always somehow expected in the back of my mind, and yet at the same time coming on me unawares. In all the world, there is no sound like it for disturbing the peace.

My peace just then consisted of falling gently asleep beside Karen Christie in her apartment after, I trust, a mutually satisfying encounter. When the telephone rang at 2:00 A.M., we both reached. I let her have it — not because it was probably for her. Since I was on call, it would more likely be the hospital night operator extending me an invitation to return to those corridors. But it might have been Karen's so-called boyfriend.

Indeed it was the hospital operator, who put me through to a nurse. "Doctor, would you come immediately? One of Dr. Jarvis's private patients is having trouble breathing, and Dr. Jarvis wants you to handle it."

Rolling over on my back, I stared at the ceiling and cursed inwardly, holding the telephone away from my ear. Dr. Jarvis I knew all too well. He was none other than our old friend the Supercharger, famous for his OR butchery, especially on breast biopsies. "Are you still there, Doctor?" the nurse intoned.

"Yes, Nurse, I'm still here. Does Dr. Jarvis plan to come in?"

"I don't know, Doctor."

Typical. Not only of the Supercharger, but of most private doctors affiliated with the hospital. The intern would go to see the patient, work up a recommendation, and phone the private doctor, who, of course, would tell the intern to do what he thought best. On most such occasions these guys didn't even bother with the amenities. One time I had spent about an hour going over one of the Supercharger's cases. When I called in my report. Supercharger had stepped out of his office and I had to leave a message with his secretary for him to ring me back. He rang back, all right, but to the floor nurse, not me. When she told him I wanted urgently to speak with him, he said he didn't have time to talk to every intern in the hospital. Rush, rush, for a few more bucks — that was the Supercharger's game.

Supercharger had another endearing habit. He admitted almost all his patients on the so-called teaching program. One might naturally think that a teaching program would in fact teach, at least a little. God knows, we interns were in need of it. In practice, the teaching program was a grim joke. It meant only that I or one of the other interns did the patient's whole admission history and physical — the "scut" work. As a reward, we might be allowed to do the discharge note as well. But in between we weren't allowed to fool with the orders, and in the operating room our contribution consisted of holding retractors, removing warts, and perhaps tying a few knots, if the doctor was in a condescending mood.

The ultimate in Supercharger's gall had occurred earlier, on that breast biopsy, the one he mauled so badly. On the admitting chart, giving the particulars of the case, he had written a little note saying that when the house staff — meaning the intern — worked the case up, he was not to examine the breasts. Now, how was I supposed to do an adequate history and physical on a breast-biopsy case without examining the breasts? Farcical. And now he wanted me to pop over at two in the morning to straighten out another of his messes.

The nurse was still waiting on the line.

"Has the patient had surgery?" I asked.

"Yes, this morning. A hernia repair," she replied. "And he's not in good shape. The breathing difficulty has been going on for several hours."

"All right, I'll be over to see him in a few minutes. Meanwhile, have a portable X-ray machine brought to the room and get a chest film. And get me some blood for a complete blood count, and be sure there's a positive-pressure breathing machine and an EKG machine on the floor."

I didn't want to wait the rest of the night for that stuff. Maybe I wouldn't need it, but all the better if it was there anyway. When I got out of bed, Karen didn't budge. Not that it mattered. As I put on my clothes, I thought again what a convenience she was. Her apartment was just across the street from the hospital, even closer than my room in the quarters. It held all the creature comforts — television set, record player, a refrigerator well supplied with beer and cold cuts.

Karen and I had started seeing one another four months earlier, just after I had looked at her unusual pelvic X-ray the night she fell down the hospital stairs. Right after that she had been moved to a day shift, where we met again and started having coffee breaks together. One thing led to another, and going to her apartment became a habit — just about the time Joyce stopped being one.

Joyce, who'd been switched to the day shift, too, began wanting to play the tourist, make all the night spots. With that came some pressure to meet her parents and an increasing distaste for those surreptitious leave-takings in the early-morning hours. I tried to go along with her, but her roommate, the TV addict, was still there, and our relationship, which hadn't been very healthy to begin with, finally went completely sour. In any case, Joyce and I decided to cool it a while, to give ourselves a chance to think.

Karen did have another boyfriend, who continued to puzzle me. She saw him every now and again, perhaps two or three times a week, when they would go to a movie or even to a night club. She said that this fellow wanted to marry her, but she couldn't make up her mind. I didn't know him, or much about him, although we had talked once, briefly and quite by accident, when he phoned Karen's place. On the whole, I was not inclined to imperil a good thing by further investigation.

On my way over to see Supercharger's patient, I noticed that the night was unusually quiet, with almost no wind, although a low bank of clouds hung over the island, obscuring the sky. It had been raining hard all week. As I walked around to the west end of the hospital I glanced over into the ER, and the memory of my blind, exhausted bustle there came rushing back. I could see the usual clumps of activity, with people waiting and nurses appearing for fleeting moments in a seemingly disorganized jumble. It looked a little busier than usual for a Tuesday night, and I hoped that it would stay quiet enough not to require my presence. Whenever I got a night call from the ER, it usually meant an admission — probably surgery, and that could be bad.

The hall of the ward was deathly quiet and dark except for the little night lights that peeked out of the rooms as I walked briskly past them toward the nurses' station. The nurses' station was at the far end of the ward, and as I approached the light gradually grew brighter. It was a familiar sensation to me by now, walking down those dark corridors, the silence broken only by an undercurrent of hospital sounds— the light tinkle of an IV pole, an occasional sleepy moan — sounds that always made me feel I was alone in the world. Other doctors have told me of similar feelings. Actually, I had stopped analyzing the hospital and its effects on me as much as I used to, having become, in a sense, blind to my surroundings. Like a blind man, I took for granted the landmarks, the various doors and turns, and often reached my destination without noting my route or my thoughts along the way.

Some months ago the operator had called me in the early-morning hours for a cardiac arrest. I had gotten up, dressed, and run all the way over to the hospital before I realized that she had forgotten to tell me where the patient was, in which ward. Fortunately, I had guessed right about the location— through some sixth sense, you reached the point of being so routinized that when you were awakened you automatically plugged in the right information without being told.

This had its occasional disadvantages — as, for instance, on one of the frequent night calls to see a patient who had fallen out of bed. I made the automatic, insensate run to the ward and found him there, in good shape, of course. After calling his doctor, I left an order for an injection of Seconal, to be sure he'd sleep, and then plodded back to bed. All without ever coming fully awake. The same nurse called just a little later to say that the patient had fallen again, this time down a flight of stairs. So I got up again, plugged in the ward, and started off. In the middle of the journey, while climbing a flight of stairs, I stumbled across an inert mass lying on the landing. Standing there, dazed, I took fully ten seconds to reprogram myself to the fact that lying before me was the patient I had come to see. He should have been on the floor above! But, of course, he was where he was because he had fallen downstairs. Being totally limp during the fall, he hadn't hurt himself a bit. It turned out that all his shots — the painkiller, his antihistamine, his muscle relaxant, and my Seconal order — had been given simultaneously by the nurse and had taken effect at the same time, just as he took the first downward step.

I didn't always walk around in a fog. I simply developed an uncanny ability to continue sleeping while on the way to do some stupid job in the middle of the night. It was different when I got called for something serious, or when I was angry. But since our hospital suffered from an epidemic of patients who habitually fell out of bed, I learned to carry out that mission only half-awake.

The nurses' station seemed as bright as a television studio after that long walk in the dark. The nurse was effusively glad to see me and ticked off what she had done. The blood had been sent up and the X ray taken, and the EKG and positive-pressure breathing machines were both standing ready in the patient's room. I took the chart from her hand and scanned the work-up, which, of course, had been done by a fellow intern. A box of chocolates beckoned from the nearby desk, and I popped a couple in my mouth. Temperature was normal. Blood pressure was up and pulse very high. The rum-cherry centers were particularly good. I could find nothing to explain the breathing trouble. All seemed more or less normal for a recent hernia operation.

I turned back down the hall and retraced my steps almost to the end. Entering the room, I snapped on the light, illuminating a pale-looking man propped up in bed and forcibly inhaling with each breath. As I got closer I could see that he was quite diaphoretic, with beads of perspiration glistening on his forehead. He glanced at me for a second and then looked off, as if he had to concentrate on his breathing. Squinting, I realized I could see the apartment building next door, and Karen's window, the second from the right on the third floor. I wondered if she knew I was gone.

With my stethoscope in my ears, I pushed the patient forward and listened to his lung fields. The breath sounds were clear — no popping, no crackles, no rhonchi, no wheezing. Nothing there. Perhaps his lung fields sounded a little high; that seemed to go along with the fact that his abdomen was swollen and rather firm. It was not tender, however. Listening to his abdomen, I heard the familiar, reassuring gurgles. The heart sounds were normal; he had no signs of cardiac failure. About all that remained was to see if his stomach was full of air. Gastric dilatation was a frequent problem after general anesthesia. I told the nurse to get a nasogastric tube, and meanwhile I hooked up the EKG machine. These EKG contraptions were a source of irritation to me whenever I tried to use one at night, with no technicians around to help. Since I could never seem to get a good electrical ground, the tracing would wander all over the page. But I got this one going okay by hooking the ground wire to the drainpipe of the sink, and I took a tracing while the patient lay there still puffing hard. The nurse had returned with the nasogastric tube before I finished with the EKG. As I greased the tube, I couldn't help thinking of that doctor sleeping away at home while I was putting in his NG tube.

One thing had stayed with me, even grown stronger, over the past ten months — the satisfaction in achieving a quick, desired result — and I felt relieved when I evacuated a large quantity of fluid and air from the patient's stomach. My relief was minimal, however, compared to his. He was still having some troubles, but his breathing was much easier. When he thanked me very much, it took him two breaths to get the phrase out. I listened to his lungs again, just to make sure that there wasn't any fluid in them. They were clear. His legs were normal, too, showing neither edema nor any suggestion of thrombophlebitis. Peeking under the dressing, I thought his incision looked fine, without excessive drainage. I told the nurse to get a suction machine for the NG tube and hook it up, while I went back to the nurses' station with the EKG.

I was still pretty shaky at reading EKG's, but his looked okay to me. At least, there were no arrhythmias. Possibly there was some slight suggestion of right heart strain with the S wave, but nothing drastic. As a precautionary measure, I decided to call the medical resident for support on the EKG reading. After a rather awkward minute or so during which I explained the situation and the resident listened, he finally said he wouldn't come down to see the EKG because it involved a private surgical patient.

I could understand his reluctance. It resembled mine when the medical intern on duty called me at night for help with a cutdown or something else on a private medical patient. Had the attendings made us feel it was a matter of reciprocal co-operation, each fellow holding up his end, those nasty little jobs would have been easier to take. But in American medicine, much of the difference between an intern and a full-fledged doctor is literally the difference between night and day. They would let us do virtually anything at all after the sun went down, when teaching was nonexistent, but nothing during the day, when we might learn something. As always, a few pleasant exceptions proved the rule — but damn few.

Early in my internship, I had been rather naïve about this master-slave relationship, knowing nothing of my rights. Until it wore me out, I tried to see every patient, private or charity, on the teaching service or not, no matter how minor the complaint. Finally, however, it was a question of my survival. Nowadays, whenever I got called at night for some routine matter concerning a private patient — a temperature elevation, for instance — I always asked the name of the doctor. If he was on the wrong side of the answer — and most of them were — I told the nurse to call him back and say that interns are not required to see private cases except in emergencies. This was not true, of course, for private cases on the teaching service. Then I had to go no matter who the doctor was.

Doctors of middle age or older were fond of making invidious comparisons between our supposedly soft life and their Spartan days way back when. To hear them tell it, thirty years ago an intern lived well below the poverty line. Our sumptuous salaries, which I reckoned to be about half what was paid to a plumber's assistant, simply enraged them. What is the world coming to? they would say. Why, we had to do workups on every patient, no matter what his status, and we never slept, and we didn't have all these fancy machines, and so forth and so on. Their attitude toward us was a simple matter of venom: they had suffered, and so would we. Thus does medical education in this enlightened time creep from generation to generation; each takes its sweet revenge.

Where was the patient in all this? Caught right in the middle — a most uncomfortable place, with the shells and bombs of medical warfare landing all around him.

Curiously, most of the legislation corning out of Washington was only making the situation worse. The thrust was very strongly toward providing more and more private care at government expense, but without any attempt either to control the quality of the medical care or to educate the potential patient. Suddenly armed with dollar power, previously indigent patients were being thrust on the medical market with no notion whatsoever of how to choose a doctor, and somehow, as if by mischievous grand design, they seemed to flock toward those marginally competent M.D.'s whose practice depended on volume, not quality. The immediate result was that the kinds of patients whom the interns and residents used to care for were now appearing on the private floors under the tender care of doctors who, like the Supercharger, did not know how to treat, let alone teach. Even old Roso had appeared again, for some minor complaint, under the care of a. private physician who didn't want the house staff nosing in the chart. Left stranded by the tide of money, the interns were forced into the clutches of these archaic doctors in order to gain experience in dealing with certain types of cases. Everybody suffered. In years past, when these patients were admitted on the staff service, they were taken care of with the help of the best specialists around. It would turn out, logically, that the most capable and knowledgeable attendings were also on the staff teaching service, because the hospital teaching committee and the house staff selected the best they could get. And the attendings who were most interested in teaching were almost invariably the most knowledgeable. If ever I was called at night to see one of their patients, I went, no matter what the reason.

But now, instead of being admitted on the staff service, where they were invaluable for teaching purposes and at the same time got better medical attention than anybody else in the hospital, these former staff patients were all flocking to the Neanderthals. How could something as vital as medical education and care get so screwed up? It seemed especially scary to me in respect to surgery, and it certainly made the English, the Swedes, and the Germans seem enlightened. They allow only specialists to operate in their hospitals. In the United States, any screwball with a medical diploma can perform any kind of surgery he wants to, as long as the hospital allows it. I knew how inadequate my medical-school training had been with respect to patient care; yet I also knew that I could get a license to practice medicine and surgery in any of the fifty states. What is it in the American psyche that allows us to spend billions policing the globe and yet makes us willing to put up with a criminally backward medical system? Like every other important question during my internship, this one was finally pushed aside by exhaustion. I began to accept the situation as if there were no alternative. In fact, there is no alternative at present. Now the problem only popped into my head when trouble was brewing, and I knew I would have plenty of trouble with the Supercharger over those X rays and other tests I had ordered on his hernia repair. I wondered again why I didn't go into research.

Before I called Supercharger and woke him up, I wanted a look at the X ray that had been taken on the portable machine. He'd probably explode when he found out about it in the morning, but I couldn't have cared less.

The hall got darker and darker as I retraced my steps and plodded through the hospital labyrinth on my way to X-ray. It was so silent and dark when I got there that I could not find the technician. Finally, in desperation, I picked up a telephone and dialed one of the numbers of the X-ray department. All around me, about a dozen phones came to life. Someplace, somebody answered one, silencing the others. I told the speaker that I was in his department and wanted to see a portable he had taken only an hour or so ago, whereupon he appeared through a door not ten feet away, blinking and tucking in his shirt. I followed him to a bunch of view boxes, waiting while he sifted through a stack of negatives.

One thing about the X-ray department — it never seemed to know where anything was. This X ray was less than an hour old, and still he couldn't find it. He said he couldn't understand it. They always said that, and I had to agree with them. The secretaries during the day were good at finding the blasted things, but they were the only ones. As the technician went through one stack of film after another, I leaned back against the counter and waited. It was like watching an endless replay of an incomplete pass. Finally he pulled one film from a bunch that were supposed to have already been read. Flicking it up into the X-ray view box, he turned on the light, which blinked a couple of times and then stayed on. The film was on backwards, so I turned it around.

It was a mess — the X ray, not the patient. Portable films were not, in fact, very good at all, and I was sure the radiologist would tell me that it had been ridiculous to order portables when the patient could have been sent upstairs to get a good film. I never tried to explain that a portable was justified because I could order it by phone from my room and then have it — provided it wasn't lost — by the time I reached the patient. Otherwise I would end up sitting on my ass for an hour in the middle of the night waiting while the patient had a regular shot. This type of reasoning didn't make much sense to someone — a radiologist, say — who slept all night long.

The X ray looked normal for a portable, which is to say that it was a blurred smudge except for the gas in the stomach and the fact that the diaphragm appeared elevated. Even that was misleading, because with the guy lying in bed you could never be sure from what angle the X-ray technician had taken the shot. Anyway, it looked all right.

Next I got the lab technician on the telephone and asked for the blood-count results. The blood lab was pretty good; usually they found test results right away. But tonight the technician there wanted my identification, because the hospital was not allowed to give out such information to unauthorized people. What a ridiculous question! Who else would be calling up about a stat blood count at three o'clock in the morning? I identified myself as Ringo Starr, which seemed to satisfy the girl. The blood count was normal, too.

Armed with all this information, I dialed the Supercharger. The sound of the phone ringing on the other end was a delight to my ears. Four, five, six times it rang. Supercharger, true to his reputation, was a deep sleeper. Finally he answered.

"This is Dr. Peters at the hospital. I've seen your patient, the hernia who was having trouble breathing."

"Well, how is he?"

"Much better. Doctor. His stomach was badly dilated, and I evacuated almost a pint of fluid and a bunch of gas by putting down a nasogastric tube."

"Yes, I thought that was the trouble."

What a fake, I thought, convinced that Supercharger hadn't had any notion about where the trouble might lie. I went on. "I thought it advisable to check out his other systems, too, so I have the results of a blood count, chest X ray, and EKG. They look acceptable. Everything but the diaphragm, which—"

A blast came through the telephone. "My God, boy, you don't need all those crutches. My patient isn't a millionaire, and this isn't the Mayo Clinic. What the hell are you doing? I could have told you what was wrong by using nothing more than a stethoscope and a little percussion. You kids think the world was made for machines. Back when I was doing your job, we didn't…" I could imagine his face getting red, the veins standing out on his neck. I sincerely hoped he would have insomnia for the rest of the night.

"And what have you done about the NG tube, Peters?"

"I put it on suction, Doctor, and left it in."

"Don't you know anything? He'll just get pneumonia, with that thing down him. Get it out of there right now."

"But, Doctor, the patient is still short of breath, and I'm afraid his stomach will dilate again right away."

"Don't argue with me. Get it out. None of my hernia patients are to have NG tubes. That's one of my basic rules, Peters, basic." Click. I was holding a dead telephone.

I went back to the ward and pulled the tube out. The patient was still struggling for breath, but not as badly as before. As I was leaving a nurse came in, obviously a little surprised and nervous to see me still there. She held a needle. Somewhat guiltily, she said that the Supercharger had called and ordered more sedative. I was so pissed off I didn't even ask her what it was; I just left.

Now I had to decide where to go, my room or Karen's apartment. The latter didn't make sense, because Karen was surely sound asleep. Besides, none of my shaving stuff was there — a policy we followed to avoid explanations to the other fellow. If I went back to my own room, I could shave when I got up in the morning, a few hours from now. It was after three. So I returned to my quarters and called the night operator to tell her I was not at the other number any more. She said she understood. I wondered how much she understood.

I was hardly down on the pillow when the phone rang again. Sweet Jesus, I thought, probably an ER admission. What a bitch of a Tuesday night! But it was the same nurse saying that the hernia patient was much worse again, and the private doctor wanted me to see him again immediately. I was getting tired of this routine — up, down, up, down, seeing patients for whom my responsibility was so muddled and indistinct that I never knew where I stood. The ironies of the situation were considerable. Here the Supercharger had no sooner finished bawling me out for ordering some laboratory tests and for leaving in the NG tube than he had called the nurse — not me — to give some medication; and now he wanted me to see the patient again. It didn't make any sense until you realized that you were just a convenient means of keeping the doctor up on his sleep. The patient obviously wasn't getting what he was paying for. And I? Well, I was getting less than zero teaching. Someday, if I was lucky, I could look forward to being a doctor like him and not giving a shit about the intern, the patient, or medical care in general.

So, for me, it was down the elevator again, through the long hall, into the dark blue light that enveloped the sleeping hospital, my footsteps making distinct clicking noises, as if in a vacuum. It was peaceful now, but come seven-thirty I would be in poor shape for surgery. I felt like checking myself into the hospital for a good going-over. I had lost fifteen pounds since the first day of internship.

Suddenly, from behind me, the world was shattered by frantic sounds of glass and metal hitting against each other. Turning around, I saw the ER intern coming at a run toward me in the blue light of the hall, clutching his laryngoscope and an endotracheal tube. A nurse behind him pushed the tinkling crash cart.

"Cardiac arrest," he panted, motioning for me to follow. We both ran now, and I wondered if it was the hernia patient.

"Which floor?" I asked.

"The private surgical ward, this floor." He went headlong through the swinging doors. A light shone from the room where I had been before, and we rushed in, filling it up. The patient was on the floor near the sink. He had pulled the IV out of his arm and gotten out of bed. Two nurses were there, one trying to give closed-chest massage. I grabbed the board brought in by the nurse and threw it on the bed to make a firm surface for the massage.

"Put him up here," I yelled, and the four of us lifted him onto the board. There was no pulse, no respiratory effort. His eyes were open, with widely dilated pupils, and his mouth was grotesquely agape. The ER intern slapped the chest very hard; no response. I pinched his nose, sealed my mouth over his, and blew in. There was no resistance, and the chest rose slightly. I breathed into him again and then motioned for the laryngoscope, while the ER intern began to give cardiac massage, getting up on the bed and kneeling beside the patient to do it. Every time he pushed on the chest, the patient's head bounced violently.

"Can you hold the head still?" I asked one of the nurses. She tried, but couldn't really. Between bounces, I slid the laryngoscope through his mouth and down into his throat. The epiglottis alternated in and out of view. Advancing the tip farther, I pulled up, and the 'scope clanked against his teeth. Nothing. I couldn't orient myself in the red folds of mucus membrane. Quickly taking out the 'scope, I blew in a few more breaths between compressions. The ER intern was getting nice sternal excursions; the breastbone was moving in and out about two inches, undoubtedly forcing blood through the heart quite well. I tried with the laryngoscope again, down to the epiglottis, tip of the 'scope up, then in farther, and down. There, I saw the cords for a second.

"The endoctracheal tube." A nurse handed it to me. I didn't take my eyes away from his throat. "Push on his larynx." I motioned to the neck. The nurse pushed. "Harder." Then I saw the cords again and pushed in the tube. "The Ambu bag." I hooked up the Ambu breathing bag and watched his chest as I compressed it. Instead of the chest rising, the stomach bulged a little. "Damn! Missed it." I pulled the tube out, put my mouth over the patient's again, and blew, twice more. Then the laryngoscope again. I had to get it this time. "Push again on his larynx." I pulled up very strongly, and then I could see the cords between each chest compression. "Hold it. Okay, stop the compression." The ER intern interrupted his rhythm for a second while I slid in the tube; then he immediately recommenced the massage. With the Ambu bag attached and compressed, the chest rose nicely. The ER nurse had put in the needle leads for the EKG, and we had a blip on the oscilloscope. It wasn't grounded very well.

“Put the EKG on lead two," the ER intern said. That was better. I was compressing the Ambu when a nurse-anesthetist arrived. She took over the Ambu.

"Medicut." The nurse gave me a catheter, and I put a piece of rubber very tightly around his left upper arm. Medicuts can be tricky, especially when you're in a hurry, but they're much faster than cutdowns, because you put the medicut into the vein by just pushing it through the skin rather than making an incision as with the cutdown. I pushed the medicut into the patient's arm and advanced it until I thought I was in the vein; fortunately blood came back into the syringe — but that was only half the battle. I pushed the plastic catheter forward on the needle, hoping it would remain within the lumen of the vein. Then, by wiggling the needle back and forth, I attempted to advance the catheter still farther into the vein. When I pulled out the needle, some dark brownish-red blood flowed through the catheter over his arm and onto the bed. A nurse was still struggling with the plastic tubing from the IV bottle. I just let the blood flow; it didn't make any difference. After securing the end of the tubing to the catheter, I could see the blood disappear from the catheter, running back into the vein as the IV started up. Snapping off the rubber tourniquet, I watched the drip, and opened it all the way until it was running fine. "Tape." I secured the catheter to the arm. The EKG still showed rapid but coarse fibrillation. "Epinephrine," I barked. I thought a heart stimulant might smooth out the fibrillation, before we tried to change it electrically to a regular heartbeat.

"How about directly into the heart?" The ER intern suggested.

"Let’s try just IV first." I wasn't very confident of that intracardiac method. The nurse gave me a syringe and said it was 1:1,000 diluted to 10 cc. I injected it rapidly into the new IV site through a small length of rubber tubing, being careful to compress the distal plastic tubing to keep the epinephrine from going back into the IV bottle. "Bicarbonate," I said to the nurse, holding out my free hand. The nurse gave me a syringe, saying it held 44 milliequivalents. "How are you doing with the pumping?" I asked the ER intern.

"I'm fine," he answered.

I injected the bicarbonate into the same IV site— and pricked my finger in the process by putting the needle all the way through the little rubber section. Sucking my index finger, I watched the EKG. Slowly it began to show stronger fibrillation.

"How about defibrillating now?" the ER intern suggested. The defibrillator was all charged up. A nurse held the paddles, with a smear of conductant on each one. Stopping his pumping, the ER intern took the paddles, placing one over the heart and one to the side of the chest. "Away from the bed!" The nurse-anesthetist let go of the Ambu. Wham! The patient jumped, his arms fluttered, and the EKG blip was gone. When it came back, it was just about the same. A medical resident arrived breathlessly and quickly got oriented.

"Hang up a 5-per-cent bicarbonate on the IV and give me some xylocaine." The nurse gave the medical resident 50 mg. of xylocaine. He handed it to me, and I injected it. We defibrillated him again. In fact, we tried about four times before the fibrillation disappeared. But instead of a normal cardiac rhythm taking over, all evidence of activity in the heart disappeared, as the electronic blip on the EKG screen became perfectly flat.

"Damn! Asystole," said the resident, watching the blip.

Epinephrine, isuprel, atropine, pacemaker: we tried all the stuff we had. Meanwhile, the man's pupils came down to about normal size from the widely dilated state they'd been in when we first started. At least that meant that oxygen was getting to his brain, that our cardiac massage was effective.

Another intern arrived, taking over the massage part so the ER intern could go back to his primary duty, poor fellow. Then I took a turn at the massage. "How about calcium?" the other intern suggested. The resident injected some calcium. I asked for another nasogastric tube, but didn't get to put it down until the intern could relieve me at the massage. There wasn't much in his stomach except some gas, and that was probably just what I had pushed in there earlier by mistake, through the misplaced endotracheal tube. I told the resident that this patient was the one whose EKG I had called him about earlier. I also told him that the portable X ray of the chest was generally clear.

Looking behind me, I was surprised to see the Supercharger standing there quietly watching our feverish activity. I guess the nurses had called him. He didn't say a word. The resident injected the heart several times with intracardiac epinephrine. Still we couldn't break the asystole, and we were running out of options. Pumping and breathing, pumping and breathing, for fifteen minutes more we watched the machine trace a straight line across the oscilloscope.

"All right, that’s enough. Stop now." It was the Supercharger finally speaking, after standing by in silence for almost thirty minutes. His words surprised us and failed to penetrate our routine, so that we didn't stop right away, but kept on pumping and breathing as if he hadn't said anything.

"That’s enough," he repeated. The nurse-anesthetist compressing the Ambu was the first to stop. Then the intern, who happened to be massaging at the time. All of us were tired by then, thinking about getting back to bed, and conscious of the fact that we might have stopped earlier if the man's pupils hadn't reduced so well. Constriction of the pupils is one of the signs of revival; that had kept us going. But clearly this time it had been a false sign. So we stopped, and the man was dead. The Supercharger walked out and disappeared down the corridor toward the nurses' station, where he did the paper-work chores and called the relatives. The nurses unhooked the EKG machine, while I got out a large intracardiac needle.

"How are you at hitting the heart?" I asked the other intern.

"I've hit it one hundred per cent, but only on two tries," he answered.

"I'm only doing about fifty per cent," I confessed. After attaching a 10-cc. syringe to the needle, I walked over to the patient and felt for the transverse ridge called the angle of Louis, about midway down the breastbone. This oriented me with respect to the rib cage. It was then a simple matter to find the fourth interspace on the left. The needle went in quite easily, and when I drew back on the plunger the needle filled with blood. Bull's eye.

"I think my problem has been that I've been using the third interspace," I ventured. I tried it again, this time in the third interspace, and when I withdrew no blood appeared. "That's it. Okay, you have a go." I handed him the syringe, and he got the heart right away.

I pulled the endotracheal tube out of the dead man, wiping the rather thick mucus on the tip off onto the sheet, where it left a gray trail. "This guy was really hard to get an endotracheal tube into. Want to try?" Gingerly holding the tube between my thumb and index finger, I advanced it toward the other intern. I was pretty good at entubating now, because I had made it a point over the last few months to practice whenever we had an unsuccessful resuscitation like this one, which happened pretty often. He took the laryngoscope and slipped it in. He said he couldn't see anything. I looked over his shoulder and could tell he wasn't lifting enough with the point of the blade. "Lift until you think you're going to dislocate his jaw." His arm quivered as he strained. Still something wrong. "Let me try." I pulled up, and then with my right hand I pushed down on his larynx. The cords came into view. "He has a pretty oblique angle there. Try it again, but push a little on the larynx." The nurse stuck her head in, saying she needed the 'scope so she could return the crash car to the ER. With a wave of my hand, I staved her off for a few seconds, while I looked over the other intern's shoulder. A sound of satisfaction came out of him as he finally saw the vocal cords. Then, walking out, he handed the 'scope to the nurse, who clucked in disapproval.

Suddenly I was alone as the activity moved on, like some grim parade, to the living in other parts of the hospital. I wondered again whether to go to Karen's place or mine. It was a lonely time, especially because the man had died. I had been one of the last people to see him alive. But I had done everything I could — we all had — I guessed we had given it a good try. Besides, it was the Supercharger who had made me take the NG tube out and who had given him some sort of drug. So it wasn't my fault, though he probably thought it was. No doubt he would blame it on all those expensive tests. That was one of the troubles with the setup for private patients. I was available to see the patient but had no real responsibility, whereas the attending had the ultimate responsibility but was not on the scene. That made my position ambiguous, to say the least. It was too complicated for 4:00 a.m. Still, I was curious about Supercharger's last injection. The nurse had said it was a sedative. If I went back to look at the chart, I'd have to see the bastard again, and he'd probably have some timely comments about expensive blood counts. But, going up the hall, I decided it was worth the risk.

The Supercharger was gone already. That was a relief; it was also an indication of his interest in teaching. Seconal, the order sheet said. It added nothing to what I knew. Reading through the work-up again, I noted that the man did not have a history of heart trouble. The stomach and kidneys were normal, too. Then I read that the hernia had been a huge, basketball type of problem; yet that didn't seem to explain his course. Something had made him go into respiratory failure ultimately leading to heart failure. The gastric distention I had relieved must have added to the problem, but it had not caused it. What about the anesthesia? I wondered. Turning to the anesthesia record, I read that it had been pentothal induction, maintenance nitrous oxide, no complications. I vainly struggled to pull in all the loose pieces, but I couldn't work through the maze. I was too exhausted. Better hurry back to bed, I thought cynically, so as to be there when the operator calls to wake me up for the day. Very funny.

But it was a bad, bad Tuesday night. Tuesday nights were generally active, Like Monday nights, since both Monday and Tuesday always had full operating schedules, and that meant a lot of nighttime dressing, pain, and drain problems; still, I usually got some sleep. Not this time; hardly had I put my head against the pillow when the phone rang again. It was the OR; a case was coming up for amputation, and I was needed to assist.

There was something particularly upsetting to me about an amputation, especially of the leg. An appendectomy or a cholecystectomy or any of the other interior operations left the surface of the person intact. But lifting a foot and a lower leg from the table and carrying them away from the person they belonged to was an irreversible act of alteration. No matter how jaded I became, I was never able to look upon the removal of a human limb as just another medical procedure.

But it had to be done. So I got up again, with the most complete lack of motivation, and dragged myself over to the OR. On with the scrub suit, the hat, and the mask. Once the mask was on, I pulled it down off my face, leaving the strings tied, and studied myself in the mirror. I hardly recognized the wasted man who stared back at me.

Happily, when I got to the operating room proper I found that it was not to be an amputation, after all, but, rather, an attempt to save a leg whose knee had been crushed by a truck. Only the nerve and vein were intact, spanning the gap where the knee had been. The artery, bones — everything else was gone. To my surprise, I found two private surgeons there, both excellent vascular men. I asked if I was needed, since there were two of them, and they answered, "Perhaps." That left me no choice but to scrub and put on a sterile gown and gloves.

My job was to stand at the end of the table facing the anesthesiologist and hold the foot rigid by cupping my hands together around it. Both surgeons, of course, had to be near my end of the table to work on the knee. But they had their backs to me, as usual — especially the surgeon on my left, who was leaning over the table. I couldn't see a damn thing. The clock to my right indicated that it was almost 5:00 a.m. by the time the operation really got under way. From their conversation, I gathered that they were putting in a graft for the main artery, which runs down behind the knee toward the foot. An hour passed as slowly as an hour can, the minute hand creeping around the face of the clock. They got the graft in, and a pulse appeared in the foot, only to fade and disappear after a few minutes. That meant the surgeons had to open the graft and take out a fresh blood clot. They got another pulse, which again faded. Another clot. Open again. Clot. This process went on and on and on. I was absolutely amazed by their cool persistence and patience.

With nothing to do and nothing to see except the clock, and standing there motionless with my hands in one position, I began to get uncontrollably sleepy. The sound of the surgeons' voices wandered in and out of my head, along with the image of the room. Only half-conscious, I fought hard to stay awake, and lost; I fell asleep still holding the foot. I did not fall down. Rather, my head sank slowly until my forehead bumped gently against the shoulder of the surgeon on my left. That brought me awake, so close to the fabric of his gown I could make out the cross weave of individual threads. The surgeon looked around and pushed me back into an upright position with the point of his elbow. Over his mask, cold blue eyes cut at me in clear disapproval. I was beyond caring, but the incident did serve to keep me in the ball game, because it brought back all my pent-up fury.

It was now eight in the morning and here I was, after a sleepless night, with a full schedule of surgery ahead of me, still standing and holding that foot like so much dead weight. A job for a bunch of sandbags. In fact, sandbags would have done a better job; they do not sag or get angry. This was not the first time I had fallen asleep in the OR. Helping once on a thyroid case after a night without sleep, I had drifted away while holding the retractors. For only an instant, I think, because I had suddenly given one of those falling-asleep jerks, which startled the surgeon. He had asked, only partly in jest, if I was about to have an epileptic fit. But I don't think that surgeon knew I had fallen asleep. This one did, and he was irritated, although he and his sidekick continued to ignore me. Finally, when everything was finished and I was preparing to leave, the surgeon let me have it.

"Well, Peters, if falling asleep during a case indicates your interest in surgery, I think the fact should be brought to the attention of the board." Rather than tell him to go to hell, I backed all the way down and pleaded lack of sleep and not being able to see the operative field. He was not impressed. "I'd advise you not to let it happen again." "No, sir." I walked out, harboring ineffectual, murderous thoughts.

The regular surgical schedule had begun more than an hour before. In fact, I had missed my first case, which didn't upset me much. It was a second assistant's spot on a cholecystectomy, totally routine. Besides, I was scheduled for two more of them that afternoon. Sneaking down to the surgeons' lounge, I scrounged a few slices of bread, my first food in about fifteen hours. As for sleep, I wasn't much better off — one hour during the last twenty-six. I felt a little weak. The thought of another full day in surgery was not cheering.

In the lounge I was bearded by an irritated chief resident who demanded to know where I had been during rounds. Early on, an intern learns the impossibility of pleasing everybody. Lately, however, I was striking out every time up and pleasing nobody, least of all myself. I reported to the chief resident on the few staff patients I had. Since I was on the private teaching service, I didn't have many staff patients — only those whose surgery I'd helped with. Both hernias were doing fine; the gastrectomy was already eating; the veins were okay and walking; and neither hemorrhoid had managed a BM. The disease paraded verbally out of me, unattached to personal names or thoughts.

I almost forgot to mention the aneurysm patient whom we had scheduled for aortography that day.

He had been sent to us from one of the outer islands because his X ray showed a suspicious shadow in the left lung field. It was probably an aneurysm, a bulge in his major artery. Without surgery, such an aneurysm generally bursts in six months or so, and the patient quickly bleeds to death. So it was important to act quickly, and to be sure of the diagnosis, which we could do best by making an aortogram. This fairly simple procedure took place in X-ray, where radiopaque dye would be injected into the man's artery just above the heart. For a few moments, before the blood swept it away, the dye would outline the shape of the artery, and X rays taken in rapid sequence would pick up an imperfection. Only then would we know whether surgery was necessary. Since I had done the history and physical on the man, I wanted to be there, and I asked the chief resident about it. "Sure," he said. "If the surgical schedule permits."

That part of the system had not changed during the past nine months. We interns were still bounced back and forth between cases at the whim of the surgical schedule; too often, we had to miss seeing our own patients. If you work a patient up, you should stay with him and follow him through all his diagnostic procedures and his surgery. No one would care to argue against that, either from an academic point of view or from the standpoint of the patient's good. Nevertheless, whenever someone needed an extra pair of hands on a gall-bladder attempt (our minds, it seemed, were never in demand), we were sacrificed, without regard to the educational aspect or to the psychological effect on our own patients. It was another way to impress upon us how very dispensable we were.

The chief resident disappeared, and a few minutes later I got a call from the surgical desk telling me that he had assigned me to help on a gastrectomy that was already under way. Apparently those extra hands were needed. I finished my stale bread and plodded once more into the OR area, mentally mapping out the rest of my day in surgery. After the present gastrectomy, I was scheduled for a nephrectomy — a kidney removal — in Room 10, and then the two cholecystectomies. As I passed Room 10 I realized the nephrectomy was already under way and that I would miss it. Nakano, another intern, was scrubbing on the case. Lucky bastard. That nephrectomy was more interesting to me than all the other cases put together. The patient had a tumor on his kidney, and the tumor had to be removed, even though it was not malignant. Until very recently, the surgeon on such a case would have been forced to take out the whole kidney; now, with advanced radiology, such tumors could be "mapped" very accurately, so that only the involved portion need be cut away. Ah, well, another time. I continued down the corridor toward my gastrectomy assignment. Normally I would also have been dismayed at the prospect of back-to-back cholecystectomies. But today I was in for a bit of luck, because both were scheduled with a good teaching surgeon. This man was like an oasis in a desert of conservatism. Of course, there was always a chance that the gastrectomy I was joining now would run over into the first cholecystectomy with the teaching surgeon. I hoped not.

Hardly noticing the activity around me, I strolled slowly down toward Room 4, in no hurry, forcing myself all the way. A glance at the operating schedule posted on the bulletin board increased my dismay.

Like the Supercharger, this G.P. was a man of advanced age, small skill, and no modesty. He was also given to interminable and egotistical stories about his travail in the early days. Apparently, he had for years carried most of the burden of American medical service on his shoulders, performing feats of skill and endurance that blew the mind. At least, they blew his mind. A puckish resident had once dubbed him Hercules, and the name stuck. Hercules was another who always admitted his patients on the teaching service, so that the house staff would do histories and physicals for him. If you ever ordered an X ray, or even an extra blood count, he'd hit the ceiling, bawling you out for extravagant utilization of costly laboratory tests. Apparently 99 per cent of the lab tests had been developed since he graduated from medical school about the time the Curies were beginning to play around with pitchblende. Moreover, he had a favorite habit of prescribing penicillin or tetracycline for every cold that appeared in the ER — a practice that virtually all medical authorities now agree is worse than doing nothing at all. That he was supposed to be one of our teachers was simply a bad joke.

I had scrubbed with Hercules several months earlier, on a kidney-stone removal. At the time, he'd just finished reading, so he said, an article in a recent surgical journal recommending a new way to remove kidney stones. I doubted that Hercules read deeply or often, but this article had intrigued him — although he could not seem to remember the name of either the author or the journal, or even where the experiment had been conducted. As he worked down to the kidney, fondling the notion of this new procedure, he had indulged his habit of slicing through arteries indiscriminately and then stepping back to say, "Get that bleeder, boy," hardly interrupting what he was talking about. The resident would scramble around in the wound, dabbing with gauze sponge and hemostats, while the surgeon pontificated.

This new kidney method of Hercules's involved putting a 2–0 chromic suture — a very large thread— through the kidney and then, by holding the suture at both ends and manipulating it somewhat like a blunt knife, sawing back up through the kidney. This was supposed to reduce bleeding. The procedure sounded a bit strange and oversimplified to me. As it turned out, mine was a healthy skepticism. Hercules had forgotten one vital point that the article repeatedly emphasized: before "sawing" with the suture, the surgeon must first gain control of the kidney pedicle — the source of blood to the kidney — so that the blood flow through the organ is essentially stopped. Well, our fearless innovator plunged ahead, making no provision to control the blood flow, but sawing nonchalantly up through the kidney "to minimize bleeding." The result was the worst uncontrolled hemorrhage I have ever seen in an operating room — except for the time the right atrial catheter of a heart-lung machine fell out of the patient. But that was a legitimate mistake. The kidney disaster was not. Blood from the kidney vessels filled the wound instantaneously, overflowing it and soaking the table and all the operating team. We began to pour blood into the man through the IV, as down a deep well. Eight pints later, we had finally clamped down on the kidney, sucked out the wound enough so that the stone could be removed, and put enormous sutures through the kidney cortex. Since the human body holds only about twelve pints of blood, we had practically drained the poor man and filled him up again. It scared hell out of everybody. Even the anesthesiologist — normally in another world up behind the ether screen, with one eye on the automatic breather and both hands on his newspaper — was upset.

Naturally, then, I wasn't looking forward to this gastrectomy with Hercules, whom I could see inside working away as I scrubbed. I hoped he hadn't read any more current literature. A resident named O'Toole was there, too, but no intern was in evidence. As I backed in, surrendering, I could tell the atmosphere was anything but congenial.

"I want a decent clamp," yelled Hercules to the scrub nurse as he threw one over his shoulder against the white tile wall. "Peters, get the hell in here. How is a man supposed to do surgery without any help?" Some of these surgeons took a bit of getting used to. Much of the time they behaved like petulant children, especially when it came to the instruments, which they tended to throw around rather indiscriminately and to use in unexpected ways — such as cutting wire with dissecting scissors. Yet the next time they were handed one of these instruments that they might have damaged themselves, they'd stomp and rage, blaming all their recent bungles on a lack of proper equipment. No one ever said anything about these outbursts. You got used to them after a while.

As I moved in next to Hercules, he clamped my hands around a couple of retractors and said to lift up, not pull back. A familiar line. Actually, I was able to fake it, because there was nothing to retract at the moment. The stomach, which Hercules was working on, sat right on top of the incision in full view. He would need retraction later, while making the connection between the stomach pouch and the beginning of the intestine called the duodenum. I fervently hoped he had already cut the nerves to the stomach that are partially responsible for the secretion of acid. Those vagus nerves wind around the esophagus, and in order for the surgeon to cut them the intern has to hold up the rib cage; I hated that retraction.

Here I was again at my post in the OR watching a minute hand that appeared to be glued in place. As I fought to stay awake, my eyes blurred after each yawn, and my nose itched uncontrollably on the left side, a little below my eye, as if I were being attacked by a subtle, sadistic insect.

The position of my mask was another subtle torture. Each time I yawned it moved a little down my nose, perhaps half an inch. After five yawns it fell completely off my nose and was just covering my mouth. This called into play the circulating nurse. She hopped around to my side and lifted the mask up, touching it ever so carefully to avoid my skin, almost as if my whole face were infectious. Wishing to relieve the itch, I tried several times to push my nose against her hand as she adjusted the mask. But she was too quick for me, and pulled away each time before hand and nose could meet.

Hercules was even more nervous and erratic than usual. None of us around the table could anticipate what his next move might be. Fortunately I was immobilized by the retractors and not expected to contribute otherwise, but poor O’Toole was like a rat in an uncharted maze being called upon to perform impossible feats of anticipation.

"O’Toole, are you with me or against me? Hold that still!” While delivering this rhetorical question, Hercules gave O’Toole's left hand a sharp swat with the Mayo scissors. O’Toole gritted his teeth and adjusted his grip on the stomach.

“For Christ's sake, Peters, haven't you learned how to retract?" He grabbed my wrist for about the sixth time to readjust the retractors, even though retracting had nothing to do with what was going on at the moment. In fact, I wasn't needed; yet he wanted me there. He was like a lot of surgeons, who felt slighted if they weren't assisted by both a resident and an intern, regardless of need. I was a status symbol.

Hercules had rotated in front of me so that I was staring at his back as he began putting in the second layer of sutures on the stomach pouch. I could see neither the operative field nor my own hands.

The anesthesiologist spoke up rather suddenly. "Peters, please don't lean on the patient's chest. You're compromising his ventilation." He pushed my lower back through the ether screen to keep me from crowding the intravenous line. But I had no place to go, being already mashed up against Hercules.

Just then O’Toole stepped abruptly back with a startled expression on his face, holding up his right hand. I could see a few drops of blood dripping out of a neat slice through the rubber glove into the side of his index finger.

"If you had your finger where it was supposed to be it wouldn't have happened, O’Toole. Let’s wake up," boomed Hercules.

O’Toole said nothing as he turned to the scrub nurse, who slipped on another glove. I guess he was thankful to be still in possession of the finger.

Despite all, the surgeon somehow finished, and we began to close. One of my jobs was to irrigate with the bulb syringe after the strong, fibrous fascial layer of the abdominal wall had been closed with silk sutures about a quarter of an inch apart. O’Toole and I were feeling frisky by then, and as Hercules was rinsing his hand I raised the syringe up over the wound, over the patient, and shot a stream of warm saline across the table, hitting O'Toole in the gut. Our eyes met in understanding; we were partners in an unhappy situation.

Rejoining us at the table, Hercules turned suddenly jovial. Obviously, he thought he had accomplished the impossible once again. "If s too bad that my art gets covered up under the skin instead of being visible to the patient. All he has to show is this little incision." O'Toole's eyes rolled up into his head in mock dismay.

Since both O'Toole and Hercules were on hand to finish up, I marshaled my courage for the exit. "I have several other operations coming up, Doctor. Will you excuse me, please?" That irritated the old boy a little, but he waved me free with a gesture of noblesse oblige.

First I scratched my nose, long and hard, a sensual experience. Then I urinated, which was equally satisfying. It was eleven-twenty-five, and since the nephrectomy patient was just coming out of Room 10, I had a few minutes while it was being made ready for the first of my cholecystectomies. Nearby, at the door of the recovery room, I saw Karen, my angel of mercy and sex, pristine in her white uniform. She had come to take a patient down to the ward, and when she saw me she smiled broadly, asking with a trace of sarcasm if I had slept well last night. I told her to be pleasant or one of these nights I would roll her out of bed. Glancing around, she shushed me, adding that she had told her boyfriend she didn't want to go out that evening; she would be in, probably from eleven on, in case I was free. I filed the fact away, but I didn't think I'd be up to doing anything about it.

My aneurysm had been scheduled for his aortogram at eleven-fifteen, and I went down to see what was happening. Stepping into the fluoroscopy room, I saw that the chief resident was in the final preparations for the study. "You're ten minutes late, Peters. I could have used you to help get the catheter into the aortic bulb."

"And I would have been here, but I had to scrub for another case." I consciously withheld a "thanks to you."

"Well, here's the catheter position. Put on a lead-lined apron first. This fluoroscopy puts out a lot of radiation. Gotta protect the old gonads."

Following his advice, I took one of the heavy leaded aprons and put it on. By stepping behind him I could see the fluoro screen. As the lights went out, the fluoroscope came on automatically with a low resonant dick. Then image was extremely faint, as usual. In order to see a fluoroscopy well, you ought to adapt your eyes by wearing red goggles for thirty minutes or so beforehand. I couldn't tell very much about the aneurysm patient on the fluoro screen, because I hadn't had the chance to dark-adapt my eyes, but I could distinguish the heavy radiopaque stripe on the catheter.

"Here's the end of the catheter." The chief resident's pointing finger was silhouetted by the light from the screen. "If s in the aorta just above the heart. See it jump with each heart contraction?" I could see that with no difficulty. "Now, we went to inject enough radiopaque dye into the artery to get an image, and to do that we have to use the pressure injector." He indicated a small machine that looked something like a bicycle pump turned on its side. It had three or four stopcocks positioned on the end — I thought one or two should have been sufficient to prevent a mishap. "All we do is push this handle, which shoots the dye very rapidly into the heart, at about 400 psi. At the same time the Schonander camera will be shooting X rays at a rate of one every half second for ten seconds. We'll watch on the fluoro screen."

The chief resident swung into the final preparations, calling to make sure the X-ray technicians were ready and positioning himself behind the arm of the pressure injector. Desiring all the protection I could get, I squeezed in behind the lead screen with the X-ray technician, who was a solid little thing. We watched through the quartz window.

At a yell from the chief resident, the X-ray technician started the Schonander camera, which cranked and pounded, taking X ray after X ray in rapid succession, while die chief resident plunged the pressure injector all the way down. The dye shot from the injector into the stopcocks, and then, instead of being propelled into the patient's heart, rose in a graceful geyser to the ceiling, splattering there and running a little way along before dripping down onto the chief resident, the patient, and the mass of machinery. The chief resident had forgotten to open the last stopcock. As for the patient, he just lay there blinking and looking around, trying to figure out what sort of strange test this was. The chief resident was in a state of shock blending rapidly into exasperation. Since the whole procedure would now have to start over and I was already a little late for the cholecystectomy, I took the opportunity to make an unobtrusive exit and hurried back to the OR.

Working with a real professional is different in every way from assisting a Hercules or a Supercharger, and Dr. Simpson was the best the hospital had. With the resident on one side of him and me on the other, we scrubbed together, talking and joking. Simpson told us the one about a Columbia professor who discovered a way to create life in the laboratory. Everything went well until his wife caught him.

A simple joke — perhaps, on reflection, not even a very good one. But in the context of my hours with Hercules, the image of dye all over the fluoro-room ceiling, and my tiredness, that joke plunged me into hysterical laughter. We were still chuckling as the three of us entered the operating room, where the atmosphere changed immediately to one of congenial concentration. Ready to go, we were still light toned, but nevertheless intensely interested in the task ahead.

The nurse handed Simpson a scalpel. Interesting how he started an operation. There was no pause. The knife shot in to the hilt and zoomed cleanly, diagonally down the abdomen. He didn't pause to catch bleeders with hemostats. "Why scratch around like a chicken?" he would say, completing the incision rapidly, with the same sharp, purposeful dissection, as the tissue fell apart. The resident would then pick up the tissue on his side, the surgeon on the other, both using tooth forceps, and with a final flash of the knife they were into the abdomen. Only then were a few bleeders caught and tied. No more than three minutes from skin to peritoneal cavity. Perfection.

This time, however, Simpson didn't make the first cut. He surprised us by handing the knife to the resident instead. "Your gall bladder," he said. "One false move and you'll be doing enemas for a month." Under his expert eye, the same kind of incision was made, at just about the same speed. The surgeon explored rapidly inside, then the resident, then me. Stomach, duodenum, liver, gall bladder (I could feel the stones), spleen, intestines. The examination was gingerly but thorough; with your arm elbow deep in someone's abdomen, you tend to be gingerly. I told Simpson I was having trouble feeling the pancreas. He explained a landmark and a bulge. Then I felt it.

Using Simpson's technique, the resident carefully placed the saline-soaked white towels that are used to separate the gall bladder from the mass of intestines. I was given the usual retractors. At a suggestion from Simpson, the resident moved down a little, enabling me to see into the wound. It all went rapidly, with encouragement but no manual assistance from Simpson. The gall bladder came out cleanly the base was closed, and then the skin, all within thirty minutes. Feeling good now, I congratulated the resident on our way to the recovery room. He had done a professional job.

With thirty minutes between cases, Simpson and I went down to see several of his patients, one of whom, a gastrectomy, I was following closely after having helped with the surgery. I had been given total responsibility for writing orders on the case, although I tried to follow Simpson's preferences, which, I knew by now, were sound and sensible. When he changed one of my orders, as occasionally happened, he invariably wrote out a short explanation, an opinion on some drug or procedure. He was a born teacher.

After our trip to the ward, we put on another set of clean scrub suits and began to scrub again, in the same bantering way, this time without hysteria on my part. I decided, on reflection, to switch to Betadine for this scrub; its pale yellow color offered a bit of variety, after the colorless phisohex we usually used. Entering the OR, we observed the usual hierarchic routine. A towel went first to Simpson, then one to the resident, and then one to me. It was the same with gloves.

As we huddled around the patient, the nurse handed Simpson a scalpel, and to my utter confusion he handed it on to me. "Okay, Peters. Get the gall bladder, and get it right the first time or I'll remove yours without anesthesia." Obviously, I had never done a cholecystectomy before, though I had seen a hundred or more, and this development was definitely not in my imagined scenario. I had looked forward to another session as interested spectator, watching two professionals (the resident had come of age) work together. Now, however, I was to be not a spectator, but a participant — indeed, the chief actor. Suddenly the man on the table and the scalpel in my hand took on new reality. Inwardly awash with uncertainty, I knew that if I hesitated now, I might be too scared ever to try again. I somehow conquered a tremor that threatened to develop in my right hand, grasped the knife firmly, and tried to duplicate Simpson's first slice into the top of the abdomen, going straight in, up to the hilt, then coming diagonally down the blade at a ninety-degree angle with the skin. I wanted to please Simpson as a son wants to please his father.

"By golly, there's hope for you yet," he said in jest, not knowing how sweet the words were to me. As I repeated the maneuver, muscles and fat parted and, retracted. Some bleeding followed, but not much.

"Forceps." The nurse gave them to me, and a pair to the surgeon. I lifted one side of the incision, he the other. At this point we were very close to the thin, peritoneal membrane that forms the lining of the abdominal cavity. We were lifting now to protect the underlying organs as I pushed in the blade of the scalpel. Pop! A hole appeared in the abdomen, and I let go of the forceps.

"Keep the forceps," Simpson suggested, "and cut while you can see." I tried, going carefully because the liver and intestines were clearly visible in the widening incision. It worked fine. Then, for the lower end of the incision, I had to change the technique. Dropping the forceps, I slid my hand into the wound and opened the rest of the peritoneum by cutting between my fingers. My heart was racing. I didn't feel tired now, nor did I notice the clock, the radio, or the anesthesiologist. I was scared but determined. Simpson felt around, then I did, then the resident, and the resident took the retractors as I moved down to give him an open view if he wanted it. I also tried to follow Simpson's technique with the abdominal tapes. He helped me with the last one, and then with his hand he rolled the duodenum far enough that I could see a smooth curve of tissue stretching from the top of the duodenum to the gall bladder. After clamping the gall bladder and pulling up, I used the Metzenbaum scissors to push down the delicate tissue. An artery was in there somewhere, the cystic artery, which carried blood to the gall bladder. Mustn't cut it.

The muscles of my neck were hard as rocks as I bent far over, trying to see clearly. Simpson told me to straighten up or I wouldn't last fifteen minutes. The artery appeared — about the usual size for a cystic artery — and I isolated it with a gall-bladder clamp. A tie went around, and I took the ends. First throw. I ran it down with my right index finger. Good. Second throw. Down. How much tension should I put on the thread? That was enough; I didn't want it to break. One more throw, just to be sure. With the help of the gall-bladder clamp, another suture went around the cystic artery. This time I had to make the tie way down, close to the hepatic artery going to the liver. The cystic artery branched from the hepatic artery, and by pulling slightly on the suture already tied around the cystic artery I could see the wall of the hepatic artery. In fact, I could even see the branch going to the right side of the liver. That made me feel better, because there was always the danger of confusing that bugger with the cystic artery and tying it off.

I was quite concerned about this second knot on the cystic artery. It was the single most important tie of the whole operation. If it fell off some days later, the patient could bleed to death internally. With this in mind, I ran down the first throw and then peered into the hole. It looked okay. Involuntarily, I glanced at Simpson, who didn't complain. So I finished it, and then cut through the artery between the ties, beginning the isolation of the gall bladder.

Next came the cystic duct, through which the bile normally flows. I handled it the same way, tying it with two sutures and then cutting between the knots. Once the gall bladder was isolated, I tensely ran a scalpel lightly around its bed so that just the outside layer of glistening tissues parted. With the scissors, I began to lift the gall bladder away from the liver.

"He's making this look difficult," kidded Simpson.

"If he takes much longer, the thing will develop gangrene." I hardly heard him. The whole operation was only twenty-five minutes old.

With one more gentle cut and a tug, the gall bladder came free. I plopped it in the pan proffered by the nurse. With her other hand she gave me a needle holder with 3–0 chromic suture. Picking up the tissue from the edge of the gall-bladder bed and pulling it over the exposed hepatic duct and right hepatic artery, I took a stitch and tied it down firmly. Too firmly. The suture broke. Another, same place, tied this time with more care, less tension. Then with a running stitch I closed the gall-bladder bed.

After removing the towels used to separate the gall-bladder area from the other internal organs, I began to close. The nurses started their sponge and instrument count to make sure I hadn't left anything behind. All was in order. Carefully I identified all the levels of the abdominal wall, especially the tough fascial layer, which had retracted back out of sight. Stitch after stitch went into the wound, with both the surgeon and the resident helping me tie. I dug the curved needle into the lower side, took it out through the incision, repositioned it with my left hand, then through the upper side. Layer by layer I closed the incision, as if shuffling a deck of cards, watching them snap together and overlap. Finally the skin. When it was over a soaring confidence came over me, like the feeling you get at the end of a good wave when your board breaks out of the white water. As I snapped off my gloves, the resident returned my earlier compliment. The world was mine.

Accompanying the patient down the hall to the recovery room, I was still on a high. Two nurses took charge of the patient while I wrote postoperative orders and dictated the operative note. Then the fatigue came back, hard. I was hungry, too, and I decided to eat, because I hadn't had anything but those two slices of bread since supper the night before, nineteen hours ago; it was 2:00 p.m.

Outside the hospital it was pouring rain; had been all day, I guessed, since water was standing in the low spots. The sky swirled with gray clouds chased in over the island by strong kona winds. It was raining so hard I could barely see the coffee ship a hundred yards away. As I ran the breeze ruffled the puddles of water collected under the overhang. I felt my luck go off a little when I saw Joyce across the room, and, sure enough, she immediately came over to join me. With plenty of other people near us busily talking about the rain, the Hula Bowl, and what not, Joyce said little at first, which suited me. Then, as if by signal, everyone else left and Joyce started in.

"Have you been thinking a lot?" she asked.

"About what?" I was curious.

"You know, about us, like you said you'd do."

"Oh, about us. Yeah, I've been giving it some thought," I said.

"Well, I have, too," she added, sitting up a little. "And I think we should be more open with each other."

"You do, huh?" I was slightly sarcastic, but not enough for her to notice.

"We just haven't been telling each other enough about our feelings and our thoughts," she added.

She was wrong there. She had been telling me too much, especially about how terrible it was sneaking down those back stairs. Uneasily, I realized she was only a step from proposing an instant cure to sneaking around — marriage. She was slightly out of control.

"You had been telling me what was on your mind pretty well," I said. "You never stopped talking about those stairs and how lousy everything was."

"Well, that was getting very uncomfortable," she said righteously.

"Uncomfortable. Well, that’s true. Why don't you do something about your Miss-Apples-and-TV so we can go to your apartment like normal people?"

"My roommate has nothing to do with it."

"Your roommate has a lot to do with it. If it weren't for your roommate, we could stay over there at your apartment, and you wouldn't have to sneak down the stairs."

"You don't care about me at all," she said petulantly.

"Of course I do, but that’s not the point. If you—"

"It is the point," she interrupted.

"You're changing the subject," I protested.

"Well, it's the only subject I'm interested in," she said staidly, standing up and scraping back her chair. "Anyway, I've decided you can stop thinking about us, and drop dead." She strode out indignantly.

Drop dead. A great suggestion. Actually, the idea held a kind of morbid appeal. I was that tired. With Joyce gone, the room moved away from me suddenly. A lot of people were still sitting around other tables, but not a soul was there with me. The sounds of a hundred voices mingled, all distant and incomprehensible. Staring through the window at the rain and the gray scudding clouds, I chewed absent-mindedly, overcome by loneliness. Nothing remained of that good feeling after the gall bladder; in its wake, I was simply drained of all emotion. Looking at the clock, I realized I had been going full steam for thirty hours. I thought about the clinic, and that I should go over there. Interns are supposed to help with outpatients in their "free time." But in my state I wouldn't be of any use. To hell with the clinic.

Raindrops danced around the overhang as the wind whipped them into sheltered areas. It was surprisingly cold. When tired, the body cannot tolerate much in the way of temperature variation. So the chills I felt coursing through me were probably more a product of my physical condition than of the weather. I hurried along, concentrating totally on my bed, anticipating the pleasure. All interns develop an extraordinary appreciation for simple things others take for granted — free muscular movement; the right to relieve an itch, void one's bladder, or empty one's bowels; more or less regular meals; a decent amount of sleep. In bed, I felt my body sinking, growing tremendous and filling the room, until my huge body and the room gradually merged, became one, and I slept.

The abscess was small when I began, no more than a pimple. Now it was enormous, covering most of the left arm and growing. No matter how much I cut, more appeared; now it crept toward the shoulder. Behind me, Hercules was whispering to the Supercharger, "He'll never make it. Neither will the patient." For encouragement, I looked toward Simpson, who said, "Get it right the first time, Peters, or it's Hicksville for you." In one final, desperate effort, I slashed to the bone through tissue, and to my horror I severed the ulnar nerve, immobilizing the hand forever. Time's up, I thought, as the bell rang; failure! It was, of course, the telephone. I leaped to answer it, still half in the dream and confused by the light. Had I missed rounds? No, they weren't until five o'clock, and my watch indicated three. It was surgery. I had been put on a case scheduled to start in fifteen minutes.

Hanging up, I slowly regained orientation. Why should I have waked up in such a state of terror? Then I connected the dream with the incision and drainage I had done yesterday on a huge elbow abscess. After opening the abscess with a sharp blade, causing a spontaneous flow of pus, I had pushed in the tip of a hemostat clamp to insure good drainage. But the abscess was much deeper than I had expected; it seemed to extend to the area of the ulnar nerve. So I had cut down and down, never truly getting to the bottom of the abscess and finally quitting for fear I would cut the ulnar nerve, if I hadn't already. Anyway, I decided to stop by now and check the case on the way to surgery.

The fright reflex had gotten me out of bed, but then my state of physical disintegration began to finger its way back. After having been up for so long, sleeping less than an hour just made everything worse. Nothing about me seemed to work right; I felt dizzy and slightly nauseous when I stood up after putting on my shoes. Unfortunately, I looked into the mirror — a serious mistake, because I realized I would have to shave to join the living. My hand was shaky, and, as usual, I cut myself a couple of times, not badly, but enough so that the blood kept running despite tissue, cold water, and a heavy, stinging application of styptic pencil.

I hurried over to the ward. It had stopped raining, although clouds still hung thick and heavy over the hills. My abscess patient was probably a bit startled when I ran into the room and asked him to hold up his hands and spread his fingers. As he did so, I tried to compress all the fingers together and got good resistance; that indicated his ulnar nerve was all right. I didn't have time to see anybody else except my waterlogged edema patient, whose bed was right next to that of the abscess. He had a question about his diuretic pills that I couldn't ignore.

I had developed a great respect for serious edema cases of the sort that requires a lessening of body fluids by one kind of diuretic or another. My awakening had been sudden and brutal — a carcinoma patient, transferred from a medical ward, who had swelled up through total body edema, a condition called anasarca. I decided that she was in that state because the medical department had missed the boat; there was always a little friction between those who cut — the surgeons — and those who treated with drugs — the medicine guys. This patient had cancer, diagnosed from a lymph-node biopsy. Although the primary site had never been found or the exact type of cancer determined, somebody decided to zap her with radiotherapy, which did nothing to the cancer, and then with chemotherapy, which was equally useless. Meanwhile, the patient was on IV's, and the medical boys allowed her to gather so much water that her sodium and chloride levels dropped to the point where she was practically delirious. And they ignored her plasma proteins, which dropped as well. When I got the patient, I was determined to get rid of all that water. By giving her some albumin and a diuretic, I achieved some diuresis, and hence a slight improvement in the edema. But I wanted more. When I tried to get some advice, nobody was much interested, including the attending. Since her urine was alkaline, I decided to give her a good dose of ammonium chloride with the diuretic, and this time the results were spectacular. What a diuresis! Water. poured out of her as her urinary output soared. It was terrific, amazing — except that it would not stop, and overnight she dried up like a prune. Bronchopneumonia set in immediately, and she was dead in a day and a half. I had never said anything more to the medical guys about the case, but I was wary now of those diuretic agents. I was being very careful with this man next to the abscess. He was taking only pills.

Actually, I had learned to respect abscesses as well. There had been one patient — not mine, although I had seen him on rounds every day — who was admitted because of spreading cellulitis in his right leg from an abscessed area. When he came to us, most of his calf muscles had already liquefied. We cultured a number of different organisms out of that abscess; they all seemed to be working together against the patient. One day, when the intern handling the case was sick, I had to drain it. The smell was indescribable; once again I resorted to my three-mask ploy to keep from retching. As I attempted to open the abscess cavity, I realized that it went in every direction, as far as the hemostat would reach. An argument had raged off and on during rounds about whether his leg should come off, but advocates of a new method of continuous antibiotic perfusion won out — at least, they won the argument — and dripped gallons of antibiotic into his leg, seeming to stabilize him for a few days. But suddenly, one day while we were looking at him on morning rounds, the man died. We had just walked up to the bed, and another intern had started to say that the patient was "essentially unchanged." Odd, how often that word "essentially" was used on rounds. This man had been in liver failure, heart failure, kidney failure — in fact, total body failure. But just as the intern was mouthing his neutral status report the patient gasped, and it was over. It seemed an act of enormous bad taste. We stood there dumbfounded. No one tried to resuscitate him, because all of us had become used to the hopelessness of his condition. Our insignificant drugs had only supported him precariously for a while, until the bottom fell out, as it had with those Gram-negative sepsis cases in medical school. It was as if he had absolutely no defense against the infection. Thus I came to respect abscesses. In fact, as time went on, I was learning to respect every illness, no matter how innocuous it appeared to be.

Now I was hurrying on to surgery, already late. There was a lot of activity on the medical floor. I passed interns, residents, and doctors standing around beds talking, as they always were — unless they were sitting around talking in the lounge. Most discussions centered on treatment, on which drugs to use. As a point of agreement would near on some medication, one of the participants would bring up a side effect, whereupon a drug would be suggested to counter the side effect, which drug could, in turn, have its own side effect. Which was worse, the question now became, the second side effect or the original condition? Would the second drug make the original symptoms worse than they were before the first drug made them better? On and on it went, around and around, until usually the discussion got so complicated it seemed best to start again, on the next patient. Or that's what the medical wards looked like to me. Talk, talk, talk. At least, in surgery we did something. But the medical guys pointed out, with some truth, that we just cut it out when we couldn't cure it. We countered that cutting it out did, in fact, often cure it. The argument went inconclusively back and forth, always conducted in an entirely friendly, even jovial, style, but its roots sank deep.

Climbing into another clean scrub suit was a compounded deja vu. I was beginning to live in those things. Since no medium sizes were left, I had to wear a large, and the strings of the pants went around me twice. Through the swinging doors into the OR area. While I was putting on my canvas shoes, I glanced at the board to see who was doing the operation. Zap! It was none other than El Almighty Cardiac Surgeon. But what was he doing here? The procedure was listed as "Abdominal abscess, dirty," and obviously El Almighty usually worked in the chest. Strange things had ceased to surprise me, however. As I looked up, he saw me and greeted me by name, being very friendly, but I knew better than to lower my guard. It was just the first move, a condescending act early in the show— especially since he had to shout the greeting from halfway down the corridor to make sure everyone noted his good cheer and camaraderie.

I remembered wryly one time when a resident and I were assigned to a cardiac case with not one, but two such surgeons. These men, completely alike in manner and hidden behind masks, could be distinguished only by their girth, one being much fatter than the other. That case had begun smoothly enough, with affability and backslapping all around. Suddenly, with no warning whatever, one of the surgeons began to harangue the resident for giving blood to a patient dying of lung cancer. True, the decision was debatable, but not serious enough to warrant such a tirade in front of all assembled. He was just puffing himself up, improving his self-image. So it went throughout the operation, praise and then blame, each overdone, until we reached a kind of frantic crescendo of invective that gradually ebbed away, back into good humor. It had been like a madhouse.

There is something of this in many surgeons — a kind of unpredictable passive-aggressive approach to life. One minute you are a close and valued friend; the next, who knows? It was almost as if they lay waiting in ambush for you to cross some invisible line, and when you did—wham! — you got a fireworks of verbal abuse.

Perhaps this is a natural effect of the system, the final result of too much intensity and repression through too many years of training. I had begun to feel it in myself. If he wants to get ahead, an intern learns to keep his mouth shut. Later, as a resident, he learns the lesson so well that it becomes internalized. Underneath, however, he is angry much of the time. No matter how cleansing it might have been to tell some guy to stuff it, I never did, and neither did anybody else. Being at the bottom of the totem pole, we naturally aspired to rise higher, and that meant playing the game.

In this game, fear was symbiotic with anger. If anything, the fear portion of it was more complicated. As an intern, you were scared most of the time; at least, I was. At first, like any good little humanist, you were afraid to make a mistake, because it might harm a patient, even take his life. About six months along, however, the patient began to recede, becoming less important as your career went forward. You had by then come to believe that no intern was likely to suffer a setback because of official disapproval of his practice of medicine, however sloppy or incompetent. What would not be tolerated was criticism of the system. No matter that you were exhausted, or were learning at a snail's pace, if at all, and being exploited in the meantime. If you wanted a good residency — and I wanted one desperately — you just took it without a murmur. Plenty of hopefuls were lined up to take your place back there in the big leagues. So I held feet and retractors, and took the other shit. And all the time the anger ate at me.

Most of us didn't believe in the devil theory of history, or in an extreme notion of original sin, and so we knew that these older men we hated so much must have once been like us. At first idealistic, then angry, and then resigned, they had finally come to be mean as hell. At last the anger and frustration, held in so long, were gushing out in a gorgeous display of self-indulgence. And at whose expense? Who else? The sins of the fathers and grandfathers were visited on us, the sons of the system. Would it happen to me? I thought it would. Indeed, it had already started, because I had advanced beyond my period of medical-school idealism. I was no longer surprised that there were so few gentlemen among surgeons; in fact, the wonder of it to me was that any doctors at all came out as whole human beings. Apparently, few did. Not among them was El Almighty, whom I was about to face.

He slapped me on the back, wanting to know how every little thing was. It was as if he were going to give me candy or kiss my baby like a corrupt big-city politician gathering votes. Actually, he was gathering ego points. I was so tired I didn't care what he said or did. I kept my head down, scrubbing away, taking one step at a time. I put on the gown, and then the gloves. The scene around me was unreal. The surgeon's voice boomed on about nothing and everything, several decibels above everyone else. The anesthesiologist seemed to have either a special immunity or effective earplugs; oblivious to the surgeon, he went quietly about his business. Even the nurse ignored El Almighty. Whether he asked politely for a clamp or thundered for one, she would hand it to him in the same reserved efficient way and go on adjusting the instruments. I hoped he was listening closely to himself, because he apparently was his only audience.

The case turned out to be a reoperation for inflammation of the little pockets older people sometimes get in the lower colon. This unlucky patient had been operated on for his diverticulitis, as the condition is called, about a month before. Normally, a three-stage operation is recommended, but the first surgeon to operate on the fellow had tried to do it all at once. The result was a large abscess, which we were about to drain, and a fecal fistula, leading through the previous incision down into the colon, that was draining pus and feces.

Mercifully, the procedure was short. I tied a few knots, all unsatisfactory to the surgeon. Otherwise, I remained silent and immobile as he went on about the vicissitudes of his life when he was an intern. "Really tough in those days… do histories and physicals… every patient… through the door… and besides… quarter of the salary.. and you crooks get…" I hardly heard it. My exhaustion really made me immune, bouncing all his comments off my brain.

At the end I wandered out and changed into my regular clothes. It was almost four. A little afternoon sun had dodged the thick clouds and was sneaking in the window. The rays refracted and sparkled off the raindrops clinging to the window. It made me think of going surfing. But afternoon rounds were still to come; I wasn't free yet.

Descending to one of the private surgical wards, I saw my gall-bladder patient, who was doing fine. Blood pressure, pulse, urine output — all normal. The IV was going well, and orders were adequate for the night. I wrote in the chart and walked down to the other gall bladder, although I was sure the resident had seen her. And he had.

Stopping by X-ray, I asked a secretary to locate the aortogram taken on my aneurysm that morning, so I could have a quick look. The chief resident had apparently accomplished the job after his mighty struggle. The secretary found the films right away, and I began to put them up on the viewer. There were so many they would not all fit on the screen. Thank goodness the numbers allowed me to get them up in sequence. Now to find the problem— usually an educated guess for me. But this time even I could make out a sizable bulge in the aorta, just beyond the left subclavian artery. Catching sight of me in front of the X rays, the radiologist called me over to give me the usual pitch on portable films, with special reference to the hernia man of the night before. But this time I got the last word. The radiologist was subdued to learn that the patient had died. Perhaps he believed now that I couldn't have sent him up for a regular shot. I relished the victory, although of course I didn't think the X ray, good or bad, could have made any difference.

Everybody on ward service was under control. Both hernias were in good condition, already walking; the gastrectomy had taken a full meal; the veins were ready to go home in the morning; one of the hemorrhoids had had a bowel movement. My abscess patient, not unreasonably, wanted to know why I had squeezed his fingers, and the edema man asked again about his pills, wondering how they made him lose water. I humored both patients with overly simplistic answers.

Only one problem — a new patient, or, rather, a new-old patient, for me to work up. This man, a big decubitus ulcer, had a history of at least twenty-five previous admissions. One was for swallowing razor blades, others for attempted suicide by more traditional methods and for psychoneurohc-conversion reactions, convulsions, alcoholism, abdominal pain, gastric ulcer, appendicitis, liver incompetence — his chart was a checklist of primary and secondary diseases. He had also been in and out of the state mental hospital for ten years. Just the sort of patient I needed, in my freshness and good humor. Talking with him was impossible, because he was so intoxicated he could remember only wild, sketchy details about the previous few hours. Trying to examine him and go through the charts took over an hour. Then I had to clean out his ulcer, a process known by the romantic-sounding French word debridement.

Bent over his buttocks and staring into the black and oozing necrotic ulcer that he had contracted from lying in the same position too long, I wished I had studied law. With a law degree, I would already have been out earning a living for two years. A full wardrobe, an impressive office, crisp, clean papers, a secretary, long, full nights of sleep — all would have been mine. Not one of them was mine now. Instead, I was crouching over an alcoholic's smelly posterior snipping out dead tissue, trying to avoid the stench and discourage nausea. It had been exciting the first time in medical school, putting on that white coat and pretending I was a part of the seething, mysterious hospital complex. And how I'd envied the senior students and interns, with their stethoscopes and little black books and purposeful, knowledgeable ways. I had made it, slowly climbing the ladder of medicine and jumping the specific hurdles — until reality yawned before my eyes. Those buttocks were reality, the rear end of life, where I lived.

As I cut, the ulcer started to bleed a little at the edges. When the patient's knuckles turned white where he was gripping the sheets, and when he started to swear and pound the pillow, I decided that I had reached viable tissue. I squirted in some Elase, which was supposed to continue cleaning the wound by enzymatically breaking down the dead tissue; then I packed it with iodoform gauze. That iodoform gauze was not Chanel No. 5, but at least it dominated the other smells, changing them from sickly dirty to unpleasantly chemical. I preferred the chemical smell. The Elase? I didn't know whether it would work, but I put it in because of an article I'd read recently; it made me feel I was doing something scientific.

Before me now was the joy of afternoon rounds. No one liked these rounds, and few felt it was necessary for all of us to be there, because all essential arrangements were made by committee, so to speak. Nevertheless, we had afternoon rounds as if they were one of the Ten Commandments. Standing for long dreary minutes on one foot, then the other, we talked and gestured, indicating here a hemorrhoid, there a gastrectomy. We looked into all the wounds to make sure they were closed and not fiery red. The dressings were replaced rapidly, haphazardly, while the patients submitted like silent sacrifices on an altar. When one of them ventured a question, it was usually ignored, lost in the patter—"How many days since the operation?" "Should we switch to a soft diet or stay with full fluids?" Like the others, I presented my cases in a terse monotone. "Hemorrhoids, two days postoperative, wick out, no bleeding, no BM yet, normal diet."

We shuffled to the next bed; a couple of doctors seemed to become interested in a crack in the ceiling plaster near one of the lights. "Gastrectomy, six days postoperative, soft diet, has passed flatus but no BM, wound healing well, sutures out tomorrow, discharge anticipated." Somebody asked if the operation had been a Billroth I or II. Of course, he didn't give a damn; it was just one of those questions you always asked about a gastrectomy. "Billroth II."

Somebody else asked if there had been a vagotomy. "Yes, there was a vagotomy, and final path report was positive for neural tissue." The patient suddenly got interested and asked what a vagotomy was, but no one paid any attention. Instead, a resident asked if the vagotomy had been selective— another timely query that would lead into a maze. "No, it was not selective. The path report on the ulcer substantiated a preop diagnosis of peptic disease." By suddenly injecting concrete information not directly associated with the trend of the conversation, I had effectively changed the subject, and we shuffled on to the next bed.

Somnolently we went, growing tired and fidgety, and messing up all the dressings. The attending said that everything seemed to be under control and that he'd see us at the same time the following day. As in the sixth grade, in a game of spud, everybody scattered in all directions, except me. Apparently I had the ball, because I simply stood there, not thinking about anything in particular, just staring at the corner of a table that was tilted somehow and made the perspective look a little strange.

When I broke out of my semitrance, I was undecided about what to do. I could check on the private cases again, or I could sit around the ward and wait for new admissions, or I could go back and take a nap. The last option was immediately ruled out on superstitious grounds. If I went to sleep, I was sure to be called about some admissions, whereas if I stayed on the ward perhaps none would come in. A very scientific point of view. Anyway, I parked myself at the nurses' station and leafed through some back issues of Glamour one of the girls had left behind. I wasn't recording anything I saw. Flipping the pages and watching the patterns of colors as pictures mingled with print, I was lost in my own closed world, taking account of the sounds and motions around me but indifferent to them. One external event did penetrate my wall: it had started to rain again. Curiously, the sound of rain made me want to go surfing; a good wave or two might rinse away my depressing thoughts. I was overtired, and I knew that I'd be restless if I went directly to bed. Besides, there was a good hour of daylight left.

The rain fell cold on my bare back as I tied the board to the roof of the VW. Once in the car, I turned on the heater and strained to see out the window. It was raining quite hard, and the wipers were having trouble, as usual, keeping up with the water. I had great faith in VW's, except for the wipers. They never kept the window clear without distortion — curiously bad engineering on an otherwise reliable car.

As I drove toward the beach the rain increased, breaking my image of the road into blurs of gray and black. From time to time I strained my head out the side window to regain perspective. The passenger-side wiper was working a little better now, and I found I could see pretty well by leaning over that way. Somehow the rain began to comfort me, closing in the world a little and heavily dominating my awareness.

The rain felt even colder on my back as I struggled to get the surfboard off the rack. The heater in the car had not been a good idea. Once the board was off the car and on my head, however, I was protected from the icy drops. Eager to see the waves, I trotted across the street and onto the beach, but, of course, I could not see more than a few yards into the gray of air and sky. For the first time in my experience, the beach was completely deserted. Plopping the board in the water, I jumped on in a kneeling position and began to paddle out furiously, trying to generate some heat in my cold bones. The rain pelted down hard enough to hurt, my nose, forcing me to put my head down and peer ahead from under my eyebrows. The water was choppy and disorganized as I headed out. The farther I went, the more difficult it became to maintain speed and direction in the face of the strong onshore kona wind. Paddle, paddle, looking down, most of the time, at my board just in front of my knees. The water swept by in swirls. When the front of the board came out of the water, it would appear to be dry because of the wax, but then the board would go awash again as I leaned into another stroke.

Out in the surf, the beach, and the whole island, vanished in a misty wall of rain. This was storm surf, choppy, windy, and completely unpredictable. When I caught a wave, I couldn't tell how it would go, whether it would break or just disappear. Gone were the usual harmonic motions and familiar landmarks. I could have been a thousand miles at sea. The only sounds were those of wind, rain, and waves. My mind began to see fantastic shapes in the waves and in the unvarying gray curtain that hung over me. Imagining sharks patrolling under the disturbed surface of the water, I pulled my arms and legs up and lay flat on the board. A wave suddenly reared, broke, and turned me over. In a panic, I scrambled back on the board like a cat with his ears flattened, afraid to look back. I let the wave action and the wind push me toward shore as I searched for signs of the island, reassurance that I was not adrift on a lonely sea. Relief flooded over me as the hazy outline of a building took shape. My skeg scraped coral. Then the deserted beach appeared, its texture beaten by the rain into millions of miniature craters. A few people hurried along, grotesque and faceless blobs trying to shield themselves from the rain and wind.

Once in the car, I turned the heater back on, with wrinkled fingers, and felt its welcome heat rush out of the vent. I was blue and shivering by the time I headed back to the hospital, again leaning over to the passenger side to see out It was still raining very hard, and the lights of the other cars shot off the wet pavement in broken, scattered paths.

Happiness is a hot shower. Billows of warm vapor filled the stall, washing away the salt and the cold and the stupid little fears my tired mind had conjured up. I stayed there for almost twenty minutes, letting the warm water splash onto the top of my head and run down all the crevices and bumps of my body. As I relaxed, I began to think about how to pass the evening. Sleep. I should sleep. I knew that. But I also had a compulsion to get away from the hospital, to see someone. Karen had said she was not going out, after all. Karen. That was it: I'd park in front of her TV set, drink beer, and let my mind vegetate. Every other night I was off duty the telephone stayed quiet. It was a pleasure to know it wouldn't ring. Tonight was going to be one of the quiet nights. Ahhhh.

I dried myself, slowly and luxuriously, and then padded back to my room with a towel wrapped around my middle. The bed looked tempting, but I was afraid that if I slept for six hours or so and then got up, I wouldn't be able to drop off again. It was better to stay up and sleep later. Then the phone rang. In all innocence, I answered it. I shouldn't have, because it was the intern who was on call. He was in a jam and had to go home for an hour, maybe two at the most. It was a problem that couldn't wait.

"I'm sorry, Peters, but I've got to do it. Would you cover for me?"

"Is there any surgery scheduled?"

"No, none at all. Everything's quiet."

Though the idea of covering made me weak, I couldn't refuse. Ifs a part of the code to help, and who knew? — I might want the favor returned sometime.

"Okay, I'll cover for you."

"God, thanks, Peters. I'll let the operator know you're covering, and I'll be back as soon as possible. Thanks again."

Hanging up, I thought wearily that if I had to go to surgery I'd pass out. I was sure to go to pieces either mentally or physically if faced with a long session of any sort, especially a scrub with somebody like the Supercharger or Hercules or El Almighty Cardiac Surgeon.

In anticipation, I put on my whites, again hoping to ward off evil by excessive preparation. When I called Karen I got no answer, and I vaguely remembered her saying something about eleven, but I couldn't remember exactly. For lack of anything else to do, I lay down and opened a surgical textbook, propping it on my chest. Its weight made breathing a little difficult. Not really concentrating on the book, my mind wandered to Karen. What was she doing at seven o'clock if she wasn't out with her boyfriend? I couldn't say I had much reason to trust her. Still, what did I mean by trust? Why should the word enter into it at all? It was a bit adolescent to speak of trust when we were just a convenience to each other.

I had been lulled to sleep by my reveries when the phone woke me up. The blasted surgical text was still on top of my chest, and I was breathing with my abdominal muscles. It was the emergency room.

"Dr. Peters, this is Nurse Shippen. The operator says you're covering for Dr. Greer."

"That’s right." I reluctantly agreed.

"The intern on duty here is really behind. Would you come down and help out?"

"How many charts are waiting in the basket?"

"Nine. No, ten," she answered.

"Did the intern actually ask for help?" Hell, I'd been ten charts behind every Friday and Saturday night during my months on the emergency service.

"No, but he's quite slow, and—"

"If he gets behind about fifteen or so, and if the intern himself asks for me, then call back."

I hung up, stuffed to the eyeballs with those ER nurses, always pretending to run the show and make the decisions. The ER was that intern's territory; perhaps he would be angry if I suddenly appeared. There was a grain of truth and a pound of rationalization in that, I suppose. Still, during my two months in the emergency room, not once had I asked for help from the on-call intern. I couldn't imagine its being uncontrollably crowded and busy on a Wednesday night. I tried to read a little more, making no headway and growing more nervous and upset. My hands shook slightly — something new — as I balanced the book on my chest. My thoughts raced around disconnectedly from surgery to Karen to the lousy time I had had surfing and back to surgery. Getting up, I went to the toilet, indulging a slight diarrhea— not unusual with me these days.

When the phone rang again, it was the same officious ER nurse saying with satisfaction that the intern had requested help. It so pissed me off that I didn't say anything, just hung up. Before I could even get out of the room, the phone rang once more. It was the nurse asking huffily whether I was coming or not. I summoned as much acid as possible and said that I'd be there if they could possibly handle things while I put on my shoes. It had no effect. She was beyond insult, and I was almost beyond caring, in no hurry to rush over; perhaps by the time I got there things would be quiet. I wouldn't have minded doing a quiet suture or two, something like that. But I was sure to get slugged with a freeway wreck or convulsion.

The rain had passed overhead, and a star or two twinkled between the black violet hulks of heavy clouds. The wind had shifted again, back to the trades, blowing away the kona weather.

Upon reaching the ER, I had to admit that things were far from calm. A medical intern and two residents were working away. In addition, four or five attendings were there seeing their own patients. One of the nurses handed me a chart and said that this fellow had been waiting for some time; they hadn't been able to reach his private physician. I took the chart and headed for the examining room, reading as I went. Chief complaint was "Nervousness; ran out of pills." Christ! I stopped and looked closer at the chart. The private doctor was a psychiatrist; no wonder they couldn't locate him. And the patient, a thirty-one-year-old male, was in the psych room. That was back the other way, to the right. Just my luck, I thought, a psych patient. Why not a simple scalp laceration — something I could fix — instead of an inside-the-head job?

As I walked into the psych room and sat down, I faced a youngish-looking man sitting on the bed. The bed and the straight-backed chair I was in were the only two pieces of furniture in an otherwise plain, white-walled room. Both bed and chair were securely fastened to the floor. It was spotlessly clean in there, and quite bright from a bank of white fluorescent lights built into the ceiling. After glancing at the chart again, I looked at him. He was a reasonably good-looking fellow with brown hair, brown eyes, and neatly combed hair. His hands were clasped in front of him, giving the only hint of his nervousness; they worked against one another as if he were molding clay in the palms of his hands.

"Not feeling well?" I asked.

"No. Or, yes, I'm not feeling too well," he replied, putting his hands on his knees and looking away from me. "I suppose you're an intern. Isn't my doctor coming?"

I looked at him for a few seconds. I had learned that letting them talk was the best thing, but it became apparent he wanted me to answer his questions. "Yes, I'm an intern," I said, a bit defensively. "And no, we can't reach your doctor. However, I believe we can help you now, and you can see your own doctor later, perhaps tomorrow."

"But I need him now," he insisted, taking out a cigarette, which I allowed him to light. Psych patients could smoke if they wanted to; there was no oxygen in this room.

"Why don't you tell me something about what's bothering you, and either I or the psychiatry resident will be able to help." I was certain I couldn't get the psychiatry resident to come in, but I could probably get him on the phone.

"I'm nervous," he said. "I'm nervous all over, my whole body, and I can't sit still. I'm afraid I'm going to do something."

There was a pause. He was looking at me again, steadily. Although he had lit the cigarette, he did not raise it to his mouth, but held it between his second and third fingers, with its trail of smoke snaking up past his face. His eyes, wide open, showed relatively dilated pupils. Moisture glistened at the hairline above his forehead.

"What kind of thing are you afraid you'll do?" I wanted to give him all the rope he'd take. Besides, I didn't really care whether I sat there for a long time or not. The other ER problems, out in the pandemonium, would get solved without me. Served them right for giving me a psych patient.

"I don't know what I might do. That's half the problem. I just know that when I get this way I don't have too much control over what I think… over what I think. Think." He was looking straight ahead at the white wall, staring without blinking. Then he made a sudden grimace, his mouth forming a tight slit.

"How long have you been having this type of problem?" I asked, trying to break the trance, to keep him talking. "How long have you been under the care of a psychiatrist?"

At first he seemed not to hear me at all, and I was about to repeat my question when he turned toward me once more. "About eight years. I have been diagnosed as a schizophrenic, paranoid type, and I've been hospitalized twice. I have been under a psychiatrist's care ever since the first hospitalization, and doing well, especially over the last year or so. But tonight I feel like I did a number of years ago. The only difference is that now I know what is happening. That's why I need more Librium, and why I must see my doctor. I have to stop this before it gets out of control."

His insight surprised me. I surmised that he had been under quite intensive care, maybe even psychoanalysis. He was intelligent, without a doubt. Although I was a novice at this sort of thing, I knew enough to try to keep him talking and communicating. It would have been easy just to give him some more Librium and wait for it to take effect or not. But I was interested now, partly in him and partly in his ability to keep me out of the rest of the ER. In the background I picked up the wail of a screaming child. "What necessitated your hospitalization?" I asked.

He responded eagerly. "I was in college, in New York, and having some mild difficulties with my studies. I was living at home with my mother. My father died when I was a baby. Then, during my second year of college, my mother started having an affair with this man, which bothered me, although at first I didn't know why. He was very gentlemanly, handsome and pleasant and all that. I suppose I should have liked him. But I didn't. I know that now. In fact, I hated him. At first I kept telling myself I liked him. I mean I was attracted to him. I know that now, too."

I was beginning to get the picture — the same one that psychiatry had given him, a framework for his anxieties. Now that I had him started, he kept going.

"And my mother, well, I began to hate her, too, for several reasons. It was hate on an unconscious level, of course. One reason was for starting up with this man and leaving me out in the cold, and the other for keeping him to herself. I think I had latent homosexual tendencies. But I loved my mother. She was the only person I was close to at all. I didn't have many friends — never had — nor did I find much enjoyment in dating. Well, then President Kennedy was killed, and I heard it was some young guy. I was riding in the subway coming home from school at the time, and I could see the newspapers all around me: KENNEDY ASSASSINATED BY YOUNG MAN. I Was nervous, had been for days, and all of a sudden, since I was a young man, I decided, don't ask me how, that I had been the one who killed Kennedy. The next couple of days were just hell, as much as I can remember about them. I didn't go home. I was terrified that everybody was out to get me. What made it worse, people were crying everywhere. I was worried that they would find out about me being the murderer, so I just kept running, for two days, apparently, afraid of every person I saw, and, believe me, it's hard to get away from people in New York. Luckily, I ended up in a hospital. It took me almost a year to calm down, and another year of intensive care to understand what had happened to me. Then things went…"

Suddenly he stopped dead in the middle of the sentence and stared at the wall again. Then he looked at me and asked, "Would you take my blood pressure? I'm worried if s too high."

I didn't mind taking his blood pressure, but the room held no equipment. I went out for a pressure cuff, slightly dazed by the sudden, concise, and overwhelming history of a paranoid schizophrenic. On my way back, a nurse tried to give me another chart, but I waved her off, saying that I wasn't finished with my present patient.

Back in the room, my patient had his sleeve rolled up in anticipation. He was intensely interested as I put the cuff around his arm, and he tried to see the gauge when I pumped it up. His pressure was 142/96. I told him it was slightly elevated, but consistent with his agitation. Actually, I was a little surprised at its height. Then I asked him what had happened after he got out of the hospital.

"Which time?" he asked.

"You were hospitalized more than once?"

'Twice. I told you."

"What happened after the first hospitalization?"

"Everything went fine. I saw my psychiatrist regularly. Then, out of the clear blue sky, I started getting nervous, like now, and it got worse and worse, until I had to go back in the hospital for another four months."

"How long was the interval between hospitalization?" I asked.

"About a year and a half. The real problem was that we could never figure out why it happened the second time. I wasn't paranoid, just nervous. I had what they call all-pervading anxiety. Then my psychiatrist started to talk about pseudoneurotic schizophrenia, but I didn't understand that so well, even though I read a lot about it. That’s why this situation worries me so much. I'm nervous now, really nervous. I have that same anxiety like before I went into the hospital the second time, and I can't stand it. I don't want things to go crazy again. I don't know why I should be feeling like this now. Everything has been going fine lately. Even my business is good."

I realized that he must have been psychologically well compensated. He had been able to make a new home in Hawaii and even to start a business. Oddly, I felt nervous, too, but of course, for different reasons and to a different degree. I was exhausted, but my trouble could be cured with a little sleep and relaxation. His was long-term, and, besides, he was worried that he might go suddenly out of control. A nurse opened the door, started to say something, and then closed it when she saw us talking.

"Do you have many friends here?" I asked.

"No, not really. I've never had very many friends. I prefer to stay home and read. I just don't enjoy going out and sitting in bars and drinking. It seems like such a waste of time. I guess I don't have very much in common with other people. I like to surf now and then, and I have a couple of guys I go surfing with, but not always. Most of the time I surf by myself..

That amused me for a moment. A schizophrenic surfer. But in some ways his style was a little like mine. "How about your mother? Where is she these days?"

"She's back in New York. She married that fellow she had been going with. My psychiatrist suggested I go away for a while. That's why I came to Hawaii. It certainly has changed my life for the better."

I got up and walked over toward the door. One of my legs had begun to go to sleep, and my foot was tingling. "What kind of business are you in?"

"Photography," he answered. "I'm a photographer, a free lance, but I also do some industrial work. That's what keeps me busy." He got up to stretch and walked toward the other end of the room, near the chair. I turned around, put my hands behind my back, and leaned on the door. He seemed a little calmer, slightly relieved of his anxiety.

"What about women?" I asked, a little hesitantly, wondering what had become of those latent homosexual tendencies he mentioned earlier.

He looked at me briefly after the words left my mouth, and then he sat down in the chair, looking at the floor. "Fine, just fine. Never better. In fact, I'm getting married very soon to a fine girl. That's why I want to be sure everything is all right with me. I don't want to spend any more time in the damn hospital. Not now."

I could understand his concern. By voicing it, he had suddenly moved the conversation to a more personal plane. Not that we hadn't been talking very personally already; but the fact that he connected a desire to get married with his mental difficulties made it easier for me to understand and empathize with him. After all, if he could pull it off and establish a real relationship with his fiancee, she might be the means to a permanent compensation. At least, it was a chance. Unlike many mentally disturbed people, this guy was really trying. I liked that. I sat down on the bed, near the chair he was in.

"That’s good," I said. "You're overcoming your basic problem."

"Yeah, it's wonderful," he repeated, without much emotion.

The fact that schizophrenics display blunted affects appeared in my mind from some dim psychiatry lecture. It gave me a momentary feeling of understanding and academic pleasure.

"When are you getting married?" I asked, to see if I could get any emotional response from him.

"Well, that’s one of the problems," he said. "She hasn't really set a date yet."

That comment set me back somewhat. "But she has agreed to marry you, hasn't she?"

"Certainly she has. But she just hasn't decided exactly when we should get married. In fact, I was planning to ask her again tonight if we could get married during the summer. I'd like to get married this summer."

"Well, why don't you?" I asked. I began to formulate a definite impression of a case of a schizophrenic's hypersensitivity toward any sign of rejection. Perhaps his anxiety had risen because he was afraid of being rejected by the girl. All signs led to it.

"I can't tonight," he said.

"Why not?" This was a crucial point. If things went smoothly, he could be golden; but if she rejected him, it could be devastating. He knew it, too.

"Because she called this morning and said she couldn't see me tonight. When I asked her why not, she just said she had something important to do. She does that every so often."

I knew he was in a difficult position. The more he pushed, the more he came to. depend on his fiancee for mental stability. I didn't know what to say. We had reached a sort of impasse, and I thought now might be the time to give him some Librium or something. Then he started talking again.

"Maybe you know her," he said. "She's a nurse in this hospital."

"What's her name?" I was curious.

"Karen Christie," he said. "She lives very close to the hospital, just across the street."

His words smashed into my brain, tearing down carefully constructed walls of defense and carrying everything away. I felt my jaw drop open involuntarily and a glaze cover my eyes, reflecting the confusion and disbelief inside. I struggled hard to regain my outward composure. He was sunk too deep in his own troubles to notice my discomfort. He went on, describing his relationship with Karen. Now, twenty seconds after the revelation, I was outwardly calm again, and listening, but inside, my own urgent messages robbed his words of all meaning. We were like two men discussing the same subject, but in different languages.

So here was the "boyfriend," the "fiance." I was sharing Karen with a schizophrenic who depended totally on her for mental equilibrium, whose world fell apart when that compensation was denied him, as it had been by Karen's decision to stay home with me tonight. In a grotesque but very real way, we had exchanged roles: he was now the therapist and I the patient. How fitting that I sat on the bed and he was in the chair. About a half hour earlier, I had felt rejected because Karen could only see me late at night, after eleven. At the same time, I had illogically blessed my luck that she had another man willing to take her out, but bringing her home in time for beer and sex with me. The fact that I had been sharing a role with a schizophrenic made it tempting to identify with him, to see myself in the same light. I wondered how much of my own personality was schizophrenic. But surely I wasn't schizophrenic; my grasp of reality was too good. I couldn't believe I had any delusions, because, if anything, I was the realist, especially about my role as a intern. Besides, I never hallucinated. I would have known, I thought. Wouldn't I have known?

It suddenly got through that he was looking at me as if expecting an answer. With my eyes, I asked him to say it again.

"Do you know her?" he was repeating.

"Yes," I said mechanically. "She works days."

We began to speak and think in different languages once more, as he went on drawing out the story of his half life with Karen and I retreated into my speculations. No, I most certainly was not schizophrenic, but perhaps was tending toward schizoid. Searching back through lectures and pages of textbooks, I tried to remember the characteristics of schizoid personality. Most such cases, I remembered, avoided close or prolonged relationships. Did that fit me? Yes, most definitely, of late. Certainly no one would describe my associations with Karen, Joyce, or even Jan as close, or characterized by respect and affection. They were more in the realm of reciprocating conveniences in which I — and perhaps the girls, too — hadn't invested much genuine emotion or attachment. I had to admit that to me they were more like walking vaginas than whole people, serving not as a means to move close, but as a method of escape and further withdrawal. It was the same with my patients. Over the months my attitude toward them had changed. Each case had become an organ, a specific disease, or a procedure. Since Roso, I had avoided all close contact, intimacy, and involvement. Even that seemed schizoid now. Suddenly, vile, sick thoughts flooded through my brain, poisoning me, and I realized that I had to leave this room quickly and get away from the hospital, to some place where I could breathe. Mustering my thoughts, I concentrated on the reality in front of me. "What kind of tranquilizer have you been taking?" I asked hurriedly.

"Librium, 25 mg. size," he answered, a little confused. Evidently I had interrupted him.

"Fine," I said. "I'll give you a supply, but I recommend that you contact your doctor tonight or tomorrow. Meanwhile, I'll prescribe an injection of Librium to give you an immediate effect."

Before he could say anything else, I rose quickly from the bed, opened the door, and stepped out into the fluorescence and bustle of the ER. Mechanically, I wrote a prescription for "Librium 25 mg., sig: T tab P.O., QID, disp. 10 tabs," my mind going back over the absurdity of patient becoming therapist. That in itself seemed an almost schizophrenic delusion. A nurse tried to give me another chart, but I waved it away. I told another nurse to give the patient in the psych room 50 mg. of Librium intramuscularly. I was only half aware of the activity around me. Then, before leaving, I just had to go back and look in on that schizophrenic once more, to make sure he wasn't a hallucination. I opened the door. He was there, all right, staring out at me.

I closed the door and started down the long passageway to my room. It was all too true — all the things I had thought about myself in those seconds after he said Karen's name. I was a cold, detached son of a bitch and getting more so. Everything I thought about confirmed it. My initial relationship with Carno, for instance; it had just disappeared in a disguise of inconvenience. In fact, I had been too selfish and lazy to keep it going. Surfing was probably the biggest cop-out of all, especially since I apparently was using it to cover and relieve my progressively isolated life. And Karen herself — a vacant and meaningless relationship if ever there was one. Feelings I had vaguely noticed, the emptiness and undirected yearning — I had sought vainly to repress them by encounters with Karen and Joyce, even Jan. Much of this became horribly clear to me as I sat in the chair in my dark room, searching for answers.

I hadn't always been like this. Not in college, where friends had come easily and stayed. And the lonely yearning so much a part of me now? Perhaps a little during the first year of college, but not after that. Medical school had come next. Had the seeds of change been planted there? Yes, after all, it was during medical school that friends had drifted away, and attitudes and practices with women had changed, out of necessity, driven as I was by hard economics and limited time. But not until internship had the seeds of change germinated. Now I was sexually and socially little more than a cruiser, except that I operated in a hospital rather than the real world. How different it had all turned out. The phone rang, but I ignored it. Taking off my whites, I put on some wheat-colored jeans and a black turtleneck.

Why had this happened to me? Was it only the schedule? Or that combined with the fear and anger always inside me? Was it basically my self-disgust at not speaking up when I believed the system was rotten, at letting myself be carried along nevertheless, holding it all in? Was my brain so warped by exhaustion it was no longer logical? I didn't know. The more I thought, the more confused and depressed I became. Confused about causes, not effects. In perspective, the effects were clear: I had become a real bastard.

Suddenly, I thought of Nancy Shepard, of how I had pushed her out of my mind, rejected her questions and accusations. That night we argued, she had been trying to tell me what I had just learned from my therapist — my therapist, the schizophrenic. What a triangle, I thought: a double-dealing nurse, a barely compensated schizophrenic, and a screwed-up intern. Nancy Shepard had called me an unbelievable egotist, a selfish blob working toward a point at which love would be impossible. And she had been right. What did it matter that there was more to it; that it was not innate in my personality, but developed; that I had been encouraged, day in and day out, to avoid genuine emotional involvement because to do so was the only natural defense I could conjure up to deal with the anger, hostility, and exhaustion? What did it matter that an intern's routine was senseless monotony, or that the medical system was designed to use and harass him? To a Nancy Shepard — to anyone — the end personality result was all that mattered. She had brushed me lightly with some truth, and I had kicked her out of my life for her pains.

Lying down on the bed, I wondered what to do now. For the moment, sleep. How many bridges did I still have standing? And Karen? I didn't know. Maybe I'd see her, maybe not. I hoped I wouldn't, but I knew I probably would.