by Josh Bazell
Copyright © 2009 by Josh Bazell
All rights reserved. Except as permitted under the U.S. Copyright Act of 1976, no part of this publication may be reproduced, distributed, or transmitted in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.
Little, Brown and Company
Hachette Book Group
237 Park Avenue, New York, NY 10017
Visit our Web site at www.HachetteBookGroup.com
First eBook Edition: January 2009
Little, Brown and Company is a division of Hachette Book Group, Inc.
The Little, Brown name and logo are trademarks of Hachette Book Group, Inc.
The characters and events in this book are fictitious.
Any similarity to real persons, living or dead, is coincidental and not intended by the author.
ISBN: 978-0-316-04030-3
Contents
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Warning
Acknowledgments
About The Author
In Memoriam
Stanley Tanz, MD
1911–1996
If Nietzsche is correct, that to shame a man is to kill him, then any honest attempt at autobiography will be an act of self-destruction.
—Camus
1
So I’m on my way to work and I stop to watch a pigeon fight a rat in the snow, and some fuckhead tries to mug me! Naturally there’s a gun. He comes up behind me and sticks it into the base of my skull. It’s cold, and it actually feels sort of good, in an acupressure kind of way. “Take it easy, Doc,” he says.
Which explains that, at least. Even at five in the morning, I’m not the kind of guy you mug. I look like an Easter Island sculpture of a longshoreman. But the fuckhead can see the blue scrub pants under my overcoat, and the ventilated green plastic clogs, so he thinks I’ve got drugs and money on me. And maybe that I’ve taken some kind of oath not to kick his fuckhead ass for trying to mug me.
I barely have enough drugs and money to get me through the day. And the only oath I took, as I recall, was to first do no harm. I’m thinking we’re past that point.
“Okay,” I say, raising my hands.
The rat and the pigeon run away. Chickenshits.
I turn around, which rolls the gun off my skull and leaves my raised right hand above the fuckhead’s arm. I wrap his elbow and jerk upwards, causing the ligaments to pop like champagne corks.
Let’s take a moment to smell the rose known as the elbow.
The two bones of the forearm, the ulna and the radius, move independently of each other, and also rotate. You can see this by turning your hand from palm up, in which position the ulna and radius are parallel, to palm down, where they’re crossed into an “X.”* They therefore require a complicated anchoring system at the elbow, with the ligaments wrapping the various bone ends in spoolable and unspoolable ribbons that look like the tape on the handle of a tennis racket. It’s a shame to tear these ligaments apart.
But the fuckhead and I have a worse problem right now. Namely that while my right hand has been fucking up his elbow, my left, having somehow come into position by my right ear, is now hooking toward his throat in a knife-edge.
If it hits, it will crush the fragile rings of cartilage that keep his trachea open against the vacuum of breathing in. Next time he tries, his windpipe will clench shut like an anus, leaving him at ReaperTime minus maybe six minutes. Even if I ruin my Propulsatil pen trying to trache him.
So I beg and plead, and coax the trajectory of my hand upwards. Past the point where it’s aiming for his chin, or even his mouth—which would have been disgusting—to where it’s aiming for his nose.
Which caves in like wet clay. Wet clay with twigs in it. The fuckhead crashes to the pavement, unconscious.
I check to make sure I’m calm—I am, I’m just annoyed— before getting heavily to my knees down next to him. In this kind of work, as in every kind of work, probably, planning and composure are worth a lot more than speed.
Not that this particular situation requires much planning or composure. I roll the fuckhead onto his side so he won’t choke to death, and bend the arm that isn’t broken under his head to keep his face off the frozen sidewalk. Then I check to make sure he’s still breathing. He is, in fact with a bubbly joie de vivre. Also the pulses at his wrists and ankles are reasonably strong.
So, as is usual in these situations, I imagine asking the Great One—Prof. Marmoset—whether I can leave now.
And, as is also usual in these situations, I imagine Prof. Marmoset saying No, and What would you do if he was your brother?
I sigh. I don’t have a brother. But I know what he’s getting at.
I put my knee into the guy’s fucked-up elbow and pull the bones as far apart as the tendons feel likely to bear, then let them come slowly back together into their positions of least resistance. It makes the fuckhead groan in pain in his sleep, but whatever: they’d just do the same to him in the ER, only by then he’d be awake.
I frisk him for a cell phone. No such luck, of course, and I’m not about to use my own. If I did have a brother, would he want me getting hassled by the cops?
So instead I pick the fuckhead up and fold him over my shoulder. He’s light and stinky, like a urine-logged towel.
And, before I stand, I pick up his handgun.
The gun is a real piece of shit. Two pieces of pressed sheet-metal—no grips, even—and a slightly off-center cylinder. It looks like something that began life as a starter pistol at a track meet. For a second it makes me feel better about there being 350 million handguns in the United States. Then I see the bright brass ends of the bullets and am reminded how little it takes to kill someone.
I should throw it out. Bend the barrel and drop it down a storm drain.
Instead, I slip it into the back pocket of my scrub pants.
Old habits die harder than that.
In the elevator up to Medicine there’s a small blond drug rep in a black party dress, with a roller bag. She’s got a flat chest, and the arch of her back boosts her ass, so she’s shaped like a sexy, slender kidney bean. She’s twenty-six after a bit too much sun exposure,* and her nose is the kind that looks like a nose job but isn’t. Freckles, I shit you not. Her teeth are the cleanest things in the hospital.
“Hi,” she says like she’s from Oklahoma. “Do I know you?”
“Not yet, no,” I say. Thinking: Because you’re new on this job, or you wouldn’t have such shitty hours.
“Are you an orderly?” she asks.
“I’m an intern in Internal Medicine.”
An intern is a first-year resident, one year out of medical school, so typically about six years younger than I am. I don’t know what an orderly is. It sounds like someone who works in an insane asylum, if there are still insane asylums.
“Wow,” the drug rep says. “You’re cute for a doctor.”
If by “cute” she means brutal and stupid-looking, which in my experience most women do, she’s right. My scrub shirt is so tight you can see the tattoos on my shoulders.
Snake staff on the left, Star of David on
the right.*
“You’re from Oklahoma?” I ask her.
“Well yes I am.”
“You’re twenty-two?”
“I wish. Twenty-four.”
“You took a couple of years off.”
“Yes, but oh my God that is a boring story.”
“It’s okay so far. What’s your name?”
“Staaaaacey,” she says, stepping closer with her arms behind her back.
I should say here that being chronically sleep-deprived is so demonstrably similar to being drunk that hospitals often feel like giant, ceaseless office Christmas parties. Except that at a Christmas party the schmuck standing next to you isn’t about to fillet your pancreas with something called a “hot knife.”
I should also maybe say that drug reps, of whom there is one for every seven physicians in the U.S., get paid to be flirtatious. Or else to actually fuck you—I’ve never been quite clear on that.
“What company do you work for?” I ask.
“Martin-Whiting Aldomed,” she says.
“Got any Moxfane?”
Moxfane is the drug they give to bomber pilots who need to take off from Michigan, bomb Iraq, then fly back to Michigan without stopping. You can swallow it or use it to run the engine.
“Well yes I do. But what are you gonna give me in return?”
“What do you want?” I say.
She’s right up under me. “What do I want? If I start thinking about that, I’ll start crying. Don’t tell me you want to see that.”
“Beats going to work.”
She gives me the play slap and leans over to unzip her bag. If she’s wearing underwear, it’s not of any technology I’m familiar with. “Anyway,” she says, “it’s just things like a career. Or not having three roommates. Or not having parents who think I should have stayed in Oklahoma. I don’t know that you can help me with that.”
She stands up with a sample pack of Moxfane and a pair of Dermagels, the Martin-Whiting Aldomed eighteen-dollar rubber gloves. She says, “In the meantime, I might settle for showing you our new gloves.”
“I’ve tried them,” I say.
“Have you ever tried kissing someone through them?”
“No.”
“Neither have I. And I’ve kind of been dying to.”
She hip-checks the elevator “stop” button. “Oops,” she says.
She bites the cuff of one of the gloves to tear it open, and I laugh. You know that feeling where you’re not sure whether you’re being hustled or in the presence of an actual human being?
I love that feeling.
“The ward is a fucking nightmare,” Akfal, the other intern on my service, says when I finally show up to relieve him. What “Hello” is to civilians, “The ward is a fucking nightmare” is to interns.
Akfal is a J-Card from Egypt. J-Cards are graduates of foreign medical schools whose visas can be rescinded if they don’t keep their residency directors happy. Another good word for them would be “slaves.” He hands me a printout of current patients—he’s got one too, though his is marked up and heavily creased—and talks me through it. Blah blah Room 809 South. Blah blah colostomy infection. Blah thirty-seven-year-old woman for regularly scheduled chemotherablah. Blah blah blah blah blah. It’s impossible to follow, even if you wanted to.
Instead I’m leaning back against the nursing station desk, which is reminding me that I’m still carrying a handgun in the inside pocket of my scrub pants.*
I need to stash the gun somewhere, but the locker room is four floors away. Maybe I should hide it behind some textbooks in the nurses’ lounge. Or under the bed in the call room. It doesn’t really matter, as long as I can focus enough to remember where I put it later.
Eventually Akfal stops talking. “Got it?” he asks me.
“Yeah,” I say. “Go home and get some sleep.”
“Thanks,” Akfal says.
Akfal will neither go home nor get some sleep. Akfal will go do insurance paperwork for our residency director, Dr. Nordenskirk, for at least the next four hours.
It’s just that “Go home and get some sleep” is intern for “Goodbye.”
Rounding on patients at five thirty in the morning usually turns up at least a handful of people who tell you they’d feel fine if only you assholes would stop waking them up every four hours to ask them how they’re feeling. Other people will keep this observation to themselves, and bitch instead about how someone keeps stealing their mp3 player or medications or whatever. Either way, you give the patient the once-over, keeping a particularly sharp lookout for “iatrogenic” (physician caused) and “nosocomial” (hospital caused) illnesses, which together are the eighth leading cause of death in the United States. Then you flee.
The other thing that sometimes happens when you round early on patients is that none of them complain at all.
Which is never a good sign.
The fifth or sixth room I enter is that of Duke Mosby, easily the patient I currently hate least. He’s a ninety-year-old black male in for diabetes complications that now include gangrene of both feet. He was one of ten black Americans who served in Special Forces in World War II, and in 1944 he escaped from Colditz. Two weeks ago he escaped from this very room at Manhattan Catholic Hospital. In his underpants. In January. Hence the gangrene. Diabetes fucks your circulation even if you wear, say, shoes. Thankfully, Akfal was on shift at the time.
“What’s going on, Doc?” he says to me.
“Not much, sir,” I tell him.
“Don’t call me sir. I work for a living,” he says. He always says this. It’s some kind of army joke, about how he wasn’t a commissioned officer or something. “Just give me some news, Doc.”
He doesn’t mean about his health, which rarely seems to interest him, so I make up some shit about the government. He’ll never find out differently.
As I start bandaging his reeking feet, I say, “Also, I saw a rat fighting a pigeon on my way to work this morning.”
“Yeah? Who won?”
“The rat,” I tell him. “It wasn’t even close.”
“Guess it figures a rat could take a pigeon.”
I say, “The weird thing was that the pigeon kept trying, though. It had its feathers all puffed out and it was covered with blood. Every time it attacked, the rat would just bite it once and throw it onto its back. Go mammals, I guess, but it was pretty disgusting.” I put my stethoscope on his chest.
Mosby’s voice booms in through the earpieces. “That rat must have done something pretty bad to that pigeon to make it keep on like that.”
“Doubtless,” I say. I push his abdomen around, trying to elicit pain. Mosby doesn’t seem to notice. “Seen any of the nurses this morning?” I ask him.
“Sure. They been in and out all the time.”
“Any of the ones in the little white skirts, with the hats?”
“Many times.”
Uh huh. You see a woman dressed like that, it’s not a nurse, it’s a strip-o-gram. I feel the glands around Mosby’s neck.
“I got a joke for you, Doc,” Mosby says.
“Yeah? What’s that?”
“Doctor says to a guy, ‘I got two pieces of bad news for you. First one is, you got cancer.’ Man says, ‘Lordy! What’s the second one?’ Doctor says, ‘You got Alzheimer’s.’ Man says, ‘Well, at least I don’t have cancer!’”
I laugh.
Like I always do when he tells me that joke.
In the bed by the door of Mosby’s room—the bed Mosby had until the ward clerk decided he’d be less likely to escape if he was five feet farther from the door—there’s a fat white guy I don’t know with a short blond beard and a mullet. Forty-five years old. Lying on his side with the light on, awake. When I checked the computer earlier, his “Chief Complaint”—the line that quotes the patient directly, thereby making him look like an idiot—just said “Ass pain.”
“You got ass pain?” I say to him.
“Yeah.” He’s gritting his teeth. “And no
w I got shoulder pain too.”
“Let’s start with the ass. When did that start?”
“I’ve already been through this. It’s in the chart.”
It probably is. In the paper chart, anyway. But since the paper chart is the one the patient can request, and that a judge can subpoena, there’s not much incentive to make it legible. Assman’s looks like a child’s drawing of some waves.
As for his computer chart—which is off the record, and would contain any information anyone actually felt like giving me—the only thing written besides “CC: Ass pain” is “Nuts? Sciatica?” I don’t even know if “nuts” means “testicles” or “crazy.”
“I know,” I say. “But sometimes it helps if you tell it again.”
He doesn’t buy it, but what’s he going to do?
“My ass started to hurt,” he starts up, all resentful. “More and more for about two weeks. Finally I came to the emergency room.”
“You came to the emergency room because your ass hurt? It must really hurt.”
“It is fucking killing me.”
“Even now?” I look at the guy’s painkiller drip. That much Dilaudid, he should be able to skin his own hand with a carrot peeler.
“Even now. And no, I’m not some kind of drug addict. And now it’s in my fucking shoulder, too.”
“Where?”
He points to a spot about midway along his right collarbone. Not what I’d call the shoulder, but whatever.
Nothing’s visible. “Does this hurt?” I say, poking the spot lightly. The man screams.
“Who’s there!?” Duke Mosby demands from the other bed.
I pull the curtain aside so Mosby can see me. “Just me, sir.”
“Don’t call me sir—” he says. I let the curtain fall back.
I look down at Assman’s vitals sheet. Temp 98.6, Blood Pressure 120/80, Respiratory Rate 18, Pulse 60. All totally normal. And all the same as on Mosby’s chart, and on the vitals sheets of every other patient I’ve seen on the ward this morning. I feel Assman’s forehead like I’m his mother. It’s blazing.
Fuck.
“I’m ordering you some CT scans,” I tell him. “Seen any nurses around here lately?”
“Not since last night,” he says.