What an old man I’ve become, he scolded. Lost in other people’s business.
He turned toward the elevator bay and nearly toppled the young woman behind him.
“I’m sorry, Dr. Salter . . . ,” she stammered. “I didn’t want to interrupt.”
“I’m the one who should be sorry. Not looking where I’m going. I am becoming one of those dotty old men, walking into walls . . . .” He inched backward, keeping a suitable distance between himself and the busty brunette. “But you really do have to call me Millard. One of these days, you’re going to be an attending yourself—and then it’s going to be awkward to change, so we might as well start off on a first-name basis . . . .”
He had been urging the medical students to call him Millard for nearly forty-five years, and had gained absolutely no traction. Of course, Lauren Pastarnack—his eyes darted across her ID badge to confirm her name—would be deprived of the opportunity that he’d promised. By the time she graduated to the rank of attending physician, he would be nothing more than “that psychiatrist who hanged himself, the old guy,” if he were lucky, or possibly his name would merely elicit blank stares. No matter. In any case, Millard felt fondly toward the young woman; she had rotated through his service the previous autumn, during her third year, and had conducted herself admirably. The girl had proven a tad naïve—a delusional patient had convinced her that he’d trained as a commercial airplane pilot—but, at her age, that was probably far better than being prematurely jaded and cynical.
“I’m not sure if you remember me,” she began.
“Of course, I remember you. Lauren Pastarnack. You took care of that aviator . . . .”
Pastarnack blushed. Immediately, Millard regretted his remark.
“I’m just pulling your leg,” he said quickly. “You did a fine job on our team.”
Her face colored even further. “Thank you, Dr. Salter. I mean Millard.” She shifted her weight from one foot to the other, her shapely, stockinged calves exposed below her skirt. Millard did not feel desire. Whatever lust he’d once had for women in their twenties had evaporated long ago. Yet he’d retained the self-consciousness that comes with fearing that others might still suspect him of desire, so he looked away. The butterscotch-haired prodigy and her parents sat ensconced at the far side of the atrium, conferring in hushed tones; both father and daughter appeared tearful. “I’ve been meaning to stop by your office,” said Pastarnack.
“Have you now?”
“I was kind of wondering if you might feel comfortable writing me a letter of recommendation?” she asked. “I’m going to apply for a residency in psychiatry—and I think I did some of my best work on the consult service . . . .”
Now the girl looked away. What a crazy system, reflected Millard, that compelled a strikingly intelligent young woman—she’d graduated from Stanford, he recalled—to approach a fossilized fool like himself as a supplicant. He did not wish to disappoint her; at the same time, his day was already packed solid—and he wasn’t sure he wanted to spend his final free moments attempting to fit letterhead into his printer. If only she had asked a week earlier. The logical thing—the path of least resistance—was to steer her to Stan Laguna for the letter. But the difference between his imprimatur and his junior colleague’s might mean the difference between remaining at St. Dymphna’s and ending up at a community hospital in Milwaukee.
“If you don’t think you can . . .” stammered the girl.
“What are you doing right now?” asked Millard.
“Nothing . . . . Studying for boards, I guess . . . .”
“Walk with me. I’m on my way to see a patient.”
They passed through the steel fire doors and climbed the stairs to the ninth story. Millard had a rule against taking the elevator for fewer than three flights up or four flights down while rounding, a principle he’d held to even after losing cartilage in his knee—although accruing the benefits of an additional five minutes of exercise seemed absurd under the circumstances. But if he didn’t need the workout anymore, at least he was setting an example. And saving energy, which on a scorching summer day might prove his last service to the commonweal.
“How is your studying going?” he inquired.
“I guess I’ll find out in three weeks. There’s so much to learn.”
And most of it thoroughly useless, thought Millard: the chromosomal positions of various gene loci, the patterns of trinucleotide repeat disorders, the symptoms of enzyme deficiency syndromes one would never encounter in practice. “I have a question for you,” he said. “In the 1920s, there were two acceptable treatments for an acute myocardial infarction in New York City. Do you know what they were?”
“Aspirin?”
“Not in the 1920s. The belief back then was that aspirin weakened the heart . . . .”
They paused opposite the orthopedics unit. Pillars of sun beamed through the rectangular skylights, dappling the carpet. Millard could sense the gears of gray matter churning behind the girl’s vast hazel eyes. “What cured everything a hundred years ago?”
“Chicken soup,” guessed Pastarnack.
Millard grinned. At least she was thinking, and thinking outside the box. He wished Lysander had found himself a girlfriend like Lauren Pastarnack.
“Bed rest,” said Millard. “At the exalted St. Dymphna’s Hospital, they treated a heart attack with six months of bed rest.”
The girl smiled up at him. He wondered if he were boring her.
“On the other side of Manhattan, a pioneering Hopkins-trained cardiologist, John Davin, adopted a different approach. This was at the height of Prohibition, and Dr. Davin’s cure for heart disease was a daily stein of beer.”
“Beer?”
“Indeed, beer. He did a land-office business, I’m sure, doling out prescriptions. Now I want you to use your extensive medical knowledge and tell me which worked better—bed rest or beer?”
“The answer has got to be beer,” said Pastarnack. “Or you wouldn’t be asking me. But I don’t know why . . . . Is there a microbe in beer that dissolves blood clots?”
“Is there a microbe in beer that dissolves blood clots?” echoed Millard. “Do we still prescribe beer for heart disease? We may have sold our souls to Merck and Pfizer, but not to Budweiser. Not yet.” He paused to let his wisdom, or at least his wit, settle in. “Beer, I’m afraid, has absolutely zero effect on clogged arteries. Dr. Davin’s patients ended up no better off than before they took up drinking—at least, from a cardiologic standpoint.”
“So bed rest is better?” Pastarnack asked.
“Heavens, no! Beer is neutral. Bed rest is fatal.” Millard heard the pedantry in his voice—but at seventy-five, wasn’t he entitled to wax a smidgeon pedantic? “Imagine all of those patients lying in bed for months at a time, without anticoagulation, without aspirin, clotting up their arteries, developing deep vein thromboses, when what the situation called for was a spirited walk around the block . . . . The exalted St. Dymphna’s Hospital and its competitors killed tens of thousands of people. A man suffered a mild heart attack—and then took to bed, and died of a major coronary event or a stroke a few weeks later. Clark Gable. John Steinbeck. Bed rest nearly killed President Eisenhower. You have heard of President Eisenhower, haven’t you?”
“He built the highways,” chirped Pastarnack. “I still remember something from high school history.”
“Yes,” conceded Millard. “He built the highways.”
But why should this girl know about Ike? What did he have to say about Calvin Coolidge or Grover Cleveland?
“You hear a lot about ‘the days of the giants’ in internal medicine,” observed Millard. “Back in that golden age when residents worked ninety-six hour shifts and performed lumbar punctures on two different patients simultaneously.” Even during his own training, there had been legacies of giants one could never venerate sufficiently or manage to slay—Halsted, Osler; men who towered over the profession like soldiers in the memories of war brides. �
��Claptrap. Romanticized bunk. I lived through the era of the giants, and I can tell you, as an eyewitness, that those so-called giants slaughtered lots of innocent people. I’d gladly throw in my lot with today’s pygmies.”
Millard stopped himself, mid-diatribe. “Pygmies” was the sort of slip that could land one in the doghouse with the associate dean. “The good news,” he said, “is that there won’t be any questions about the therapeutic qualities of beer on your exam.”
“One fewer thing to study,” said Pastarnack.
Now he was certain that he was boring her. She’d have worn the same smile while listening to him read the telephone directory like a senator conducting a filibuster; anything for a recommendation. He still recalled the humbling process of requesting his own letters half a century earlier—accompanying one self-absorbed clinician to the sauna, helping another carve gourds into bird feeders on his suburban patio. While he doubted this young woman would join him in the sauna or the steam room, he was confident that he could have her sculpting gourds with little effort.
“I have to look in on a patient—just for a moment,” he said. “Will you come with me? Then we can talk about your letter.” Assuming she’d agree, he added, “It’s a case of what we used to call reactive depression. Exogenous depression. Poor woman was riding her motorcycle when a fire truck came through an intersection. She miscarried and lost her leg.”
“That’s got to be the saddest thing I’ve ever heard,” said Pastarnack.
You dear, innocent child, thought Millard. You don’t know what’s ahead of you.
He said nothing of the asylum seekers he occasionally treated for free in St. Dymphna’s torture clinic, nothing of his days on the AIDS ward during the 1980s. He could have told her about the homeless grandmother set afire by the marauding teens, about the Pakistani illustrator blinded with lye. He didn’t even point out that, in his passé, admittedly chauvinistic opinion, women who were nine months pregnant had no business riding motorcycles.
“You’ll hear sadder,” he said, matter-of-fact.
They paused at the nursing station long enough for Millard to greet the clerk and scan the room assignments on the monitor. Patients had a knack for shifting locations during the overnight—like infantry strategically repositioned for battle. Every junior clinician had experienced the sinking terror, the sense of depth charges detonating inside one’s abdomen, when one entered the room of a young, relatively healthy patient, for an early morning physical, to find the bed bare, the linens crisp and unsullied. More often than not, this tragedy resulted from staffing logistics, not death or disease, with the perpetrator of the atrocity carrying a clipboard rather than a scythe, and the victim merely relocated across a corridor or up a flight of stairs. Dolores, it turned out, had been so moved. An MRI of a femur lasted long enough to banish a person as far as an entirely different unit, so they were fortunate to find her only two doors down from the room she’d previously occupied. She looked uncomfortable, almost contorted, tilted slightly to her side and propped at a sixty-degree angle, a turquoise scarf wrapped around her scalp. In a nearby chair, portly as a walrus, basked her torpid minder.
The suicide minder’s job was to sound an alarm if Dolores attempted to harm herself in the hospital, but she looked as though she might just as easily doze through the event. Their entrance was her cue to visit the restroom.
“Good morning, Miss Noguerra,” said Millard.
Dolores gawped back at him indifferently, her affect as blunt as a pewter plate.
He leaned against the radiator and lowered his voice. “I’ve brought one of my students with me this morning,” he said. “We wanted to see how you’re doing.”
“The same,” said Dolores. Monotone. Her blankets had shifted over the edge of the bed, revealing her bandaged stump. An ugly scar crossed her remaining ankle. “May I?” asked Lauren Pastarnack—and with the delicate alacrity of a skilled nurse, she re-draped the covers. Dolores grimaced, but said nothing.
“Yesterday, you expressed that you were having some concerning thoughts,” observed Millard. “About hurting yourself. Are you still feeling that way?”
The patient shook her head—a whispered gesture.
“Please take her away,” said Dolores. “She breathes too loud.”
For a moment, Millard thought she meant Pastarnack, but then he registered that she’d been referring to the suicide minder. “Are you sure you’ll be safe without her?”
“She breathes too loud and her stomach growls,” said Dolores. “I swear she’s going to drive me over the edge . . . .”
Millard had little doubt that the minder did breathe too loudly. And over the years, he’d come to the realization that if someone was determined to kill herself, there wasn’t much a physician—or anybody else, for that matter—could do about it. You might prevent a person from taking her life this morning, or this weekend, but not next month or next year. “How does this sound? Why don’t we keep you under observation for one more day—to err on the side of caution?” he proposed. “And if you’re still feeling safe tomorrow, we’ll cancel the one-to-one . . . .”
Dolores closed her eyes, shutting him out. The truth was that he didn’t really suspect she’d harm herself—and if she did, who could say that wasn’t a reasonable decision for a thirty-one- year-old woman who’d lost a leg and a baby? Yet even on his final workday, Millard found himself unable to call off the minder prematurely. Maybe it was instinct, a habit so ingrained that it mimicked a reflex—like his late brother’s aversion to crustaceans. They’d been raised kosher, and although both of them had drifted from organized Judaism, Lester had never been able to stomach a lobster or a shrimp cocktail. “How can I?” he’d once asked Millard. “It’s the curse of upbringing. You might as well ask me to drink human blood.” Millard, who’d grown to savor bay scallops and cheeseburgers, had suffered no such atavistic compunction.
“I’ll have Dr. Laguna stop by tomorrow to check up on you,” said Millard. “He’s a very good doctor. I think you’ll like him.”
Dolores rolled farther onto her flank. Millard waited for the minder to return from the restroom before departing. The endomorphic woman did indeed gasp as she waddled—like a pregnant basset hound on a summer afternoon—but what could be done? You couldn’t exactly instruct the woman to stop breathing. He was glad to return to the corridor, which smelled vaguely of antiseptic. Nearby, a stoop-shouldered fellow buffed the floors, humming Irving Berlin’s “This Is the Army, Mr. Jones.” Now there was a tune you didn’t hear every day! Millard steered Pastarnack past a phalanx of meal carts fortified with discarded breakfast trays, grateful to leave the unit. He didn’t say a word until they’d reached the ninth-floor courtyard, where a frangipani tree rose implausibly amid the wrought iron tables and benches. One of his self-imposed rules was that, whenever possible, he never discussed a patient while still on the unit, much as one didn’t conduct a postmortem of the opera within a ten-block radius of the performance. Who could say that the mezzo-soprano’s mousy sister from Des Moines wasn’t ambling behind you in that ragged pea coat? No need to wound feelings unnecessarily.
“So what do you think?” asked Millard. “Should we let her kill herself?”
His provocation failed to fluster Pastarnack. “Absolutely not. She’s visibly depressed . . . .”
“But her depression could be perfectly rational. Maybe you don’t know the whole story. I didn’t tell you that she was a professional marathon runner, did I? Or that her husband was killed in the accident. Or that she can’t have any more kids. She’s lost her career, her family—who wouldn’t be depressed under the circumstances?”
Flames surged into Pastarnack’s pale cheeks. “I’m not saying her depression isn’t rational—or a valid response to her suffering—only that it’s not permanent.”
“How do you know?”
“I don’t. Not for sure. But there are no guarantees for anything in medicine. We don’t know for sure that bypass surgery or a Whippl
e procedure will succeed, yet we still perform them. Let her try an antidepressant. Or shock therapy.”
“Shock therapy won’t win her the Boston Marathon.”
“There’s always the Paralympics. Or she could be a leading advocate for the disabled. Would you have let Helen Keller kill herself?”
“And what if shock therapy fails? What if fifteen years go by and you’re the head of the consult service and she’s still sitting in that room?”
“We’ll deal with that when it happens,” rejoined Pastarnack. She spoke forcefully, free from her shell of deference. “I see what you’re driving at. And yes, maybe there is a place for rational suicide if you’ve been depressed for fifteen years and failed all interventions—but that doesn’t mean every sixteen-year-old girl whose boyfriend breaks up with her should be allowed to overdose on Tylenol.”
Now Dolores Noguerra wasn’t exactly a rejected teenager . . . .
Pastarnack’s intensity surprised him. He feared he’d touched a live wire: Maybe she had a parent or sibling who’d succumbed to despair. Yet he was delighted that she’d put up an argument—even if he was no longer certain that she possessed the better part of it.
“Okay, you win,” he said. “We won’t let her kill herself just yet.” Many of Millard’s colleagues shared the girl’s caution when it came to so-called rational suicide. Outcomes after trauma proved consistently hard to predict. Some people endured the Bataan Death March, or a failed escape from Sobibór, or seven years as “guests” of Ho Chi Minh in the Hanoi Hilton—and survived psychologically unscathed, able to embrace joy like Elie Wiesel and practice forgiveness like Nelson Mandela. Others found themselves crippled for life by minor setbacks—a nonviolent mugging, a fender-bender, a lost passport. His own mother had once taken to bed for weeks after misplacing her evening gloves. “Let’s at least give her natural resilience a chance to kick in.”
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