by Robin Cook
"I am not." He practically rolled off the examining table trying to point his finger at me.
"You are so." Our level of communication was not high. We continued the childish exchange while I examined him roughly, actually bending my reflex hammer as I pressed it against his Achilles tendons but proving he had tactile sense in his lower extremities. I ended up sending him to X-ray, more to get rid of him for a while than to get films of the bones under his bruises.
About that time of the late morning, the number of patients coming in began to exceed the number going out. A bunch of screaming babies arrived together, as if by conspiracy, and were distributed to various rooms. I really didn't enjoy treating babies. It was rather like my conception of veterinary medicine— zero communication with the patient. Half the time I was forced to ignore the child and try to make some sense out of the mother. Moreover, I found it nearly impossible to hear anything through a stethoscope on the chest of a screaming two-year-old. The usual problems were colds, diarrhea, and vomiting— nothing serious. These kids seemed to anticipate my arrival, saving up so that they could either urinate or defecate while I was examining them.
That Saturday morning was no exception. Children were all over everything, up to their usual tricks. The first baby had had a discharge coming out of its right ear for several days, which the mother thought was Pablum, but she became suspicious when the discharge continued even after she changed the baby's diet. From the general hygiene of the two of them, I thought possibly it was Pablum, but it turned out to be pus. The baby had a roaring infection in both middle ears, behind the eardrums. The right drum had ruptured, causing the discharge; the left drum was still intact, bulging outward from the pressure behind it. It would have been proper to make a little hole in the left drum to release the pus, but I didn't know how to do that, and when I talked to the private doctor, he only wanted me to treat with drugs— penicillin, as usual, and gantrisin, a sulfa drug. When I emphasized the seriousness of the unruptured left eardrum, he cut me off, saying he would see the child Monday morning. Dutifully, I wrote the prescription for the penicillin and the gantrisin.
The next baby had not been eating well for a week. Some emergency. The next one had diarrhea, but only once. It seemed incredible to me that a mother would rush her child to the hospital after a loose bowel movement, but one soon learns that nothing is incredible in the ER. A few other children had colds and stuffy noses and mild temperature elevations.
In order to be thorough, I had to look in every ear, down every throat. This work was often more like wrestling than medicine. Children, even young ones, are surprisingly strong, and although I always entreated the mother to hold the child's arms against its head during the examination, she'd invariably let go and the child would grab for the otoscope, pulling it away and bringing with it a little drop of blood from the ear canal. That made everyone joyous and confident, naturally, but I'd try again, peering into the little hole in the contorting, screaming infant. If any of them had really high temperatures, 104 or over, I'd ask the mothers to give them tepid sponge baths. That morning we had two such cases going. All in all, the ER was sometimes like a pediatric clinic. Of course, there were occasional emergencies, but not as often as the public thinks. Mostly the problems were trivial, stuff that should have been treated in the clinic.
When the odd and horrible thing did happen, the whole staff would become somber and withdrawn for several hours. One morning, a small, dark lady had come in quietly, carrying a small baby in a pink blanket. At the time I hadn't paid any attention to her, being busy with someone else. A nurse took a clean chart and disappeared with the mother. A few seconds later, she reappeared on the run, saying that I should see the child immediately. When I entered the room, the child was still swathed in the pink blanket. Opening it and pulling it back, I saw a blue-black baby, its abdomen swollen to twice normal size and hard as a stone. I couldn't be sure how long it had been dead, but I guessed for about a day. The mother sat in the corner, not moving. We didn't talk; there was nothing to say. I had just looked at the baby, marked the chart, and walked out.
About once a week a pair of hysterical parents charged into the ER with a convulsing child. The child was usually pretty young, and the first time I saw one of those I almost passed out from anxiety. This little girl was about two years old. She lay doubled up, with her arms pressed against her chest; saliva and blood drooled from her mouth, and her whole body shook with rhythmic, synchronous, convulsive jerks. As usual in such cases, the child was out of control of both her urine and her feces. Still terrified, but relieved because the doctor was there, the parents put the girl down on the table. Since they were too hysterical to be of any help, I asked them to wait outside. I also wanted to avoid their judgment of my action—or inaction—for, in truth, I didn't know what to do. Then one of those great nurses bailed me out by handing me a syringe and offering to hold the child while I tried to find a vein. Suddenly I remembered: amobarbital IV. The next problem was getting the needle into the vein. Even on a quiet, resting child, finding a vein can be difficult. On one who's convulsing, it can approach the impossible. How much drug to inject was another dilemma, but I thought I'd just give a little and test the reaction. Finally getting into a vein, after several abortive probes, I gave a squirt, and the child's convulsions suddenly slowed down and then stopped; her breathing stayed strong, thank goodness. My terror of convulsing children decreased somewhat after that experience, especially after I learned to use Valium, or paraldehyde and phenobarbital intramuscularly. But the first time it could have gone either way.
An even bigger scare concerning children had occurred with a seemingly routine case. It served to reinforce my fear that an ordinary situation would deteriorate before my eyes, leaving me helpless. The boy was about six years old, a cute little guy, brought to the scary ER by his overly solicitous parents. He wasn't feeling too well—that was apparent, because he had vomited three times and had other telltale symptoms adding up to the flu syndrome. For the parents' sake as much as the child's, I treated him with an antiemetic drug called Compazine, something I'd used successfully hundreds of time after operations. However, this time I got one of those adverse side reactions you read about at the bottom of the manufacturer's product information sheet—the type of episode the drug detail men don't like to talk about and doctors seldom see. Two minutes or so after the injection the child went into a convulsion, his eyes rolled back, he couldn't sit up unaided, and he developed an obvious rhythmical tremor. The parents were aghast, especially since I had been explaining to them the boy was not very sick. I frantically sedated the child with a little phenobarbital. While I was at it, I probably should have given some to the parents, too, and taken a little myself. I ended up having to admit the child to the hospital. Needless to say, the parents had not been very pleased by this performance, nor had I.
So the early hours of Saturday passed, a combination of glorified pediatric clinic, suturing factory, and occasional true crisis. The few suturing jobs had been routine and rapid. My only disturbing problem had been that bearded fellow, but the hours and the tedium dulled it sufficiently so that the day became a typical one of generalized monotony punctuated by infrequent but memorable moments of terror and uncertainty.
I was actually beginning to like the quick, uninvolved routine of the ER. No patient required such deep attention as to make a real claim on my emotions. I could remember when it had been different, six months ago, back at the beginning of my internship. Mrs. Takura, for instance, had gotten to me. We had become friends; her long operation, throughout which I held the retractors, unable even to see her wound, had been a physical and emotional trauma. When I finally got away from her operation, out to the beach with Jan, I had been secure in my intuition that Mrs. Takura would pull through. Returning to find her dead had been the final, backbreaking straw in my disenchantment with what was happening to me as an intern. I had blown up at the system—at petty day-to-day harassment, the retractors, the la
ck of teaching, and the constant, nagging fear of failure. It had taken me a long time to get over Mrs. Takura, and, finally, I hadn't so much accepted her fate as merely put it aside, vowing not to get emotionally involved again. It became easier, then, not to let patients get inside me. I began to think of them in hard, clinical terms, as so many hemorrhoids, appendixes, or gastric ulcers.
Roso had also been a trial. Unlike the short time with Mrs. Takura, my rapport with him had developed over several months. I even gave him a haircut, after he had been with us so long that his hair was a shabby mane flowing halfway down his back. He didn't have any money, so I offered to cut it if he wanted me to. He was delighted; perched high on a stool in the sunlight of the alcove by the ward, he seemed proud to be alive. Everybody thought it was the worst haircut they had ever seen.
Roso had always smiled, even when he felt terrible, which was most of the time. In fact, he had nearly every complication I had ever read about, and a few that were not even in the medical literature. His vomiting and hiccups had persisted until another operation became imperative. I was in my familiar position, both hands clenched around pieces of metal and looking at the back of the chief resident for six and a half hours while Roso's Billroth I was converted to a Billroth II; his stomach pouch was now attached to the small intestine at a point about ten inches farther down than usual. It was hoped that this procedure would end Roso's troubles, because the obstruction in his digestive system that was causing them was at the very connection between the stomach and the intestine that had been made in the first operation. But even after this second operation everything on his chart hovered near critical; his course was like a sine wave. Hiccups, vomiting, weight loss, and several horrendous episodes of upper gastrointestinal bleeding kept me busy— especially those bleeding episodes. A week after the Billroth II, Roso vomited up pure blood and rapidly sank into shock. I stayed with him several nights in a row, continuously irrigating his stomach with iced saline, and pulling out the nasogastric tube when it got clogged and pushing it back in. He hung on, somehow, through our mistakes and my miscalculations, and through his own relentless, troubled course.
After the bleeding, nothing would go through his stomach until I was lucky enough to pass a nasogastric tube down through the anastomosis and into his small intestine. Using that as a start, I fed him directly into the intestine with special stuff. Some stayed down—but he got diarrhea. Then one day he sneezed out the nasogastric tube. I had him on intravenous feedings off and on for four months, balancing sodium and potassium and magnesium ions. He developed a wound infection, inflammation of his leg veins, a touch of pneumonia, and a urine infection. Then we became aware of an abscess under his diaphragm, which was causing the hiccups; back to surgery again. Somehow he managed not only to live through all this, but actually to recover. It took me four hours to do his discharge summary; his chart weighed five pounds—five pounds of my own writing, frequently stained with blood, mucus, and vomitus. When he left the hospital, I was happy to see him alive and vastly relieved to have him gone. His case and my attachment to it had been almost too much to bear on top of everything else. At times during his bleeds, administering the iced saline and seeing to his tube, I had begun to wonder if I had set him up as a challenge just because everybody said he wouldn't make it. Maybe I didn't give a damn about him, was just using him to prove to myself that I could handle a tough case. Eventually, though, I stopped examining my motivations and began to treat my patients as hernias, or whatever they had; it was infinitely less wearing. The ER was easy on a brooder. You were always too busy or too tired or too scared to think....
Eleven forty-five in the morning. I was about to go to lunch when a rather pale young woman in her early twenties walked in with two girl friends. After a hushed consultation with the nurse, the pale one followed her into one of the examining rooms. The other two sat down and nervously lit cigarettes. The sound of a New York accent drifted out of the examining room as I wrote the last sentence on a baby's chart and put it in the "Finished" basket. Eager to get away for lunch, I pushed into the room where the nurse had taken the girl. The chart indicated vaginal bleeding for two days, clots that morning. The girl took out a cigarette.
"Please, no smoking here, Miss."
"I'm sorry." She carefully put the cigarette back and looked at me, then away. She was of average build, and dressed in a short-sleeved blouse and a miniskirt. With some color in her face, she would have been pretty. Her conversation suggested no more than a high-school education.
"How many days have you been bleeding?"
"Three," she said. "Ever since I had the D and C." We were both nervous. Wondering if my uncertainty showed, I tried to stand motionless and appear knowledgeable.
"Why did you have a D and C?"
"I don't know. The doctor said I had to have it, so I had it, okay?" She feigned irritation.
"Where was it, here or in New York?"
"New York."
"Then you came here right away?"
"Yeah," she said. She really had an accent. The fact that she had come to Hawaii so soon was off center. A six-thousand-mile trip directly after a D and C was not standard medical procedure.
"Was it done by a professional person?" I asked.
"Of course. Whaddaya mean, by a professional person? Who else?"
What to do? If she had had an abortion—and I was pretty sure of it—I knew I would have some difficulty getting a private M.D. Also, I remembered all too well from medical school a string of girls in endotoxin shock from infections caused by bad D and C's. It can happen so fast; the kidneys give up and blood pressure disappears. However, this girl's blood pressure was obviously all right for the moment. In fact, she was functioning well in all respects, except that she was quite jumpy and a little pale. I wondered if she was trying to follow my thoughts. She need not have worried. I didn't care how she had gotten into her condition, only how to get her out of it. My chances of discovering the exact cause of her bleeding were pretty small. She'd probably have to have another D and C. In that case, I would try to locate a private gynecologist, but few of them cared to get mixed up in such an affair—picking up someone else's pieces, so to speak. One way or another, a pelvic examination was in my future, and that was the last thing I wanted right before lunch.
The memory of my first pelvic floated across my consciousness. It had been during a second-year medical-school course in physical diagnosis. I had had no preconceptions, which was fortunate, because my patient was quite a hefty lady. She was a clinic patient in for a regular checkup. At first I didn't think my arm was long enough to reach the uterus, and the guy after me claimed he lost his watch— although he found it later in the bag where we threw the gloves. At the time, we had not yet been through obstetrics or gynecology, and reaching into the lady was strangely unsettling. But after a hundred or so, a pelvic examination is a routine like any other. The only problem is finding the cervix—which might seem absurd, because it's always there. But when there's a lot of blood and dots, the job can be hard, particularly if the patient is uncooperative. Moreover, you don't want to hurt the patient by fumbling around. So it pays to take a few minutes extra and do a good job. But not before lunch.
"How long had you been pregnant?" I suddenly asked the girl from New York.
"What?" She was sputtering again, in obvious surprise. Since it was important for me to know, I let the question hang in silence. "Six weeks," she said finally.
"And was it a doctor or someone else?"
"A doctor in New York," came the resigned answer.
"Well, we'll do what we can for you," I said, and she nodded in relief.
Leaving the room, I told the nurse to get her ready for a pelvic. In a matter of minutes the nurse reappeared to say that everything was ready, and when I walked back in the patient was draped and waiting nervously in the stirrups, with her skirt rumpled around her waist. As I prepared to insert the speculum, I couldn't help recalling a night six weeks before when I had b
een waked up by a nurse saying that she couldn't catheterize an elderly patient with a full bladder because she couldn't find the right hole. I had gotten up and been halfway over to the hospital before the ridiculousness of the situation hit me. If the nurse couldn't find it, how could I? But I did, after a while; it was just a matter of persistence.
It was the same with finding this cervix. Persistence. Surrounded by blood and clots, which I cleared away as best I could, the cervix suddenly popped into view. The orifice was closed, and no new blood appeared when I dabbed it with a sponge stick. I pushed down on the abdomen, to the girl's great discomfort, and got nothing. Then I noticed a small tear, bleeding very slowly, on the posterior aspect of the cervix. Almost surely that was the problem. I cauterized it with silver nitrate, called a gynecologist, explained things, and walked over to lunch with a unique feeling of accomplishment. Miraculously, I was still hungry.
Lunch was a rapid affair; fifteen minutes of stuffing down two sandwiches and a pint of milk amid careless banter of surfing, surgery, and sex. Nothing serious—there wasn't time for it. I made some tentative plans with Hastings to go surfing late the following afternoon about four-thirty. Carno was eating at a distant table; except for seeing each other at the hospital, we rarely got together any more. I also talked with Jan Stevens for a few minutes. I hadn't seen much of her lately, although during July and August, early in my internship, we had had quite a spree, culminating in an unusual weekend trip to Kauai.