by Robin Cook
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 ..."