by Robin Cook
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.
DAY 365
Leaving
The appendix lay to one side in a steel dish, where I had put it a moment earlier before turning back to the operating table. The surgeon was finishing sewing up the stump where the appendix had been. Our concentration was so intense that neither of us saw the hand until it crept into the operative field and began groping aimlessly around, palpating the fleshy, moist intestines. The hand was ungloved—most definitely out of place in our previously sterile operative field. It seemed to be a foreign thing from the twilight zone beneath the surgical drapes. The surgeon and I looked up at each other in alarm, and then at Straus, the newly arrived intern, but Straus couldn't take his eyes off the hand. The next few seconds whirled in mental confusion as the three of us strove to connect the intruder with one of the operating team. Just as I dropped my needle and thread and was reaching to pull the hand away from the incision, the surgeon figured it out. "For Christ's sake, George, the guy's got his hand in his belly!"
Awakened from his reverie, George, the anesthesiologist, poked his nose over the ether screen and commented, "Well, I'll be damned," in a noncommittal sort of way, before dropping back on his stool. With a deftness that belied his apparent torpor, he injected a potent muscle-paralyzing drug, succinylcholine, into the IV tubing. Only then did the patient's hand relax and fall back onto the surgical drapes.
"When you said you'd keep the patient light, I never thought I'd be wrestling with him," said the surgeon.
Instead of answering, George eased off on the succinylcholine IV with his right hand while his left opened the tank of nitrous oxide a few more turns. After several forceful compressions of the ventilation bag, to speed the nitrous oxide into the patient's lungs, George looked up to join the fray.
"You know, George, this epidural anesthesia of yours is good fun. Puts the challenge back in surgery. In fact, this case is exactly like a sixteenth-century appendectomy."