by Samuel Shem
3
It must have been the Fat Man who first showed me what a gomer was. The Fat Man was my first resident, easing my transition from BMS student to intern in the House of God. He was wonderful, and a wonder. Brooklyn?born, New York City?trained, expansive, impervious, brilliant, efficient, from his sleek black hair and sharp black eyes and bulging chins through his enormous middle that forced his belt buckle to roll over on its belly like a shiny fish, to his wide black shoes, the Fat Man was fantastic. Only New York City could have bounced back from his birth to nourish him. In return, the Fat Man was skeptical of whatever wild country existed to the west of that great frontier, Riverside Drive. The only exception to this urbane provincialism was, of course, Hollywood, the Hollywood of the Stars.
At six?thirty in the morning of July the first, I was swallowed by the House of God and found myself walking down an endless bile?colored corridor on the sixth floor. This was ward 6?South, where I was to begin. A nurse with magnificently hairy forearms pointed me to the. House Officer's On?Call Room, where rounds were in progress. I opened the door and went in. I felt pure terror. As Freud had said via Berry, my terror was "a straight shot from the id."
Around the table were five people: the Fat Man; an intern named Wayne Potts, a Southerner whom I'd known at BMS, a nice guy but depressed, repressed, and kind of compressed, dressed in crisp white, pockets bulging with instruments; the three others seemed eager, and this told me they were BMS students doing their medicine clerkship. Each intern was to be saddled with a BMS, each day of the year.
"It's about time," said the Fat Man, biting a bagel. "Where's the other turkey?"
Assuming he meant Chuck, I said, "I don't know."
"Turkeys," said Fats, "he'll make me late for breakfast."
A beeper went off, and Potts and I froze. It was the Fat Man's: FAT MAN CALL THE OPERATOR FOR AN OUTSIDE CALL, THE OPERATOR FOR AN OUTSIDE CALL, FAT MAN, RIGHT AWAY.
"Hi, Murray, what's new?" said Fats into the phone. "Hey, great. What? A name? Sure sure yeah no problem hang on." Turning to us, Fats asked, "OK, you turkeys, what's a catchy doctor's name?"
Thinking of Berry, I said, "Freud."
"Freud? Nah. Gimmee another. Stat "
"Jung."
"Jung? Jung. Murray? I got it. Call it Dr. Jung's. Great. Remember, Murray, we're gonna be rich. Millions. Bye?bye:" Turning back to us with a pleased smile, Fats said, "A fortoona. Ha. OK, we'll start rounds without the other tern."
"Great," said one of the BMSs, leaping to his feet. "I'll get the chart rack. Which end of the ward do we start on?"
"Sit down!" said Fats. "What are you talking about, chart rack?"
"Aren't we going on work rounds?" asked the BMS.
"We are, right here"
"But . . . but we're not going to see the patients?"
"In internal medicine, there is virtually no need to see patients. Almost all patients are better off unseen. See these fingers?"
We looked carefully at the Fat Man's stubby fingers.
"These fingers do not touch bodies unless they have to. You want to see bodies, go see bodies. I've seen enough bodies, and especially bodies of gomers, to last me the rest of my life."
"What's a gomer?" I asked.
"What's a gomer?" said the Fat Man. With a little smile he spelled out "G?O . . ."
He stopped, his mouth still set in the "O," and stared at the doorway. There stood Chuck, wearing a collar?to?toes?length brown leather coat with tan fur ruffles at the edges, sunglasses, and a brown leather hat with a broad rim and a red feather. He walked clumsily on platform heels, and looked as if he'd been up dancing the night away.
"Hey, man, what's happenin'?" said Chuck, and slid into the nearest chair, slouching down, covering his eyes with a weary hand. As a token gesture, he unbuttoned his coat and threw his stethoscope on the table. It was broken. He looked at it and said, "Well, I guess I broke my scope, eh? Rough day."
"You look like some kind of mugger," said a BMS.
"That's right, man, 'cause you see, in Chicago where I come from, there are only two kinds of dudes?the muggers and the mugged. Now, if you don't dress like a mugger, man, you automatically gets youseff mugged. You dig?"
"Never mind dig," said the Fat Man, "pay attention. I was not supposed to be your resident today. A woman named Jo was, but her father jumped off a bridge and killed himself yesterday. The House switched our assignments, and I'll be your resident for the first three weeks. After what I did as an intern last year, they didn't want to expose the fresh terns to me today, but they had no choice. Why didn't they want you to meet me, your first day as a doctor? Because I tell things as they are?no bullshitology?and the Fish and the Leggo don't want you to get discouraged too soon. They're right?if you start to get as depressed now as you'll be in February, in February you'll jump off a bridge like Jo's pop. The Leggo and the Fish want you to cuddle with your illusions, so you don't give in to your panic. 'Cause I know how scared you three new terns are today."
I loved him. He was the first person to tell us he knew about our terror.
"What's there to be depressed about?" asked Potts.
"The gomers," said the Fat Man.
"What's a gomer?"
From outside the room there came a high?pitched, insistent cry: GO AVAY GO AVAY GO AVAY . . .
"Who's on call today? You three interns rotate days on call, and you only admit patients on your on?call day. Who's admitting today?"
"I am," said Potts.
"Good, 'cause that awful sound comes from a gomer. If I'm not mistaken, it's from one Ira Goober, whom I admitted six times last year. A gomer, or rather, the feminine, gomere. Gomer is an acronym: Get Out of My Emergency Room?it's what you want to say when one's sent in from the nursing home at three A.M."
"I think that's kind of crass," said Potts. "Some of us don't feel that way about old people."
"You think I don't have a grandmother?" asked Fats indignantly. "I do, and she's the cutest dearest, most wonderful old lady. Her matzoh balls float?you have to pin them down to eat them up. Under their force the soup levitates. We eat on ladders, scraping the food off the ceiling. I love . . ." The Fat Man had to stop, and dabbed the tears from his eyes, and then went on in a soft voice, "I love her very much."
I thought of my grandfather. I loved him too.
"But gomers are not just dear old people," said Fats. "Gomers are human beings who have lost what goes into being human beings. They want to die, and we will not let them. We're cruel to the gomers, by saving them, and they're cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them."
"I don't get it," said Potts.
"After Ira you'll get it. But listen?even though I said I don't see patients, when you need me, I'm here with you. If you're smart, you'll use me. Like those dolled?up jets that cargo the gomers to Miami: 'I'm Fats, fly me'. Now, let's get on to the cardflip."
The efficiency of the Fat Man's world rested on the concept of the three?by?five index card. He loved three-by?five cards. Announcing that "there is no human being whose medical characteristics cannot be listed on a three?by?five index card," he laid out two thick decks on the table. The one on the right was his. The duplicate deck on the left he split in three, and handed a stack to each of the new terns. On each card was a patient, our patients, my patients. The Fat Man explained how on his work rounds he would flip a card, pause, and expect that tern to comment on the progress being made. Not that he expected progress to have been made, but he had to have some data, so that at the next cardflip, a condensed version later in the morning with the Fish and the Leggo, he could relate "some bullshit or other" to them. The first cards flipped every day would be the new admissions from the tern who'd been on call the night before. The Fat Man made it clear that he was not interested in fancy elaborations of academic theories of disease. Not that he was anti-academic. To the contrary, he was the only resident to have his own reference file on every disease there was, on th
ree?by?five cards. He loved references on three-by?five cards. He loved everything that was on a three-by?five card. But the Fat Man had strict priorities, and at the top was food. Until that awesome tank of a mind had been fueled via that eager nozzle of a mouth, Fats had a low tolerance for medicine, academic or otherwise, and for anything else.
Rounds over, Fats headed to breakfast, and we headed out to the ward to get to know the patients on our cards. Potts, looking green, said, "Roy, I'm as nervous as a whore in church." My BMS, Levy, wanted to go see my patients with me, but I shooed him away to the library, where BMSs love to be. Chuck and Potts and I stood at the nursing station, and the hairy-armed nurse told Potts that the woman on the stretcher was his first admission of the day, named Ina Goober. Ina was a great mass of flesh sitting upright on a stretcher, wearing, like a uniform, a gown that had blazoned across its front, "The New Masada Nursing Home." Glowering, Ina clutched her purse. She was yelling a high?pitched: GO AVAY GO AVAY GO AVAY…
Potts did what the textbooks said to do: introduced himself, saying, "Hello, Mrs. Goober, I'm Dr. Potts. I'll be taking care of you."
Upping her volume, Ina screamed: GO AVAY GO AVAY GO AVAY . . .
Potts next tried to engage her using the other textbook method, grasping her right hand. Quick as lightning Ina struck him a southpaw blow with her purse, knocking him back against the counter. The sinister violence of it shocked us. Potts, rubbing his head, asked Maxine, the nurse, whether Ina had a private doctor who could provide information.
"Yes," said Maxine, "Dr. Kreinberg. Little Otto Kreinberg. That's him over there, writing Ina's orders in her chart."
"The private doctors are not supposed to write orders," said Potts, "that's a rule. Only interns and residents write orders"
"Little Otto is different. He doesn't want you writing orders on his patients."
"I'll talk to him about that right now."
"You can't. Little Otto won't talk to interns. He hates you."
"He hates me?"
"He hates everyone. See, he invented something having to do with the heart thirty years ago, and he expected to get the Nobel Prize, but he hasn't, so he's bitter. He hates everyone, especially interns.
"Well, man," said Chuck, "sure is a great case. See you later."
I was so scared at the thought of seeing patients that I had an attack of diarrhea, and sat in the toilet with my How to Do It manual spread on my knees. My beeper went off: DR. BASCH CALL WARD 6SOUTH RIGHT AWAY DR. BASCH . . .
This scored a direct hit on my anal sphincter. Now I had no choice. I could no longer run. I went out onto the ward and tried to go see my patients. In my doctor costume, I took my black bag and entered their rooms. With my black bag I came out of their rooms. All was chaos. They were patients and all I knew was in libraries, in print. I tried to read their charts. The words blurred, and my mind bounced from How to Do cardiac arrests to Berry to this strange Fat Man to Ina's vicious attack on poor Potts and to Little Otto, whose name rang no bell in Stockholm. Running through my mind, over and over like Muzak, was a mnemonic for the branches of the external carotid artery: As She Lay Extended Olaf's Potato Slipped In. And even there, the only one I could remember was Olaf's, which stood for Occipital. And what the hell use was that?
I started to panic. And then finally the cries coming from the various rooms saved me. All of a sudden I thought "zoo," that this was a zoo and that these patients were the animals. A little old man with a tuft of white hair, standing on one leg with a crutch and making sharp worried chirps, was an egret; and a huge Polish woman of the peasant variety with sledgehammer hands and two lower molars protruding from her cavernous mouth became a hippo. Many different species of monkey appeared, and sows were represented in force. In my zoo, however, neither were there any majestic lions, nor any cuddly koalas, or bunnies, or swans.
Two stand out. First, a heifer named Sophie, who'd been admitted by her Private Doctor with a chief complaint of "I'm depressed, I've got headaches all the time." For some reason her Private, Dr. Putzel, had ordered the complete Gastrointestinal workup, consisting of barium enema, upper GI series, small?bowel follow?through, sigmoidoscopy, and liver scan. I didn't know what this had to do with depression and headache. I entered her room and found the old lady with a balding little man who was sitting on her bed patting her hand affectionately. How sweet, I thought, her son has come to visit. It was not her son, it was Dr. Bob Putzel, whom Fats described as "the hand?holder from the suburbs." I introduced myself, and when I asked Putzel about the reason for the GI workup for depression, he looked sheepish, straightened his bowtie, murmured "flatulence," and, kissing Sophie, hurried out. Confused, I called in the Fat Man.
"What is it with this GI workup?" I asked. "She says she's depressed and has a headache."
"It's the specialty of the House," said Fats, "the bowel run. TTB?Therapeutic Trial of Barium."
"There's nothing therapeutic about barium. It's inert."
"Of course it is. But the bowel run is the great equalizer."
"She's depressed. There's nothing wrong with her bowels."
"Of course there's not. There's nothing wrong with her, either. It's just that she got tired of going to Putzel's office, and he got tired of calling at her house, so they both pile into his white Continental and come to our House. She's fine, she's a LOL in NAD?a Little Old Lady in No Apparent Distress. You don't think Putzel knows that too? And every time he holds Sophie's hand, it's forty of your Blue Cross dollars. Millions. You know that new building, the Wing of Zock? Know what it's for? The bowel run of the rich. Carpets, individual changing rooms in radiology with color TV and quadraphonic sound. There's a lotta money in shit. I'm searching for a GI fellowship, myself."
"But with Sophie it's fraud."
"Of course it is. Not only that, it means work for you, and Putzel is the one making the money. It sucks."
"It's crazy," I said.
"It's doing medicine the House of God way."
"So what can I do about it?"
"Start by not talking to her. If you talk to these patients, you'll never get rid of them. Then sic your BMS on her. She'll hate that."
"Is she a gomer?"
"Does she act human?"
"Of course she does. She's a nice old lady."
"Right. A LOL in NAD. Not a gomere. But you're sure to have a gomer on your service. Here, let's see. Rokitansky. Come on."
Rokitansky was an old bassett. He'd been a college professor and had suffered a severe stroke. He lay on his bed, strapped down, IV's going in, catheter coming out. Motionless, paralyzed, eyes closed, breathing comfortably, perhaps dreaming of a bone, or a boy, or of a boy throwing a bone.
"Mr. Rokitansky, how are you doing?" I asked.
Without opening his eyes, after fifteen seconds, in a husky slurred growl from deep down in his smushed brain he said: PURRTY GUD.
Pleased, I asked, "Mr. Rokitansky, what date is it today?"
PURRTY GUD. .
To all my questions, his answer was always the same. I felt sad. A professor, now a vegetable. Again I thought of my grandfather, and got a lump in my throat. Turning to Fats, I said, "This is too sad. He's going to die."
"No, he's not," said Fats. "He wants to, but he won't."
"He can't go on like this."
"Sure he can. Listen, Basch, there are a number of LAWS OF THE HOUSE OF GOD. LAW NUMBER ONE: GOMERS DON'T DIE."
"That's ridiculous. Of course they die."
"I've never seen it, in a whole year here," said Fats.
"They have to."
"They don't. They go on and on. Young people-like you and me?die, but not the gomers. Never seen it. Not once."
"Why not?"
"I don't know. Nobody knows. It's amazing. Maybe they get past it. It's pitiful. The worst."
Potts came in, looking puzzled and concerned. He wanted the Fat Man's help with Ina Goober. They left, and I turned back to Rokitansky. In the dim half-light I thought I saw tears trickling down the old man
's cheeks. Shame swept over me. My stomach churned. Had he heard what we'd said?
"Mr. Rokitansky, are you crying?" I asked, and I waited, as the long seconds ticked away, my guilt moaning inside me.
PURRTY GUD.
"But did you hear what we said about gomers?"
PURRTY GUD.
I left, and stopped by to listen to Fats on Ina Goober.
"But there's no indication for the bowel run," Potts was saying.
"No medical indication," said Fats.
"What else is there?"
"For the House Privates, a big one. Tell him, Basch. tell him."
"Money," I said, "there's a lotta money in shit:"
"And no matter what you do, Potts," said the Fat Man, "Ina will be here for weeks. See you on Visit Rounds in fifteen."
"This is the most depressing thing I've ever done," said Potts. lifting up a pendulous breast as Ina continued to shriek and attempt to whack him with her tied-down left hand.
Under the breast was greeny scumlike material, and as the foul aroma hit us, I thought that this first day must be even worse for Potts. He was a displaced person, from Charleston, South Carolina, to the North. He came from a rich Old Family who owned a dream house on Legare Street amidst the magnolias and yellow jasmine, a summerhouse on Pawley's Island, where the only competition was between waves and winds, and an upriver plantation, where he and his brothers would sit out on the porch of a cool summer night and peruse Moliere. Potts had made the fatal mistake of coming north to Princeton, and then compounded his mistake by coming to the BMS. There, over the stiffs in the Path course, he'd met a classy female BMS from Boston, and since up till that time Potts's sexual experience had consisted only of "an occasional recreational encounter with a schoolteacher from North Charleston who was fond of my blue?steel throbber," he'd been assaulted by the female BMS in both intellectual and sexual terms, and, like a false spring in February when all the bees hatch and are killed by the next frost, there had blossomed in these two BMSs something each called "love." The wedding had been held just prior to both internships, his in medicine at the House, hers in surgery at the MBH?Man's Best Hospital?the prestigious BMS?affiliated WASP hospital across town. Their on?call schedules would rarely coincide, and their joy of sex would curdle to their job of sex, for what erectile tissue could stand two internships? Poor Potts. Goldfish in the wrong bowl. Even at BMS he'd seemed depressed, and each choice since then had served only to deepen his depression.