The house of God

by Samuel Shem

  "Oh, and by the way," said the Fat Man, poking his head in again, "I've written an order for this."

  In his hand was a Los Angeles Rams football helmet.

  "What's that for?" asked Potts.

  "It's for Ina," Fats said, strapping it on her head. "LAW NUMBER TWO: GOMERS GO TO GROUND."

  "What does that mean?" I asked.

  "Fall out of bed. I know Ina from last year. She's a totally demented foxed?out gomere, and no matter how securely restrained, she'll go to ground every time. She cracked her skull twice last year, and was here for months. Till we thought of the helmet. Oh, and by the way?even though she's dehydrated, whatever you do, do not hydrate her. Her dehydration's got nothing to do with her dementia, even though the textbooks say it does. If you hydrate her, she stays demented, but she gets incredibly abusive."

  Potts's head turned to watch the Fat Man go, and somehow, her left hand free, Ina slugged him again. Reflexively Potts raised his hand to hit her, and then stopped himself. The Fat Man nearly keeled over with laughter.

  "Ho ho, did you see that? I love 'em, I love these gomers I do . . ." And he laughed his way out the door.

  The manipulation of her head intensified Ina's screams: GO AVAY GO AVAY GO AVAY . . .

  And so, leaving her tied down six ways from Sunday, the ram horns curling around her ears, we proceeded to Visit Rounds.

  Being an academic House affiliated with the BMS, the House of God had a Visit for each ward team: a member of the Privates or the Slurpers, who held teaching rounds every day. Our Visit was George Donowitz, a Private who'd been pretty good in the pre-penicillin era. The patient presented was a generally healthy young man who'd been admitted for routine tests of his renal function. My BMS, Levy, presented the case, and when Donowitz grilled him about diagnoses, the BMS, straight from the library of obscure diagnoses, said "amyloidosis."

  "Typical," muttered the Fat Man as we gathered around the patient's bed, "typical BMS. A BMS hears hoofbeats outside his window, the first thing he thinks of is a zebra. This guy's uremic from his recurrent childhood infections that damaged his kidneys. Besides, there's no treatment for amyloid, anyway."

  "Amyloid?" asked Donowitz. "Good thought. Let me show you a bedside test for amyloid. As you know, people with the disease bruise easily, very easily indeed."

  Donowitz reached down and twisted the skin on the patient's forearm. Nothing happened. Puzzled, he said something about "sometimes you have to 'do it a bit harder" and took hold of the skin, wadded it up, and gave it a tremendous twist. The patient gave a yelp, leaped up off the mattress, and began to cry with pain. Donowitz looked down and found that he'd ripped a big chunk of flesh from the guy's arm. Blood was squirting from the wound. Donowitz turned pale and didn't know what to do. Embarrassed, he took the piece of flesh and tried to put it back, patting it down as if he could make it stay in place. Finally, mumbling, "I . . . I'm so sorry," he ran out of the room. With a cool expertise the Fat Man put a gauze compression bandage on the wound. We left.

  "So what did you learn?" asked Fats. "You learned that uremic skin is brittle, and that the House Privates stink. What else? What do we have to look out for in this poor bastard now?"

  The BMSs ventured several zebras, and Fats told them to shut up. Potts and I went blank.

  "Infection," said Chuck. "In uremia you gotta watch for infection."

  "Exactly,' said Fats. "Bacteria City. We'll culture for everything. If it hadn't been for Donowitz that guy would be going home tomorrow. Now, if he lives, it'll be weeks. And if he knew about this, it would be Malpractice City."

  At this thought the BMSs perked up again. The BMS now comprised a majority of minority groups, and "Social Medicine" was a hot ticket. The BMSs wanted to tell the patient so he could sue.

  "It won't work," said Fats, "'cause the worse the Private, the better the bedside manner, and the higher the patient's regard. If a doctor buys the TV illusion of 'the doctor,' so does the patient. How can the patient know which are the 'Double O'Privates? No way."

  " 'Double O'?" I asked.

  "Licensed to kill," said Fats. "Time for lunch. We'll see from the cultures where Donowitz last stuck his finger before trying to murder that poor uremic schlump."

  The Fat Man was right. Colorful and esoteric bacteria grew out of the wound, including one species that was native only to the rectum of the domestic duck. Fats got excited about this, wanting to publish "The Case of Duck's Ass Donowitz." The patient flirted with death but pulled through. He was discharged a month later, thinking it usual, even a necessary part of his successful course of treatment in the House, for the skin to have been ripped off his arm by his dear and glorious physician.

  When the Fat Man went to lunch and we did not, the terror returned. Maxine asked me to write an order for aspirin for Sophie's headache, and as I started to sign my name, I realized I was responsible for any complications, and I stopped. Had I asked Sophie if she was allergic to aspirin? Nope. I did. She was not. I started to sign the order, and stopped. Aspirin causes ulcers. Did I want to have this poor LOL in NAD bleed out and die from an ulcer? I would wait for the Fat Man and ask him if it was all right. He returned.

  "I've got a question for you, Fats."

  "I've got an answer. I've always got an answer:"

  "Is it all right to give Sophie two aspirin for her headache?"

  Looking at me as if I were from another planet, Fats said, "Did you hear what you just asked me?"

  "Yes."

  "Roy, listen. Mothers give aspirin to babies. You give aspirin to yourself. What is this, anyway?"

  "I guess I'm just afraid to sign my name to the order."

  "She's indestructible. Relax. I'm sitting right here, OK?"

  He put his feet up on the counter and opened The Wall Street Journal. I wrote the order for the aspirin, and feeling dumb, went to see a gorilla named Zeiss.

  Forty?two, mean, with bad heart disease, Zeiss needed a new IV put in. I introduced myself, and tried. My hand shook, and in the hot room I got sweaty, and the drops of sweat plopped onto the sterile field. I missed the vein, and Zeiss yelped. The second time, I went in more slowly, and Zeiss squirmed, moaned, and cried out:

  "Help, nurse! Chest pain! Get me my nitroglycerin!"

  Terrific, Basch?your first cardiac patient and you are about to give him a heart attack.

  "I'm having a heart attack!"

  Wonderful. Call a doctor. Wait you are a doctor.

  "Are you a real doctor or what? My nitros! Fast!"

  I put a tablet under his tongue. He told me to get lost. Crushed, I wished I could.

  Filled with great moments in medicine, the day wore on. Potts and I clustered around the Fat Man like ducklings around a mother duck. Fats sat there, feet up, reading, ostensibly into the world of stocks and bonds and commodities, and yet, like a king who knows his kingdom as well as he knows his own body, who feels the rages of a distant flood in the pulsating of his own kidneys, and the bounty of a harvest in his own full gut, he seemed to have a sense for any problem on the ward, instructing us, forewarning us, helping Potts and me. And once, only once, he moved?fast, unashamedly a hero.

  A scheduled admission, named Leo, had arrived for Potts. Gaunt, white?haired, friendly, a little breathless, Leo stood at the nursing station, suitcase at his feet. Potts and I introduced ourselves and chatted with him. Potts was relieved that here at last was a patient who could talk to him, who was not deathly sick, and who would not slug him. What Potts and I didn't know was that Leo was about to attempt to die. In the midst of a chuckle at one of Potts's jokes, Leo turned blue and fell down on the floor. Potts and I stood there mute, still, frozen, unable to move. My one thought was "How embarrassing for poor Leo." Fats glanced over, leaped to his feet, yelled out "Thump him!" which we were too panicked to do and which I thought would be rather melodramatic, ran over to us, thumped Leo, breathed Leo, closed?chest?cardiac?massaged Leo, IV'd Leo, and organized with a cool virtuosity Leo's cardiac arrest and Leo's return
from the world of the dead. A large crowd had arrived to assist in the arrest, and Potts and I had been pushed out of the action. I felt embarrassed and inept. Leo had been laughing at our jokes, his attempt to die was surreal, and I had denied that it existed. Fats was marvelous, his handling of the arrest a work of art.

  When Leo had returned to life, Fats walked us back to the nursing station, put his feet back up, opened the paper again, and said, "All right all right so you panicked and you feel like shit. I know. It's awful and it's not the last time neither. Just don't forget what you saw. LAW NUMBER THREE: AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE."

  "I guess I wasn't worried about him because he was an elective admission and not an emergency," said Potts.

  "Elective doesn't mean shit around here," said Fats. "Leo would have died. He's young enough to die, you know."

  "Young?" I asked. "He looks seventy?five."

  "Fifty?two. Congestive heart failure's worse than most cancers. It's ones his age that die. There's no way he'll become a gomer, not with a disease like that. And that's the challenge of medicine: gomers gomers gomers where you can't do anything for them, and then, suddenly?WHAM!?in comes Leo, a lovely guy who can die, and you gotta move fast to save him. It's like what Joe Garagiola said last night about Luis Tiant: 'He gives you all his herky?jerky stuff and then, when he comes in with his heater, it looks a whole yard faster.' "

  "His heater?" asked Potts.

  "Oh, Jesus," said Fats. "His fast ball?HIS FAST BALL!?where did they get you guys, anyway?"

  By that time I was wondering the same thing, and so was Potts. Both of us felt incompetent. For some reason, Chuck was different. He didn't need help. He knew what to do. Later that afternoon I asked him about how he seemed so competent already.

  "Easy, man. See, I never read nuthin'. I just did it all"

  "You never read anything?"

  "Just about them red ants. But I know how to put in a big line, tap a chest?you name it, I done it. Ain't you?"

  "Nope. None of that," I said, thinking about my piddling around with Sophie's aspirin.

  "Well, man, what all did you do at the BMS?"

  "Books. I know all there is to know about medicine in books."

  "Well, it looks like that was your failing, man, that right there. Like my not joinin' the army. Maybe I still . . ."

  Standing in the streaming July light was a nurse, the afternoon and evening nurse. She stood with her hands on her hips, reading the med cards, legs apart, rocking first one foot on its lateral edge, and then the other. The sharp sunlight made her costume almost transparent, and her legs flowed in smooth lines from her thin ankles and calves all the way up to where all seams meet. She wore no slip, and through her starched white dress I could see the bright patterns on her panties. She knew they would show through. Through her dress showed her bra strap, with its pleading unhookable hook. Her back was to us. Who could know about the front? I half?wished she would never turn around, never spoil the imagined breasts, the imagined face.

  "Hey, man, that's somethin' else."

  "I love nurses," I said.

  "Well, man, what is it about nurses?"

  "It must be all that white."

  She turned around. I gasped. I blushed. From her ruffled front unbuttoned down past her clavicular notch showing her cleavage, to her full tightly held breasts, from the red of her nail polish and lipstick to the blue of her lids and the black of her lashes and even the twinkly gold of the little cross from her Catholic nursing school, she was a rainbow in a waterfall. After a day in the hot smelly House, after a day of being whacked by the Privates and the Slurpers and the gomers, she was a succulent chilled wedge of an orange squirting in my mouth. She came over to us.

  "I'm Molly."

  "Gurl, the name's Chuck"

  Thinking to myself is it true what they say about interns and nurses, I said, "I'm Roy."

  "This your first day, guys?"

  "Yeah. I was just thinkin' of joinin' the army instead."

  "I'm new too," Molly said. "Started just last month. Scary, eh?"

  "No foolin'," said Chuck.

  "Hang in there, guys, we'll make it. See ya round the campus, eh?"

  Chuck looked at me and I looked at him, and he said, "Sure does make you glad to be spendin' time in here makin' it with the gomers, don't it?"

  We watched Molly disappear down the corridor. She stopped to say hello to Potts, who was talking to a young Czech patient, a man yellow from liver disease. The Yellow Man flirted with Molly, and then ogled her as she, giggling, wiggled down the corridor. Potts came over to us and picked up the lab results from the morning.

  "Lazlow's liver functions are getting worse," he said.

  "He looks mighty yellow," said Chuck. "Lemmee see. Too high. If I was you, Potts, I'd give him some roids."

  "Roids?"

  "Steroids, man, steroids. Whose patient is he, anyhow?"

  "He's mine. He's too poor to afford a Private doctor"

  "Well, I'd give him the roids. Never know if he don't have fulminant necrotic hepatitis. If'n he does, unless you hit him with the roids now, he's gonna die."

  "Yeah," said Potts, "but the tests aren't that high, and steroids have a lot of side effects. I'd just as soon wait a day."

  "Suit yourself. Looks awful yellow, though, don't he?"

  Thinking about what the Fat Man said about the young dying, I got up to do some work. When. I returned to the nursing station I saw two LOLs in NAD peering through their thick cataract?defying glasses at the blackboard on which were written the names of the new interns on the ward. They mentioned my name, and I asked them if they were looking for me. Tiny, a foot below me, huddled together, they peered up at me. "Oh, yes," said one.

  "Oh, aren't you the tall young doctor."

  "Handsome and tall," said the other. "Yes, we want to hear the news about our brother Itzak."

  "Itzak Rokitansky. The professor. Brilliant, he was."

  "How is he, Dr. Basch?"

  I felt trapped, not knowing what to say. Fighting the impulse to say PURRTY GUD, I said, "Well . . . I've only been here a day. It's too early to tell. We'll wait and see."

  "It's his brain," said one. "His marvelous brain. We're glad you'll be taking care of him, and we'll look for you tomorrow. We visit every day."

  "We spend much of our time now visiting the ones who are ill. Good?bye, Dr. Basch. Thank you so much."

  I left them, and noticed them pointing at me to each other, pleased that I would be their brother's doctor. I was moved. I was a doctor. For the first time that day, I felt excited, proud. They believed in me, in my art. I would take care of their brother, and them. Take care of the whole world, why not? I marched down the hallway with pride. I fingered the chrome of my stethoscope with a certain expertise. Like I knew what I was doing. Far?out.

  It didn't last. I got more and more tired, more and more caught up in the multitudinous bowel runs and lab tests. The jackhammers of the Wing of Zock had been wiggling my ossicles for twelve hours. I hadn't had time for breakfast, lunch, or dinner and there was still more work to do. I hadn't even had time for the toilet, for each time I'd gone in, the grim beeper had routed me out. I felt discouraged, worn. Before he left for the day, the Fat Man came by and asked if there was anything else I wanted to talk about.

  "I don't get it," I said. "This isn't medicine, this isn't what I signed up for. Not writing orders for cleanouts for the bowel run."

  "Bowel runs are important," said Fats.

  "But aren't there any normal medical patients?"

  "These are normal medical patients."

  "They can't be. Hardly any of them are young:"

  "Sophie's young; she's sixty?eight."

  "Between the old people and the bowel runs, it's crazy. It's not at all what I expected when I walked in here this morning."

  "I know. It's not what I expected either. We all expect the American Medical Dream?the whites, the cures, the works. Modern medicine's
different: it's Potts being socked by Ina. Ina, who should have been allowed to die eight years ago, when she asked, in writing, in her New Masada chart. Medicine is 'bedrest until complications,' Blue Cross payments for holding hands, and all the rest you've seen today, with the odd Leo thrown in to die."

  Thinking of the Rokitansky girls, I said, "You're too cynical."

  "Did Potts get socked by Ina, or did he not?"

  "He did, but all of medicine isn't like that."

  "Right. In the teeth of our expertise, the ones our age die."

  Cynic.

  "Ah, yes," said Fats, eyes twinkling, "no one wants you to know all this yet. That's why they wanted you to start with Jo, and not me. I wish I could lie. Doesn't matter, 'cause I can't discourage you yet. Like sex, you gotta find it out for yourself. So why don't you go home?"

  "I've got some work to do"

  "Well, you won't believe this either, but most of the work you do doesn't matter. For the care of these gomers, it doesn't matter a damn. But do you know to whom you're saying goodbye?"

  I did not.

  "To the potential father of the Great American Medical Invention. Dr. Jung's. More money than in the bowel run of the stars."

  "What the hell is this invention, anyway?"

  "You'll see," said Fats, "you will see." '

  He left. I felt scared without him, and troubled by what he'd said. Got to find it out for myself? In fifth grade, when I'd asked an Italian kid why he liked having sex, he'd said, "'Cause it feels good." I couldn't understand someone doing something because it felt good. What sense was there in that?

  Just before I left I wanted to say good?bye to Molly. I found her carrying a bedpan toward the disposal. I walked with her, the shit sloshing in the pan, and said, "It's not a very romantic way to meet someone."