by Robin Cook
In terms of the immutable intern computer-matching system, I had been destined for any Ivy League internship. On that score, it was true enough that I had dropped out. But in the end I couldn't help myself. As med school wore on I began to see that becoming a doctor meant giving yourself over to the system, like a piece of wood on a chipping machine. At the end of the machine I would be smooth and probably salable, full of knowledge. But as the chips flew away, so would those "nonproductive" personality traits — empathy, humanity, the instinct to care. I had to prevent that if I could, if it wasn't too late. So at the last minute I had jumped off the machine. "Well, Peters, you've really done it now."
Losing the skinny old man had me up tight, and I leaped off the bed even before Jan knocked. Thank God it wasn't the phone. I was afraid of the phone. "Jan, it's good to see you, mangoes and all." Mangoes, just what I needed. "Sure, you can turn on the light. I was just sitting here thinking. All right, leave it off. Knives and a dish? You want to eat those mangoes now?" I didn't want mangoes, but it wasn't worth an argument, and, anyway, she looked delicious with the soft light shining on her hair, and she smelled as if she'd just stepped out of the shower, sweeter than any perfume. But the prettiest thing about Jan was her voice. Maybe she'd sing a little for me.
I got a dish and two knives, and we sat on the floor and started eating mangoes. At first, we didn't talk, and that was one reason I liked her, for her reticence. She was good to look at, too, very much so, yet awfully young, I suspected. Before tonight we had gone out twice, yet we weren't at all close. It didn't matter. Well, it did matter, because I wanted to know her, especially right then. There was something poetic about her blond hair and small features; just then I needed us to be close.
The mango was sticky. I peeled the whole thing and went over to the sink to rinse my hands. When I turned back to her, she was facing away from me, and the light from the window was throwing areas of silver sheen on her hair. She was leaning on one arm, with her legs tucked along her other side. I almost asked her to sing 'Try To Remember," but I didn't, probably because she would have — she did almost anything I asked in the way of song. If she started singing now, though, everybody in the quarters would hear it. In fact, they probably could hear us eating the mangoes. As I sat down next to her, she tilted her face and I could see her eyes.
"Something happened tonight," I offered.
"I know," she said.
That almost stopped me right there. J know. Like hell she knew, and I not only knew that she didn't know, but also that I wasn't going to be able to explain it to her. I went on anyway.
"I pronounced a skinny old man with cancer dead, and right now I'm afraid the phone will ring and it’ll be the nurse saying he's alive after all."
She tilted her head the other way, taking her eyes away. Then she really said the right thing. She said that was funny! Funny?
"Don't you think if s crazy?"
Well, yes, it was crazy, but it was funny, too.
"You know that a person died tonight, and all I can think about is that he might still be alive and it’ll be a big joke. A big joke on me."
She agreed that it would be a joke. That was the extent of her analysis on the subject. I persisted: "Don't you think it's strange for me to think such a stupid thing about the final event of somebody's life?"
That was too much for her, I guess, because the next thing she said was to ask if I didn't like mangoes. I like mangoes all right, but I didn't want any just then; I even offered her some of mine. Despite the misfirings, I somehow felt better, as if trying to communicate my thoughts had removed the skinny old man from the front of my mind. I wondered if Jan would sing "Aquarius." This girl made me feel happy in a simple way.
I put my arm around her, and she popped a piece of mango into my mouth, ludicrously throwing up a barrier without meaning to. So, okay, we won't talk about my skinny old man, I thought. I kissed her, and when I realized she was kissing me back, I thought how nice it would be to make love with her. We kissed again, and she pressed against me, so I could feel her warmth and softness. My hands were still sticky from the mangoes, but I ran them up and down her back, wondering if she would make love. The thought chased everything else from my mind. It was ridiculous to be on the floor, and I was pondering how to get us both over to the bed when I realized she wasn't wearing anything under her light dress — I had been too busy caressing her back to notice. She sensed my desire to move, and we stood up simultaneously. As I began to lift her dress, she stopped me, clasping my forearms, undid the back, and stepped out of it, so beautiful in the soft light. She might not have understood my problem, but she certainly had cleared my mind. That poetry I had thought about her enlarged to include her breasts. I peeled off my shirt, dropped the stethoscope on the floor, and moved to her quickly, afraid she might disappear.
The telephone rang. The moment was gone, and the skinny old man was back in my life. Jan lay down on the bed while I stood looking at the phone. My mind had been clear and well directed ten seconds before; now it became a jumble again, and with confusion came the terrible thought: He's started breathing. I let the phone ring three times, hoping it would stop. When I answered, it was the nurse.
"Dr. Peters, the family has arrived."
"Thank you. I'll be right there."
A sense of relief flooded over me; it was only the family. The old man was still dead.
I put my hand on the small of Jan's back; her soft warm skin demanded attention, and the graceful curve of her back didn't help me think how to ask the family for an autopsy. Finding my white shirt was easy, but the stethoscope eluded me until I stepped on it as I was putting the shirt on.
"Jan, I've got to run over to the hospital. I'll be right back, I hope."
Blinking, I stepped from the warmth of the room into the fluorescence of the hall, on my way to face the trial of the maroon elevator.
There is something ominous about the darkness and silence of a hospital asleep. By now it was ten-thirty, and the ward had slipped into the night routine, a kind of half life made up of soft lights and muted voices. I walked down the long hall toward the nurses' station, past rooms marked only by the flow of night lights. At the other end, I could see two nurses talking, although no sound reached me. The hall seemed especially long this time, like a tunnel, and the light at the end reminded me of a Rembrandt painting, sharply bright areas surrounded by burnt umber. I knew that the calm could be shattered at any moment, driving me forward to face some new crisis, but for the moment that world stood still.
Autopsy. I had to ask for an autopsy. I remembered my first one, in the second year of medical school at the beginning of our pathology course, when I still thought medicine made everybody well. "File in here, men, and group yourselves around the table." We had all looked the same in our white coats, marching in like well-behaved school children, which I suppose we were. And then I had seen her, not the one we were there to see, but another one, on the next slab, who was next in line to be autopsied. Her skin was a cold yellow gray, with a pox of herpes zoster extending from the right arm over the breast to the midline. Herpes zoster is a very serious and vivid skin disorder characterized by large crusted lesions. Its visual effect had been doubly startling in those surroundings. The woman lay on a cement table amid a thousand foul stains. Water flowed under and around her down longitudinal channels about three inches apart, falling into a drain at the base with an obscene sucking noise. Some scratchy pencil marks had been made on a manila tag tied around her right arm. Her hair looked brittle. But the thing that had bothered me most was the sickly color of her skin. About thirty, not much older than I am, I had thought. The sight had made me feel not physically ill, as a few of the med students did, but somehow mentally bankrupt.
She was undeniably dead, really dead, and yet she looked so alive except for the color. Dead, alive, dead… those words, absolute polarities, had seemed to fuse in my mind. The body I had dissected in first-year anatomy hadn't been anything like this
. It had been dead and hadn't even suggested being alive. It's the surroundings that make it bad, I had told myself, the crumbling dirty-gray room and the half-light, itself seeming foul and decayed as it struggled through grimy windows. What the hell do you want, Peters? A velvet bier, candles, and roses?
But that woman wasn't the patient we had come to see. I had pressed in among the white coats grouped around another examining table, and had caught glimpses of fleshy organs and heard gurgling noises as the pathology professor cut away, demonstrating his technique. I hadn't been able to see enough to appreciate the lesson, and, anyway, what had interested me was back over my shoulder. Everybody else had been transfixed by those organs; I couldn't stop looking at the wrong body. I hadn't wanted to touch her, but I had, and finding that she wasn't very cold had only made it worse. I hadn't been shocked anymore, just scared, and not because I had touched her but because she was slapping me in the face with the elementary fact that the difference between life and death was a matter of time and luck. Neither meant anything to her now. Scared, too, because she had been a young woman, perhaps desired and full of possibility, and now she was dead and yellow, lying on a stained cement slab in a dirty subterranean room. It was one thing to deal with sex when it hummed with life, warmth, and vigor. But I couldn't deal with this. My jumbled mind had registered a hundred thoughts; sex had undeniably been among them, my own memories of sexual love.
That had been a long time ago and six thousand miles away. Right now, I had to deal with the skinny old man's autopsy. "The family is over there, Doctor, on the couch," said one of the nurses when I reached the ward reception area. Two people seemed to appear suddenly where none had been before. As we approached each other, the word "autopsy" kept bringing back that brittle hair and herpes zoster. Maybe I should call it a "post-mortem"; sounds better.
"I'm sorry."
"It's all right, we expected it."
"We would like an autopsy." The word came quite naturally, after all.
"All right, it's the least we can do."
The least we can do? It puzzled me that they felt they had to do anything at all. I had felt rotten enough being the one to call them so late at night and say that their father was dead, and now I felt even more guilty asking for the autopsy permission. But apparently they felt guilty, too. Since no one can be blamed for death, everyone shares the guilt. The least we can do? I was making too much of a simple comment. What response had I expected from them? Accusations? Tantrums? Most people, I would learn, are simply struck numb by death and carried along by their ordinary, civil, reflexive behavior.
"We'll take care of the rest of the paper work, Doctor," one of the nurses offered.
"Thank you," I said.
"We appreciate what you've done, Doctor," said the son as I stepped away from the nurses' station.
"You're welcome." Nice people, I thought, walking away, and how lucky for me that they can't read my thoughts. Even now I felt an urge to go groping over the dead man's body for a pulse. If they knew my secret fear, would they be angry or just shocked? Shocked at first, probably, and then angry. But what would they think if their father woke up in the morgue? At that I smiled to myself, for of course hardly anybody gets taken to the morgue nowadays. Most go to a funeral home. Too many TV programs and bad movies. I was a fool, I mused, especially when I was tired, and at this point I was exhausted.
"Doctor, the phone is for you." The voice came after me as I was almost to the end of the dark hall. It must be Jan, I thought, and remembered suddenly how good she had looked standing naked in my room. Her image fused with the autopsy room in medical school, with that yellow body and the herpes zoster on the breast. But the call wasn't from Jan; it was from Ward A — another frantic nurse. Something about somebody's venous pressure going to zero. The skinny old man's son was still standing there. I caught his eye one last time, for an instant, and I suddenly felt proud to be there, and then foolish at my pride. Running the other way down the hall, I thought my situation was anything but glorious.
Venous pressure? My knowledge of it consisted of a dutifully memorized definition: "Venous pressure is the resting pressure in the large veins of the body." Other than that I knew almost nothing. Regardless, I rushed headlong, as if I knew everything. That was my job.
What little courage I had fell away when I saw that the nurses were gathered around Marsha Potts's room. Marsha Potts was the tragedy of the hospital. On rounds the very first day of my internship two weeks ago we had stood in her room as the story unfolded. Ulcer symptoms had bought her into the clinic, and there it had been, big as life, right on the X ray. It always made everybody happy when you could see an ulcer. The radiologist was pleased because he had gotten a good film, and the surgeons were ecstatic, complimenting one another on their diagnostic acumen and sharpening their scalpels. It was a fine time. Usually it was fine for the patient, too, but not for Marsha.
The doctors had performed a gastrectomy, taking out most of her stomach and sealing the end of the small intestine that normally leads out of the stomach. Then they had selected a point a few inches farther down the small intestine and, after making a hole, had sewed it to the little pouch made from the remains of the stomach, thus giving Marsha a new, if somewhat smaller, stomach. This operation, known as a Billroth II, entails an enormous amount of cutting and stitching, and is therefore popular with surgeons.
Marsha had sailed smoothly through it all — at least, everybody had thought so — until the third day, when the connection between intestine and stomach pouch broke down. This had allowed her pancreatic and gastric juices to leak out inside her abdomen, and she began to digest herself. The digestive enzymes literally ate their way up through the incision, and her abdomen became an open draining wound about twelve inches in diameter. The nurses kept it covered with baby food, in the attempt to absorb some of the pancreatic juice and neutralize the enzymes. For weeks now the putrid and penetrating smell had turned everybody's stomach. But for me the worst thing about the case was that I knew I couldn't handle it. No way.
When I entered the small room where she was isolated, the situation was as bad as it could be. Her skin was a terrible jaundiced gray, and her hands were flapping feebly by her sides. The nurse seemed relieved that a doctor had come, but, instead of gaining confidence from that, I could only think, Oh, you silly girl, if you could see into my mind you'd see nothing at all, a big void.
Marsha Potts had apparently suffered total body failure. Leafing through the stacks of charts and laboratory results, I tried to get some hint of what was going on and buy a little time to collect my wits. A large black cockroach clung to the wall over the bed, but I didn't bother it; we'd get it later. It was hard to imagine that life in any form depended on my thoughts.
Yet a bit of information was beginning to drift across my mind. The pulse, yes. I felt for it and found it strong and full, about 72 per minute, almost normal. Good. Now, if the venous pressure had gone to zero while the heart seemed to be working okay, it must mean there wasn't enough blood on the venous side. At least I was thinking. The last thing I wanted to do was remove the bulky, sodden dressing from her abdomen. Drops of perspiration rolled down my face. It was damn hot in here. Blood pressure? The nurse said it was 110/90. How the hell could her blood pressure and pulse be so good without venous pressure? With no venous pressure the heart wouldn't fill, and if it wouldn't fill nothing would come out, hence no blood pressure or pulse. That's how it was supposed to work, but obviously in this case it wasn't. Damn those physiology professors. In the medical-school physiology lab, they had a dog with tubes sticking out of his heart, arteries, and veins. Everything worked perfectly there, as it usually did in the laboratory. When the professors reduced the blood in the dog's heart by dropping the venous pressure, the dog's blood pressure followed suit and fell rapidly. It was automatic and reproducible, as if the dog were a machine.
Marsha Potts was no machine. Still, why couldn't she work like the animals in the laboratory, inst
ead of presenting me with an insoluble, overwhelming mess? I hardly knew where to start my examination. She didn't have any swelling of her skin from fluid retention, except on her backside — the usual place for such edema, as a result of lying in bed too long; Marsha had been flat on her back for about three months. I bent her left hand back, and it jerked forward. Fantastic. She had liver flap. When the liver fails, the patient develops a curious reflex: if you bend the hand back onto the wrist it jerks forward in a flapping movement, like a child waving bye-bye. Experiencing the joy of a positive finding, I looked again at the chart. Liver flap was not listed. I didn't know much about venous pressure, but I could write whole pages about liver flap, which I had found only once before. I tested her other hand, and the reflex worked again. It meant she was in very bad shape. In fact, while I was slipping into an academic appreciation of my diagnosis the woman was dying before my eyes.
In truth, she was already virtually dead; yet, technically, she was still alive. She had friends and a family who thought of her as a living person. But she couldn't talk, and every organ system was failing. Could she think? Probably not. In fact, for just a moment I knew she'd be better off dead, but I pushed the notion roughly away. How can you know someone's better off dead? You can't; if s sheer presumption. Marsha Potts's case was getting physically confusing, too. The woman with the herpes on her breast had looked alive but was in fact dead. The one in front of me in that small hot room was alive, but… What about the intravenous?
"How much IV fluid has she had over the last twenty-four hours?" I asked the nurse.