by Robin Cook
“I’d like some epinephrine, please,” said Dr. Kingsley. “But it doesn’t look good. I think this patient arrested some time ago.”
Jerry Donovan thought about saying he had the same impression but decided against it.
“Call the EEG lab,” said Dr. Kingsley, continuing to massage the heart. “Let’s see if there’s any brain activity at all.”
Trudy went to the phone.
Dr. Kingsley injected the epinephrine but could see that there was no effect on the EKG. “Whose patient is this?” he asked.
“Dr. Ballantine’s,” said Pamela.
Bending over, Dr. Kingsley peered into the wound. Jerry guessed he was assessing the surgical repair. It was common hospital knowledge that on a scale of one to ten, as far as operative technique was concerned, Kingsley was a ten, and Ballantine, despite the fact that he was chief of the cardiac surgery department, was about a three.
Dr. Kingsley abruptly looked up and stared at the medical student as if he’d seen him for the first time. “How can you tell at the moment this isn’t a case of an AV block, Doctor?”
All color drained from the student’s face. “I don’t know,” he managed finally.
“Safe answer,” smiled Dr. Kingsley. “I wish I had had the courage to admit not knowing something when I was a medical student.” Turning to Jerry he asked: “What are his pupils doing?”
Jerry moved over and lifted Bruce’s eyelids. “Haven’t budged.”
“Run in another amp of bicarbonate,” ordered Dr. Kingsley. “I assume you gave some calcium.”
Jerry nodded.
For the next few minutes there was silence as Dr. Kingsley massaged the heart. Then a technician appeared at the doorway with an ancient EEG machine.
“I just want to know if there’s any electrical activity in the brain,” said Dr. Kingsley. The technician attached the scalp electrodes and turned on the machine. The brain wave tracings were flat, just like the EKG.
“Unfortunately, that’s that,” said Dr. Kingsley as he withdrew his hand from Bruce’s chest and stripped off his gloves. “I think someone better call Dr. Ballantine. Thank you for your help.” He strode from the room.
For a moment no one spoke or moved. The EEG technician was first. Self-consciously he said he’d better get back to the lab. He unhooked his paraphernalia and left.
“I’ve never seen anything like that,” said Peter, staring at Bruce’s gaping chest.
“Me neither,” agreed Jerry. “Kinda takes your breath away.”
Both men stepped up to the bed and peered into the wound.
Jerry cleared his throat. “I don’t know what you need more, competence or self-confidence, to cut into someone like that.”
“Both,” said Pamela, pulling the plug on the EKG machine. “How about you fellows giving us some room to get this place in order. By the way, one thing I forgot to mention. When I found Mr. Wilkinson, his IV was running rapidly. It should have been barely open.” Pamela shrugged. “I don’t know if it was important or not but I thought I’d let you know.”
“Thanks,” said Jerry absently. He wasn’t listening. Daintily he stuck his index finger into the wound and touched Bruce’s heart. “People say Dr. Kingsley is an arrogant son of a bitch, but there is one thing I know for sure. If I needed a bypass tomorrow, he is the one I’d have do it.”
“Amen,” said Pamela, pushing her way between Jerry and the bed to begin preparation of the body.
One
“There was one new admission last night,” said Cassandra Kingsley, glancing down at her preliminary work-up. She felt distinctly ill at ease, having been thrust into the spotlight of the early morning team meeting on the psychiatry ward, Clarkson Two. “His name is Colonel William Bentworth. He’s a forty-eight-year-old Caucasian male, thrice divorced, who’d been admitted through the ER after an altercation in a gay bar. He was acutely intoxicated and abusive to the ER personnel.”
“My God!” laughed Jacob Levine, the chief psychiatric resident. He took off his round, wire-rimmed glasses and rubbed his eyes. “Your first night on psychiatry call and you get Bentworth!”
“Trial by fire,” said Roxane Jefferson, the black, no-nonsense head nurse for Clarkson Two. “No one can say psychiatry at the Boston Memorial is a boring rotation.”
“He wasn’t my idea of a perfect patient,” admitted Cassi with a weak smile. Jacob’s and Roxane’s comments made her feel a bit more relaxed, sensing that if she made an ass of herself with her presentation, everyone would excuse her. Bentworth was no foreigner to Clarkson Two.
Cassi had been a psychiatry resident for less than a week. November wasn’t the usual time for people to begin a residency, but Cassi had not decided to switch from pathology to psychiatry until after the beginning of the medical year in July and had only been able to do so because one of the first-year residents had quit. At the time Cassi thought she’d been extraordinarily lucky. But now she wasn’t so sure. Starting a residency without other colleagues equally as inexperienced was more difficult than she’d anticipated. The other first-year residents had almost a five-month jump on her.
“I bet Bentworth had some choice words for you when you showed up,” sympathized Joan Widiker, a third-year resident who was currently running the psychiatric consultation service and who had taken an immediate liking to Cassi.
“I wouldn’t want to repeat them,” admitted Cassi, nodding toward Joan. “In fact he refused to talk with me at all, other than to tell me what he thought of psychiatry and psychiatrists. He did ask for a cigarette, which I gave him, thinking it might relax him, but instead of smoking it he proceeded to press the lighted end against his arms. Before I could get some help, he’d burned himself in six places.”
“He’s a charmer all right,” said Jacob. “Cassi, you should have called me. What time did he come in?”
“Two-thirty A.M.,” said Cassi.
“I take that back,” said Jacob. “You did the right thing.”
Everyone laughed, including Cassi. For once there wasn’t that substratum of hostile competition that had colored all her years of training. And none of the half-respectful, half-jealous commentary that had surrounded her relations at Boston Memorial since her marriage to Thomas Kingsley. Cassi hoped she would be able to repay their support.
“Anyway,” she said, trying to organize her thoughts. “Mr. Bentworth, or I should say Colonel Bentworth, U.S. Army, presented with acute alcohol intoxication, diffuse anxiety alternating with a depressionlike state, fulminating anger, self-mutilating behavior, and an eight-pound chart of his previous hospitalizations.”
The group erupted with renewed laughter.
“One point to Colonel Bentworth’s credit,” said Jacob, “is that he has helped train a generation of psychiatrists.”
“I had that feeling,” admitted Cassi. “I tried to read the most important parts of the chart. I think it’s about the same length as War and Peace. At least it kept me from making a fool of myself and hazarding a diagnosis. He’s been classified as a borderline personality disorder with occasional brief psychotic states.
“On physical examination he had multiple contusions on his face and a small laceration of his upper lip. The rest of the physical examination was normal except for his recent self-inflicted burns. There were slight scars across both wrists. He refused to cooperate for a full neurological exam, but he was oriented to time, place, and person. Since the present admission mirrored the last admission in terms of symptoms and since amytal sodium was used on the previous admission with such success, half a gram was given slowly IV.”
At almost the exact instant that Cassi finished her presentation, her name floated out of the hospital page system. By reflex she started to get up, but Joan restrained her, saying the ward clerk would answer.
“Did you think Colonel Bentworth was a suicide risk?” asked Jacob.
“Not really,” said Cassi, knowing she was hedging. Cassi was well aware that her ability to estimate suicide risk wa
s approximately the same as the man in the street’s. “Burning himself with his cigarette was self-mutilating rather than self-destructive.”
Jacob twirled a lock of his frizzed hair and glanced at Roxane, who had been on Clarkson Two longer than anyone else. She was recognized as an authority of sorts. That was another reason why Cassi enjoyed the psychiatry service. There wasn’t the stiff structure that existed elsewhere in the hospital, with physicians implacably at the top. Doctors, nurses, aides, everyone was part of the Clarkson Two team and respected as such.
“I’ve tended to ignore the distinction,” said Roxane, “but I suppose there is a difference. Still we should be careful. He’s an extremely complex man.”
“That’s an understatement,” said Jacob. “The guy had a meteoric rise in the military, especially during his multiple tours of duty in Vietnam. He was even decorated several times, but when I looked into his army record, it always seemed as if a disproportionate number of his own men were killed. His psychiatric problems didn’t seem to show up until he’d reached his present rank of colonel. It was as if success destroyed him.”
“Getting back to the risk of suicide,” said Roxane, turning to Cassi. “I think the degree of depression is the most important point.”
“It wasn’t typical depression,” said Cassi, knowing she was venturing out on thin ice. “He said he felt empty rather than sad. One minute he acted depressed and the next he’d erupt with anger and abusive language. He was inconsistent.”
“There you go,” said Jacob. It was one of his favorite phrases, and its meaning was related to how he stressed the words. In this instance he was pleased. “If you had to pick one word to characterize a borderline patient, I think ‘inconsistency’ would be the most appropriate.”
Cassi happily absorbed the praise. Her own ego had had very little to feed on during the previous week.
“Well, then,” said Jacob. “What are your plans for Colonel Bentworth?”
Cassi’s euphoria vanished.
Then one of the residents said, “I think Cassi should get him to stop smoking.”
The group laughed and her tension evaporated.
“My plans for Colonel Bentworth,” said Cassi, “are…” she paused, “that I’m going to have to do a lot of reading over the weekend.”
“Fair enough,” said Jacob. “In the meantime I’d recommend a short course of a major tranquilizer. Borderlines don’t do well on extended medication, but it can help them over transient psychotic states. Now then, what else happened last night?”
Susan Cheaver, one of the psychiatric nurses, took over. With her usual efficiency, Susan summarized all the significant events that had taken place since late afternoon the previous day. The only happening out of the ordinary was an episode of physical abuse suffered by a patient called Maureen Kavenaugh. Her husband had come for one of his infrequent visits. The meeting had seemingly gone well for a while, but then there were angry words followed by a series of vicious openhanded slaps by Mr. Kavenaugh. The episode occurred in the middle of the patient lounge and severely upset the other patients. Mr. Kavenaugh had to be subdued and escorted from the ward. His wife had been sedated.
“I’ve spoken with the husband on several occasions,” said Roxane. “He’s a truck driver with little or no understanding of his wife’s condition.”
“And what do you suggest?” asked Jacob.
“I think,” said Roxane, “that Mr. Kavenaugh should be encouraged to visit his wife but only when someone can be with them. I don’t think Maureen will be able to retain a remission unless he’s brought into the therapy in some capacity, and I think it’s going to be hard to get him to cooperate.”
Cassi watched and listened as the whole psychiatric team participated. After Susan had finished, each of the residents had an opportunity to discuss their patients. Then the occupational therapist, followed by the psych social worker, had a chance to speak. Finally Dr. Levine asked if there were any other problems. No one moved.
“Okay,” said Dr. Levine, “see you all at afternoon rounds.”
Cassi did not get up immediately. She closed her eyes and took a deep breath. The anxiousness engendered by the team meeting had hidden her exhaustion, but now that the excitement was over she felt it with a vengeance. She’d had only three hours of sleep. And for Cassi rest was important. Oh, how nice it would have felt to just lay her head down on her arm right there on the conference table.
“I bet you’re tired,” said Joan Widiker, placing her hand on Cassi’s arm. It was a warm, reassuring gesture.
Cassi managed a smile. Joan was genuinely interested in other people. More than anyone, she had taken time to make Cassi’s first week as a psychiatry resident as easy as possible.
“I’ll make it,” said Cassi. Then she added: “I hope.”
“You’ll make it fine,” assured Joan. “In fact you did marvelously this morning.”
“Do you really think so?” asked Cassi. Her hazel eyes brightened.
“Absolutely,” said Joan. “You even drew a compliment of sorts out of Jacob. He liked your description of Colonel Bentworth as inconsistent.”
“Don’t remind me,” said Cassi forlornly. “The truth is I wouldn’t know a borderline personality disorder if I met one at dinner.”
“You probably wouldn’t,” agreed Joan. “Nor would many other people, provided the patient was not having a psychotic episode. Borderlines can be fairly well compensated. Look at Bentworth. He’s a colonel in the army.”
“That did bother me,” said Cassi. “It didn’t seem to be consistent, either.”
“Bentworth can upset anyone,” said Joan, giving Cassi’s arm a supportive squeeze. “Come on. I’ll buy you some coffee in the coffee shop. You look like you could use it.”
“I can use it all right,” agreed Cassi. “But I’m not sure I should take the time.”
“Doctor’s orders,” said Joan, getting up. As they walked down the corridor, she added, “I got Bentworth when I was a first-year resident, and I had the same experience as you did. So I know how you feel.”
“No kidding,” said Cassi, encouraged. “I didn’t want to admit it at the meeting, but I found the colonel frightening.”
Joan nodded. “Look, Bentworth’s trouble. He’s vicious, and he’s smart. Somehow he knows just how to get at people: find their weaknesses. That power, combined with his pent-up anger and hostility, can be devastating.”
“He made me feel completely worthless,” said Cassi.
“As a psychiatrist,” corrected Joan.
“As a psychiatrist,” agreed Cassi. “But that’s what I’m supposed to be. Maybe if I could find some similar case histories to read.”
“There is plenty of literature,” said Joan. “Too much. But it’s a little like learning to ride a bike. You could read everything about bicycles, for years, yet when you finally tried to ride it yourself, you wouldn’t be able to. Psychiatry is as much a process as it is knowledge. Come on, let’s get that coffee.”
Cassi hesitated. “Maybe I should get to work.”
“You don’t have any scheduled patient meetings right now, do you?” asked Joan.
“No, but…”
“Then you’re coming.” Joan took her arm and they started walking again.
Cassi allowed herself to be led. She wanted to spend a little time with Joan. It was encouraging as well as instructive. Maybe Bentworth would be willing to talk after a night’s rest.
“Let me tell you something about Bentworth,” said Joan, as if reading Cassi’s mind. “Everyone that I know who has taken care of him, myself included, was certain they would cure him. But borderlines in general and Colonel Bentworth in particular don’t get cured. They can get progressively better compensated but not cured.”
As they passed the nurses’ station, Cassi left Bentworth’s chart and asked about her page. “It was Dr. Robert Seibert,” said the aide. “He asked for you to call as soon as possible.”
“Who’s Dr.
Seibert?” asked Joan.
“He’s a resident in pathology,” answered Cassi.
“As soon as possible sounds like you’d better call,” said Joan.
“Do you mind?”
Joan shook her head, and Cassi went around the counter to use the phone next to the chart rack. Roxane came over to Joan. “She’s a nice kid,” the nurse said. “I think she’s going to be a real addition around here.” Joan nodded, and they both agreed that Cassi’s insecurity and anxiety were a function of her commitment and dedication.
“But she worries me a little,” added Roxane. “She seems to have a special vulnerability.”
“I think she’ll be fine,” said Joan. “And she can’t be too weak being married to Thomas Kingsley.”
Roxane grinned and walked down the hall. She was a tall, elegant black woman who commanded respect for her intellect and sense of style. She’d worn her hair braided in corn rows long before it was fashionable.
As Cassi put down the phone, Joan eyed her carefully. Roxane was right. Cassi did seem delicate. Perhaps it was her pale, almost translucent skin. She was slender but graceful, only slightly over five-feet-two. Her hair was fine and varied in color from a shiny walnut to blond depending upon the angle and the light. At work she wore it loosely piled on her head, held in place with small combs and hairpins. But because of its texture, wisps spilled down around her face in gossamer strands. Her features were small and narrow, and her eyes turned up ever so slightly at the outer corners, giving them a mildly exotic appearance. She wore little makeup, which made her look younger than her twenty-eight years. Her clothes were always neat even if she’d been up most of the night, and today she was dressed in one of her many high-necked white blouses. To Joan, Cassi appeared like a young woman in an old Victorian photograph.
“Instead of going for coffee,” said Cassi with enthusiasm, “how about coming with me to pathology for a few minutes?”
“Pathology,” said Joan, with some reluctance.
“I’m sure we can get coffee up there,” said Cassi, as if that was the explanation of Joan’s hesitation. “Come on. You might find it interesting.”
