by Samuel Shem
‘No hard feelings, Jo,’ I said.
‘Good. Cardiology’s my specialty, I’m going on my Fellowship to the NIH in Bethesda in July, so stick with me and you’ll learn an incredible amount. In the Unit, we’ve got total control of all cardiac parameters. It’s high-pressure, but if we work hard, we save lives, and we have good fun. Let’s go.’
Just as Jo, the head nurse, and I were wheeling the chart rack to the first room, in skipped Pinkus, the Consultant to the Unit, ready to start his teaching rounds. Pinkus was a tall, emaciated-looking Staff cardiologist, heading toward forty. A TURF from the U. of Arizona to the BMS and the House of God, Pinkus was a legend, fanatic in his personal and professional life. Pinkus, it was said, rarely left the House. I myself had seen him, night after night, prowling the corridors, in the guise of following up consults on cardiac patients. Whatever the hour, I had found him patient, helpful, courteous, ready to produce an article, ready to put in a pacemaker, ready to chat. Such was his dedication to being in the House that an apocrypha had arisen about his home life: married, with three daughters, it was rumored that the only way that his wife or daughters knew he’d been home was to notice the toilet seat flipped to the UP mode.
The other part of Pinkus’ fanaticism was his obsession with cardiac-risk factors. Smoking, coffee, obesity, high blood pressure, saturated fats, cholesterol, and lack of exercise were like death to him. Rumored at one time to have been sedentary, anxious, overweight, stuffing doughnuts and slurping coffee, Pinkus now through much effort, was on the verge of emaciation, was phobic to cholesterol, and had run himself into incredible shape, for the past two years finishing close to the time of three hours in the April Marathon. Somehow Pinkus had managed to reduce the final risk-factor variable, personality type. In a total turnabout, he’d gone from Type A (anxious) to Type B (calm).
Pinkus and Jo, in a short excoriation of the fuck-up of rounds times, had reached the decision that on this day all rounds would be one rounds, beginning at once. Despite more pressing problems, both Pinkus and Jo were interested in the woman Jo had spent the night with, Pedley. A pleasant seventy-five, Pedley had been TURFED into the House by Putzel, for the usual, the bowel run, for complaints of burping and farting after Chinese food. The bowel run had been negative. Unfortunately, some red-hot noticed on the screening EKG that Pedley was walking around in V Tach, according to the textbooks, a ‘lethal arrythmia.’ Whisked by a nervous tern in the MICU, Pedley had fallen prey to Jo, who’d taken one look at the EKG, decided Pedley was dying, and had hooked up the electrodes of the cardioverter, and without anesthetic had burned the skin off Pedley’s chest. Pedley’s heart, affronted at having been jolted into normal sinus rhythm, stayed there for only a few minutes and reverted to the beat of its own drummer, V Tach. Frantic, Jo scorched Pedley’s chest four more times before Pinkus arrived and stopped the barbecue. For the past week Pedley had remained in V Tach. Except for the festering burns on her chest, she was fine, a LOL in NAD. Pinkus and Jo, sniffing a publishable article, had employed Pinkus’ fund of expertise: cardio-pharmaco-therapeutics. Pedley had been put on every cardiac drug, to no avail, and by the time I arrived Pinkus was into drugs only he would dare use, ranging from remedies for such noncardiac diseases as systemic lupus erythrematosis (an autoimmune disorder) to tinea pedis (athlete’s foot). Pedley, held prisoner and suffering the side effects of these meds, wanted out. Daily, Pinkus and Jo would coerce Pedley into a trial of something new. That day it was ‘Norplace,’ a derivative of the grease used to stick Ollie’s EKG monitor leads to a patient’s thorax.
‘Hello, dearie, how’s the gal today?’ asked Pinkus.
‘I want to go home. I feel fine, young man. Let me go.’
‘Do you have a hobby, dear?’ asked Pinkus.
‘You ask me that every day,’ said Pedley, ‘and every day I tell you: my hobby is my life outside of here. If I had known that Chinese food would lead to this, I’d never have called Putzel. Wait’ll I get my hands on him—he won’t visit me, you know. He’s scared of me.’
‘My hobbies are running and fishing,’ said Pinkus. ‘Running for fitness and fishing for calm. I heard you had Jo worried last night.’
‘She’s worried, I’m not. Let me go.’
‘There’s a new medicine I wish you’d try today, dear,’ said Pinkus.
‘No more medicines! That last one had me thinking I was a fourteen-year-old girl again in Billings, Montana. I came in here in good faith, and you’re giving me trips to Montana! No more meds for Pedley!’
‘This one will work.’
‘There’s nothing wrong with me for it to work on!’
‘Please, Mrs. Pedley, try it for us,’ pleaded Jo sincerely.
‘Only if you get me some fish chowder for lunch.’
‘Done,’ said Jo, and we left.
In the hallway, Pinkus turned to me and said, ‘It’s important to have a hobby, what’s yours, Roy?’
Before I had a chance to answer, Jo whipped our caravan forward again. Of the other five patients, none could speak. Each suffered in the throes of some horrible, incurable, lingering disease that would almost certainly kill, usually involving major organs like heart, lung, liver, kidney, brain. The most pathetic was a man who’d started with a pimple on his knee. Without culturing it, his House Private, Duck’s Ass Donowitz, had given him the wrong antibiotic, which had eradicated the bacteria that were containing the spread of the resistant staph in the pimple, allowing the staph to spread, producing total body sepsis, and turning a happy forty-five-year-old successful broker into an epileptic, mute, debilitated skeleton who could not speak because of the hole that had rotted through the cartilage of his trachea from his months on a respirator. In our rounds, he looked at me, dumbfounded and terrified, pleading to be saved. His only hope now would be the hope of a dream, his only solace, dreamsolace, a time when his dream of his voice, of his full life, would comfort him until the daily awakening to the nightmare of his crushed life. It was obvious malpractice by Donowitz. No one had told the man who’d started with the pimple on his knee that he could sue for millions. At his doorway, I heard his story from Jo in clipped dispassionate argot like Ollie’s. I saw his eyes fasten on me, a newcomer, someone who might bring a miracle, asking me to give him back his voice, his Saturday-afternoon game of squash, his piggyback rides under his kids. I was overwhelmed. As if by fate, with a little help from an incompetent and lazy doc, a man’s life had taken a sharp permanent turn down. I turned my head away. I never wanted to look into those mute eyes again.
He was not alone. Four more times I was shaken by the horror of ruined life. One after the other, totally immobilized, lungs run by respirators, hearts run by pacemakers, kidneys run by machines, brains run barely, if at all. It was terrible. The smell was that of lingering death: sickly-sour, feverish, sliding away far off on a horizon I could barely see. I didn’t want any part of it. I would not touch these putrid ones, no. It was all too sad for me.
Not for Jo. At each room she riffled her three-by-five cards and rattled off numbers, and then had the nurse hoist the body up to sitting, so she could listen to the chest. Pinkus looked distractedly out the window, unable to ask or tell about hobbies, and I felt dead inside. Jo asked me didn’t I want to listen to their chests, and reflexively, I did. The last was a second-year BMS student who, while on a pediatrics rotation, had caught a cold from a kid, which turned into a cough, then a flu, then a something beyond the realm of the known or the treatable that had hit his lungs, heart, liver, and kidneys and left him driven by respirator, pacemaker, and kidney machine. Despite this, despite the MICU’s ‘4-plussing’ him—going all-out—he was dying. The stubble on his cheeks was blond. Jo had the nurse hoist him up. put her stethoscope on him, and motioned for me to join in, I said I’d pass.
‘What?’ asked Jo, surprised. ‘Why?’
‘I’m afraid of catching what he caught,’ I said, leaving.
‘What? You’re a physician, you’ve got to. Come back h
ere.’
‘Jo, get off my back, huh?’
Later, Pinkus and I went down to lunch, leaving Jo to tend to the Unit. Pinkus always ‘brown-bagged’ it—brought his own—so he could regulate his diet while in the House. As he picked gently at his cottage cheese, alfalfa, and fresh fruit, he inquired first about my hobbies, telling me his were running for fitness and fishing for calm, and second about my attitude toward the cardiac-risk factors. In one lunchtime I learned more about how I was destroying my life, narrowing my coronary arteries, falling prey to the endemic atherosclerosis sweeping America, than I’d learned in four years at the BMS. Pinkus suggested that, given my clear family history, I had an obligation to exert as much control as possible over my cardiac destiny, by refraining from eating what I liked (doughnuts, ice cream, coffee), smoking what I liked (cigarettes, cigars), doing what I liked (lazing around), and feeling what I felt (anxious).
‘Even coffee?’ I asked, not aware of this risk factor.
‘Cardiac irritant. Latest Green Journal. Work done right here at the BMS by intern Howard Greenspoon.’
Finally, after a lengthy discussion of running, informing me that he was up to sixty miles a week at present in preparation for the Marathon in three weeks, Pinkus invited me to his office to feel his legs. We adjourned there, where he directed my examination. From the waist up, he was toothpickoid; from the waist down, Mr. Olympia. His quadriceps, hamstrings, and calves were sleek and rippling, fastened to tendons of steel.
Returning to the MICU, repulsed by the disease and boggled by the machines, I had an urge to escape. Jo cornered me, insisting that I learn how to pop a big needle into the radial artery of the wrist, a brutal, dangerous, and more or less unnecessary procedure. After that, I escaped as far as the staff room, saying I had to read up on the patients. I picked up the chart of the BMS with the total body wipe-out of unknown etiology, and started to read. He’d started with a sore throat, a cough, a cold, a slight fever. I had a sore throat, a cough, a cold, a slight fever. My red throat was a plowed field, getting a viral seeding from the BMS. I would catch what he had. I would die. I looked around me and realized it was the nursing change of shift. The nurses came in in their street clothes and used an alcove off the staff room, where there were lockers, to change. Since there was a mad crush at about three, when everyone rushed in, there were too many nurses for the alcove, and with a nonchalance, a few spilled out into the room, slipping out of their blouses and skirts or jeans, radiating the light of their bras and panties and other undies into the staff room, and then wrapping around the green cotton MICU uniform. Even the braless ones would spill out and change in my sight, smiling at my gawking, and I was thrilled with that ease of body I’d grown to know so well, that was somehow connected with doctors and nurses who dealt, day after day, with the decay of other human flesh.
I left. As I drove through the chill April rain, my mind stuck on the Unit. What about it had been so different?
Quintessence. That was it. The Unit was the quintessence. There, after all the sorting had been done, lay the closest representation, in living terms, of death. That was to have been expected. That was the bronze Zock plaque on the wall. And there, also, lay the closest representation, in living terms, of sex. I could not fail to notice. I did not pretend to understand. Amidst the dying, these nurses were flaunting life.
Berry asked me how it had been, and I told her that it had been different, high-powered, kind of like being part of the manned space program, but that it was also like being in a vegetable garden, only the vegetables were human. I was down about it because of course they were young and would die, but that didn’t matter because I too was going to die from whatever tropical virus had attacked the little BMS. Berry suggested that my fear of dying was yet another ‘medical-student disease’ and that she was more worried about my heart. Thinking of Pinkus, I said, ‘Oh, yeah, how’d you know I was going to key more on controlling my cardiac-risk factors?’
‘No, I don’t mean the mechanics, I mean the feelings. It’s been weeks since Potts’s suicide, and you haven’t said anything about it. It’s as if it didn’t happen.’
‘It happened. So?’
‘So he was a damn good friend of yours and now he’s dead.’
‘I can’t think about it. I got a new job to do, in the Unit.’
‘Amazing. In spite of everything that happens, there’s no past.’
‘What’s that supposed to mean?’
‘You and the other interns obliterate each day, in order to start the next one. Forget today today. Total denial. Instant repression.’
‘Big deal. So what about it?’
‘So nothing ever changes. Personal history and experience mean nothing. There’s no growth. Unbelievable: all across the country, interns are going through this, and going on each day as if nothing had happened the day before. “Forget it; all is forgiven; come home; love, the Medical Hierarchy.” It rolls on, greater than anyone’s suicide. That’s what makes a doctor. Terrific.’
‘I don’t see what’s so wrong with that.’
‘I know you don’t. That’s what’s so wrong. It isn’t the medical skills you learn, it’s the ability to wake up the next day as if nothing had happened the day before, even if what happened is a friend killing himself.’
‘There’s a helluva lot new to learn in the Unit. I can’t afford to think about Potts.’
‘Stop it, Roy—you’re not some dumb clod, you’re a person.’
‘Look, I’m not your red-hot intellectual anymore. I’m just a guy out to learn a trade and make a buck, OK?’
‘Wonderful. All the shadows have been taken from your sun.’
‘How can you ask me to think when tomorrow I’m gonna die?’
19
I awoke the next morning with my throat more sore. I drove to the House coughing, oblivious to all but the tightness in the center of my back. I was about to follow the BMS into a premorbid coma. Jo had just completed examining the night’s excretia, but before we started on work rounds, I insisted she listen to my chest. She said it was clear. Despite this, I was so worried I couldn’t concentrate, and TURFED myself to X Ray for films. I went over them with the radiologist, who said they were normal. I got beeped to the unit for a cardiac arrest, and ran on up.
It was the BMS. Fifteen people had crowded into his room: a Messarabian breathing him; a nurse perched on her knees on top of the bed pumping his chest, every systolic compression lifting her skirt to her waist; the Surgical Chief Resident with wiry black chest hairs curling up over the V-necked green scrubsuit; barely in the room, Pinkus and Jo. Pinkus had been paged from his morning trot, and was in track shoes and gym shorts, looking distractedly out the window. Jo was all icewater, eyes riveted to the EKG machine, choosing medications, barking orders to the nurses. In the midst of all this, the BMS was meat.
Despite all efforts, the BMS continued to die. As usual at arrests, as if at a dud party, after about half an hour people got bored and wanted to stop and call it a day and let the patient really die, the heart following after the dead brain like a car motor stopping a few internal combustions after the ignition had been turned off. Jo, angered at the idea of failure, shouted out: ‘With this kid we’re four-plussing it, all the way!’ and wouldn’t stop. When the heart finally did stop, Jo ordered the broiling of the chest, and when four shots of that didn’t work, she paused, at the end of her medical bag of tricks. This was where the surgeons began, and the Chief Resident, sensing the chance to turn carnage into drama, got hot and said, ‘Hey, want me to open the chest? Manual cardiac massage?’ Jo paused, and then, in the hush, said, ‘You bet. This kid walked in here. We’re going all out. Four-plus!’ The surgeon ripped the chest from armpit to armpit and spread the ribs. He grabbed the heart and began to pump it with his hand. Pinkus left the room. I stood, frozen. It was clear that the BMS was dead. What they were doing was being done for them. The surgeon, hand tired, asked me if I’d like to take over. Foggy, I did. I got my hand aro
und the back of the young lifeless heart and squeezed. Tough, slippery, the sinewy muscle was a leather bag, filled with blood, rolling in the steamy chest cavity, tied to the tubes of the major vessels. Why was I doing this? My hand hurt. I gave up. The heart lay like a grayish-blue fruit on a tree of bones. Sickening. The face of the BMS was blue, turning white. The gash in his chest was bright red, turning to a clotted black. We’d ruined his body, even as he’d died. As I left the room, I heard Jo yell out with crisp authority: ‘Any BMS students here? This is a chance you don’t often get in your training, to learn to massage the heart. Great teaching case. Come on.’ Sick, I retreated to the staff room, where the nurses were chattering, eating doughnuts, as if nothing had happened outside.
‘Glad to see you’re not wrecking your coronaries with doughnuts, Roy,’ said Pinkus. ‘I’ve tried to tell the girls, but they won’t listen. They’re lucky, of course, in that the estrogens lower their incidence.’
‘I’m not hungry,’ I said. ‘I think I’ve caught what the BMS had. I’m gonna die. I just timed my respirations: thirty-two a minute.’
‘Die?’ asked Pinkus. ‘Hmm. Say, did that BMS have a hobby?’
The head nurse picked up the chart, turned to the special section created by Pinkus, called ‘Hobbies,’ and said, ‘Nope. No hobby.’
‘There,’ said Pinkus. ‘See? No hobby. He didn’t have a hobby, do you understand? Do you have a hobby, Roy?’
With some alarm I realized that I did not, and said so.
‘You should have at least one. See, my hobbies are directed to the care of my coronary arteries: fishing, for calm, and running, for fitness. Roy, in my nine years on this Unit, I’ve never seen a Marathon runner die. Not of an MI, not of a virus, not of anything. No deaths, period.’
