by Robin Cook
Most of us didn't believe in the devil theory of history, or in an extreme notion of original sin, and so we knew that these older men we hated so much must have once been like us. At first idealistic, then angry, and then resigned, they had finally come to be mean as hell. At last the anger and frustration, held in so long, were gushing out in a gorgeous display of self-indulgence. And at whose expense? Who else? The sins of the fathers and grandfathers were visited on us, the sons of the system. Would it happen to me? I thought it would. Indeed, it had already started, because I had advanced beyond my period of medical-school idealism. I was no longer surprised that there were so few gentlemen among surgeons; in fact, the wonder of it to me was that any doctors at all came out as whole human beings. Apparently, few did. Not among them was El Almighty, whom I was about to face.
He slapped me on the back, wanting to know how every little thing was. It was as if he were going to give me candy or kiss my baby like a corrupt big-city politician gathering votes. Actually, he was gathering ego points. I was so tired I didn't care what he said or did. I kept my head down, scrubbing away, taking one step at a time. I put on the gown, and then the gloves. The scene around me was unreal. The surgeon's voice boomed on about nothing and everything, several decibels above everyone else. The anesthesiologist seemed to have either a special immunity or effective earplugs; oblivious to the surgeon, he went quietly about his business. Even the nurse ignored El Almighty. Whether he asked politely for a clamp or thundered for one, she would hand it to him in the same reserved efficient way and go on adjusting the instruments. I hoped he was listening closely to himself, because he apparently was his only audience.
The case turned out to be a reoperation for inflammation of the little pockets older people sometimes get in the lower colon. This unlucky patient had been operated on for his diverticulitis, as the condition is called, about a month before. Normally, a three-stage operation is recommended, but the first surgeon to operate on the fellow had tried to do it all at once. The result was a large abscess, which we were about to drain, and a fecal fistula, leading through the previous incision down into the colon, that was draining pus and feces.
Mercifully, the procedure was short. I tied a few knots, all unsatisfactory to the surgeon. Otherwise, I remained silent and immobile as he went on about the vicissitudes of his life when he was an intern. "Really tough in those days… do histories and physicals… every patient… through the door… and besides… quarter of the salary.. and you crooks get…" I hardly heard it. My exhaustion really made me immune, bouncing all his comments off my brain.
At the end I wandered out and changed into my regular clothes. It was almost four. A little afternoon sun had dodged the thick clouds and was sneaking in the window. The rays refracted and sparkled off the raindrops clinging to the window. It made me think of going surfing. But afternoon rounds were still to come; I wasn't free yet.
Descending to one of the private surgical wards, I saw my gall-bladder patient, who was doing fine. Blood pressure, pulse, urine output — all normal. The IV was going well, and orders were adequate for the night. I wrote in the chart and walked down to the other gall bladder, although I was sure the resident had seen her. And he had.
Stopping by X-ray, I asked a secretary to locate the aortogram taken on my aneurysm that morning, so I could have a quick look. The chief resident had apparently accomplished the job after his mighty struggle. The secretary found the films right away, and I began to put them up on the viewer. There were so many they would not all fit on the screen. Thank goodness the numbers allowed me to get them up in sequence. Now to find the problem— usually an educated guess for me. But this time even I could make out a sizable bulge in the aorta, just beyond the left subclavian artery. Catching sight of me in front of the X rays, the radiologist called me over to give me the usual pitch on portable films, with special reference to the hernia man of the night before. But this time I got the last word. The radiologist was subdued to learn that the patient had died. Perhaps he believed now that I couldn't have sent him up for a regular shot. I relished the victory, although of course I didn't think the X ray, good or bad, could have made any difference.
Everybody on ward service was under control. Both hernias were in good condition, already walking; the gastrectomy had taken a full meal; the veins were ready to go home in the morning; one of the hemorrhoids had had a bowel movement. My abscess patient, not unreasonably, wanted to know why I had squeezed his fingers, and the edema man asked again about his pills, wondering how they made him lose water. I humored both patients with overly simplistic answers.
Only one problem — a new patient, or, rather, a new-old patient, for me to work up. This man, a big decubitus ulcer, had a history of at least twenty-five previous admissions. One was for swallowing razor blades, others for attempted suicide by more traditional methods and for psychoneurohc-conversion reactions, convulsions, alcoholism, abdominal pain, gastric ulcer, appendicitis, liver incompetence — his chart was a checklist of primary and secondary diseases. He had also been in and out of the state mental hospital for ten years. Just the sort of patient I needed, in my freshness and good humor. Talking with him was impossible, because he was so intoxicated he could remember only wild, sketchy details about the previous few hours. Trying to examine him and go through the charts took over an hour. Then I had to clean out his ulcer, a process known by the romantic-sounding French word debridement.
Bent over his buttocks and staring into the black and oozing necrotic ulcer that he had contracted from lying in the same position too long, I wished I had studied law. With a law degree, I would already have been out earning a living for two years. A full wardrobe, an impressive office, crisp, clean papers, a secretary, long, full nights of sleep — all would have been mine. Not one of them was mine now. Instead, I was crouching over an alcoholic's smelly posterior snipping out dead tissue, trying to avoid the stench and discourage nausea. It had been exciting the first time in medical school, putting on that white coat and pretending I was a part of the seething, mysterious hospital complex. And how I'd envied the senior students and interns, with their stethoscopes and little black books and purposeful, knowledgeable ways. I had made it, slowly climbing the ladder of medicine and jumping the specific hurdles — until reality yawned before my eyes. Those buttocks were reality, the rear end of life, where I lived.
As I cut, the ulcer started to bleed a little at the edges. When the patient's knuckles turned white where he was gripping the sheets, and when he started to swear and pound the pillow, I decided that I had reached viable tissue. I squirted in some Elase, which was supposed to continue cleaning the wound by enzymatically breaking down the dead tissue; then I packed it with iodoform gauze. That iodoform gauze was not Chanel No. 5, but at least it dominated the other smells, changing them from sickly dirty to unpleasantly chemical. I preferred the chemical smell. The Elase? I didn't know whether it would work, but I put it in because of an article I'd read recently; it made me feel I was doing something scientific.
Before me now was the joy of afternoon rounds. No one liked these rounds, and few felt it was necessary for all of us to be there, because all essential arrangements were made by committee, so to speak. Nevertheless, we had afternoon rounds as if they were one of the Ten Commandments. Standing for long dreary minutes on one foot, then the other, we talked and gestured, indicating here a hemorrhoid, there a gastrectomy. We looked into all the wounds to make sure they were closed and not fiery red. The dressings were replaced rapidly, haphazardly, while the patients submitted like silent sacrifices on an altar. When one of them ventured a question, it was usually ignored, lost in the patter—"How many days since the operation?" "Should we switch to a soft diet or stay with full fluids?" Like the others, I presented my cases in a terse monotone. "Hemorrhoids, two days postoperative, wick out, no bleeding, no BM yet, normal diet."
We shuffled to the next bed; a couple of doctors seemed to become interested in a crack in the ceiling plaste
r near one of the lights. "Gastrectomy, six days postoperative, soft diet, has passed flatus but no BM, wound healing well, sutures out tomorrow, discharge anticipated." Somebody asked if the operation had been a Billroth I or II. Of course, he didn't give a damn; it was just one of those questions you always asked about a gastrectomy. "Billroth II."
Somebody else asked if there had been a vagotomy. "Yes, there was a vagotomy, and final path report was positive for neural tissue." The patient suddenly got interested and asked what a vagotomy was, but no one paid any attention. Instead, a resident asked if the vagotomy had been selective— another timely query that would lead into a maze. "No, it was not selective. The path report on the ulcer substantiated a preop diagnosis of peptic disease." By suddenly injecting concrete information not directly associated with the trend of the conversation, I had effectively changed the subject, and we shuffled on to the next bed.
Somnolently we went, growing tired and fidgety, and messing up all the dressings. The attending said that everything seemed to be under control and that he'd see us at the same time the following day. As in the sixth grade, in a game of spud, everybody scattered in all directions, except me. Apparently I had the ball, because I simply stood there, not thinking about anything in particular, just staring at the corner of a table that was tilted somehow and made the perspective look a little strange.
When I broke out of my semitrance, I was undecided about what to do. I could check on the private cases again, or I could sit around the ward and wait for new admissions, or I could go back and take a nap. The last option was immediately ruled out on superstitious grounds. If I went to sleep, I was sure to be called about some admissions, whereas if I stayed on the ward perhaps none would come in. A very scientific point of view. Anyway, I parked myself at the nurses' station and leafed through some back issues of Glamour one of the girls had left behind. I wasn't recording anything I saw. Flipping the pages and watching the patterns of colors as pictures mingled with print, I was lost in my own closed world, taking account of the sounds and motions around me but indifferent to them. One external event did penetrate my wall: it had started to rain again. Curiously, the sound of rain made me want to go surfing; a good wave or two might rinse away my depressing thoughts. I was overtired, and I knew that I'd be restless if I went directly to bed. Besides, there was a good hour of daylight left.
The rain fell cold on my bare back as I tied the board to the roof of the VW. Once in the car, I turned on the heater and strained to see out the window. It was raining quite hard, and the wipers were having trouble, as usual, keeping up with the water. I had great faith in VW's, except for the wipers. They never kept the window clear without distortion — curiously bad engineering on an otherwise reliable car.
As I drove toward the beach the rain increased, breaking my image of the road into blurs of gray and black. From time to time I strained my head out the side window to regain perspective. The passenger-side wiper was working a little better now, and I found I could see pretty well by leaning over that way. Somehow the rain began to comfort me, closing in the world a little and heavily dominating my awareness.
The rain felt even colder on my back as I struggled to get the surfboard off the rack. The heater in the car had not been a good idea. Once the board was off the car and on my head, however, I was protected from the icy drops. Eager to see the waves, I trotted across the street and onto the beach, but, of course, I could not see more than a few yards into the gray of air and sky. For the first time in my experience, the beach was completely deserted. Plopping the board in the water, I jumped on in a kneeling position and began to paddle out furiously, trying to generate some heat in my cold bones. The rain pelted down hard enough to hurt, my nose, forcing me to put my head down and peer ahead from under my eyebrows. The water was choppy and disorganized as I headed out. The farther I went, the more difficult it became to maintain speed and direction in the face of the strong onshore kona wind. Paddle, paddle, looking down, most of the time, at my board just in front of my knees. The water swept by in swirls. When the front of the board came out of the water, it would appear to be dry because of the wax, but then the board would go awash again as I leaned into another stroke.
Out in the surf, the beach, and the whole island, vanished in a misty wall of rain. This was storm surf, choppy, windy, and completely unpredictable. When I caught a wave, I couldn't tell how it would go, whether it would break or just disappear. Gone were the usual harmonic motions and familiar landmarks. I could have been a thousand miles at sea. The only sounds were those of wind, rain, and waves. My mind began to see fantastic shapes in the waves and in the unvarying gray curtain that hung over me. Imagining sharks patrolling under the disturbed surface of the water, I pulled my arms and legs up and lay flat on the board. A wave suddenly reared, broke, and turned me over. In a panic, I scrambled back on the board like a cat with his ears flattened, afraid to look back. I let the wave action and the wind push me toward shore as I searched for signs of the island, reassurance that I was not adrift on a lonely sea. Relief flooded over me as the hazy outline of a building took shape. My skeg scraped coral. Then the deserted beach appeared, its texture beaten by the rain into millions of miniature craters. A few people hurried along, grotesque and faceless blobs trying to shield themselves from the rain and wind.
Once in the car, I turned the heater back on, with wrinkled fingers, and felt its welcome heat rush out of the vent. I was blue and shivering by the time I headed back to the hospital, again leaning over to the passenger side to see out It was still raining very hard, and the lights of the other cars shot off the wet pavement in broken, scattered paths.
Happiness is a hot shower. Billows of warm vapor filled the stall, washing away the salt and the cold and the stupid little fears my tired mind had conjured up. I stayed there for almost twenty minutes, letting the warm water splash onto the top of my head and run down all the crevices and bumps of my body. As I relaxed, I began to think about how to pass the evening. Sleep. I should sleep. I knew that. But I also had a compulsion to get away from the hospital, to see someone. Karen had said she was not going out, after all. Karen. That was it: I'd park in front of her TV set, drink beer, and let my mind vegetate. Every other night I was off duty the telephone stayed quiet. It was a pleasure to know it wouldn't ring. Tonight was going to be one of the quiet nights. Ahhhh.
I dried myself, slowly and luxuriously, and then padded back to my room with a towel wrapped around my middle. The bed looked tempting, but I was afraid that if I slept for six hours or so and then got up, I wouldn't be able to drop off again. It was better to stay up and sleep later. Then the phone rang. In all innocence, I answered it. I shouldn't have, because it was the intern who was on call. He was in a jam and had to go home for an hour, maybe two at the most. It was a problem that couldn't wait.
"I'm sorry, Peters, but I've got to do it. Would you cover for me?"
"Is there any surgery scheduled?"
"No, none at all. Everything's quiet."
Though the idea of covering made me weak, I couldn't refuse. Ifs a part of the code to help, and who knew? — I might want the favor returned sometime.
"Okay, I'll cover for you."
"God, thanks, Peters. I'll let the operator know you're covering, and I'll be back as soon as possible. Thanks again."
Hanging up, I thought wearily that if I had to go to surgery I'd pass out. I was sure to go to pieces either mentally or physically if faced with a long session of any sort, especially a scrub with somebody like the Supercharger or Hercules or El Almighty Cardiac Surgeon.
In anticipation, I put on my whites, again hoping to ward off evil by excessive preparation. When I called Karen I got no answer, and I vaguely remembered her saying something about eleven, but I couldn't remember exactly. For lack of anything else to do, I lay down and opened a surgical textbook, propping it on my chest. Its weight made breathing a little difficult. Not really concentrating on the book, my mind wandered to Karen. What was s
he doing at seven o'clock if she wasn't out with her boyfriend? I couldn't say I had much reason to trust her. Still, what did I mean by trust? Why should the word enter into it at all? It was a bit adolescent to speak of trust when we were just a convenience to each other.
I had been lulled to sleep by my reveries when the phone woke me up. The blasted surgical text was still on top of my chest, and I was breathing with my abdominal muscles. It was the emergency room.
"Dr. Peters, this is Nurse Shippen. The operator says you're covering for Dr. Greer."
"That’s right." I reluctantly agreed.
"The intern on duty here is really behind. Would you come down and help out?"
"How many charts are waiting in the basket?"
"Nine. No, ten," she answered.
"Did the intern actually ask for help?" Hell, I'd been ten charts behind every Friday and Saturday night during my months on the emergency service.
"No, but he's quite slow, and—"
"If he gets behind about fifteen or so, and if the intern himself asks for me, then call back."
I hung up, stuffed to the eyeballs with those ER nurses, always pretending to run the show and make the decisions. The ER was that intern's territory; perhaps he would be angry if I suddenly appeared. There was a grain of truth and a pound of rationalization in that, I suppose. Still, during my two months in the emergency room, not once had I asked for help from the on-call intern. I couldn't imagine its being uncontrollably crowded and busy on a Wednesday night. I tried to read a little more, making no headway and growing more nervous and upset. My hands shook slightly — something new — as I balanced the book on my chest. My thoughts raced around disconnectedly from surgery to Karen to the lousy time I had had surfing and back to surgery. Getting up, I went to the toilet, indulging a slight diarrhea— not unusual with me these days.
When the phone rang again, it was the same officious ER nurse saying with satisfaction that the intern had requested help. It so pissed me off that I didn't say anything, just hung up. Before I could even get out of the room, the phone rang once more. It was the nurse asking huffily whether I was coming or not. I summoned as much acid as possible and said that I'd be there if they could possibly handle things while I put on my shoes. It had no effect. She was beyond insult, and I was almost beyond caring, in no hurry to rush over; perhaps by the time I got there things would be quiet. I wouldn't have minded doing a quiet suture or two, something like that. But I was sure to get slugged with a freeway wreck or convulsion.
