by Robin Cook
The rain had passed overhead, and a star or two twinkled between the black violet hulks of heavy clouds. The wind had shifted again, back to the trades, blowing away the kona weather.
Upon reaching the ER, I had to admit that things were far from calm. A medical intern and two residents were working away. In addition, four or five attendings were there seeing their own patients. One of the nurses handed me a chart and said that this fellow had been waiting for some time; they hadn't been able to reach his private physician. I took the chart and headed for the examining room, reading as I went. Chief complaint was "Nervousness; ran out of pills." Christ! I stopped and looked closer at the chart. The private doctor was a psychiatrist; no wonder they couldn't locate him. And the patient, a thirty-one-year-old male, was in the psych room. That was back the other way, to the right. Just my luck, I thought, a psych patient. Why not a simple scalp laceration — something I could fix — instead of an inside-the-head job?
As I walked into the psych room and sat down, I faced a youngish-looking man sitting on the bed. The bed and the straight-backed chair I was in were the only two pieces of furniture in an otherwise plain, white-walled room. Both bed and chair were securely fastened to the floor. It was spotlessly clean in there, and quite bright from a bank of white fluorescent lights built into the ceiling. After glancing at the chart again, I looked at him. He was a reasonably good-looking fellow with brown hair, brown eyes, and neatly combed hair. His hands were clasped in front of him, giving the only hint of his nervousness; they worked against one another as if he were molding clay in the palms of his hands.
"Not feeling well?" I asked.
"No. Or, yes, I'm not feeling too well," he replied, putting his hands on his knees and looking away from me. "I suppose you're an intern. Isn't my doctor coming?"
I looked at him for a few seconds. I had learned that letting them talk was the best thing, but it became apparent he wanted me to answer his questions. "Yes, I'm an intern," I said, a bit defensively. "And no, we can't reach your doctor. However, I believe we can help you now, and you can see your own doctor later, perhaps tomorrow."
"But I need him now," he insisted, taking out a cigarette, which I allowed him to light. Psych patients could smoke if they wanted to; there was no oxygen in this room.
"Why don't you tell me something about what's bothering you, and either I or the psychiatry resident will be able to help." I was certain I couldn't get the psychiatry resident to come in, but I could probably get him on the phone.
"I'm nervous," he said. "I'm nervous all over, my whole body, and I can't sit still. I'm afraid I'm going to do something."
There was a pause. He was looking at me again, steadily. Although he had lit the cigarette, he did not raise it to his mouth, but held it between his second and third fingers, with its trail of smoke snaking up past his face. His eyes, wide open, showed relatively dilated pupils. Moisture glistened at the hairline above his forehead.
"What kind of thing are you afraid you'll do?" I wanted to give him all the rope he'd take. Besides, I didn't really care whether I sat there for a long time or not. The other ER problems, out in the pandemonium, would get solved without me. Served them right for giving me a psych patient.
"I don't know what I might do. That's half the problem. I just know that when I get this way I don't have too much control over what I think… over what I think. Think." He was looking straight ahead at the white wall, staring without blinking. Then he made a sudden grimace, his mouth forming a tight slit.
"How long have you been having this type of problem?" I asked, trying to break the trance, to keep him talking. "How long have you been under the care of a psychiatrist?"
At first he seemed not to hear me at all, and I was about to repeat my question when he turned toward me once more. "About eight years. I have been diagnosed as a schizophrenic, paranoid type, and I've been hospitalized twice. I have been under a psychiatrist's care ever since the first hospitalization, and doing well, especially over the last year or so. But tonight I feel like I did a number of years ago. The only difference is that now I know what is happening. That's why I need more Librium, and why I must see my doctor. I have to stop this before it gets out of control."
His insight surprised me. I surmised that he had been under quite intensive care, maybe even psychoanalysis. He was intelligent, without a doubt. Although I was a novice at this sort of thing, I knew enough to try to keep him talking and communicating. It would have been easy just to give him some more Librium and wait for it to take effect or not. But I was interested now, partly in him and partly in his ability to keep me out of the rest of the ER. In the background I picked up the wail of a screaming child. "What necessitated your hospitalization?" I asked.
He responded eagerly. "I was in college, in New York, and having some mild difficulties with my studies. I was living at home with my mother. My father died when I was a baby. Then, during my second year of college, my mother started having an affair with this man, which bothered me, although at first I didn't know why. He was very gentlemanly, handsome and pleasant and all that. I suppose I should have liked him. But I didn't. I know that now. In fact, I hated him. At first I kept telling myself I liked him. I mean I was attracted to him. I know that now, too."
I was beginning to get the picture — the same one that psychiatry had given him, a framework for his anxieties. Now that I had him started, he kept going.
"And my mother, well, I began to hate her, too, for several reasons. It was hate on an unconscious level, of course. One reason was for starting up with this man and leaving me out in the cold, and the other for keeping him to herself. I think I had latent homosexual tendencies. But I loved my mother. She was the only person I was close to at all. I didn't have many friends — never had — nor did I find much enjoyment in dating. Well, then President Kennedy was killed, and I heard it was some young guy. I was riding in the subway coming home from school at the time, and I could see the newspapers all around me: KENNEDY ASSASSINATED BY YOUNG MAN. I Was nervous, had been for days, and all of a sudden, since I was a young man, I decided, don't ask me how, that I had been the one who killed Kennedy. The next couple of days were just hell, as much as I can remember about them. I didn't go home. I was terrified that everybody was out to get me. What made it worse, people were crying everywhere. I was worried that they would find out about me being the murderer, so I just kept running, for two days, apparently, afraid of every person I saw, and, believe me, it's hard to get away from people in New York. Luckily, I ended up in a hospital. It took me almost a year to calm down, and another year of intensive care to understand what had happened to me. Then things went…"
Suddenly he stopped dead in the middle of the sentence and stared at the wall again. Then he looked at me and asked, "Would you take my blood pressure? I'm worried if s too high."
I didn't mind taking his blood pressure, but the room held no equipment. I went out for a pressure cuff, slightly dazed by the sudden, concise, and overwhelming history of a paranoid schizophrenic. On my way back, a nurse tried to give me another chart, but I waved her off, saying that I wasn't finished with my present patient.
Back in the room, my patient had his sleeve rolled up in anticipation. He was intensely interested as I put the cuff around his arm, and he tried to see the gauge when I pumped it up. His pressure was 142/96. I told him it was slightly elevated, but consistent with his agitation. Actually, I was a little surprised at its height. Then I asked him what had happened after he got out of the hospital.
"Which time?" he asked.
"You were hospitalized more than once?"
'Twice. I told you."
"What happened after the first hospitalization?"
"Everything went fine. I saw my psychiatrist regularly. Then, out of the clear blue sky, I started getting nervous, like now, and it got worse and worse, until I had to go back in the hospital for another four months."
"How long was the interval between hospitalization?" I aske
d.
"About a year and a half. The real problem was that we could never figure out why it happened the second time. I wasn't paranoid, just nervous. I had what they call all-pervading anxiety. Then my psychiatrist started to talk about pseudoneurotic schizophrenia, but I didn't understand that so well, even though I read a lot about it. That’s why this situation worries me so much. I'm nervous now, really nervous. I have that same anxiety like before I went into the hospital the second time, and I can't stand it. I don't want things to go crazy again. I don't know why I should be feeling like this now. Everything has been going fine lately. Even my business is good."
I realized that he must have been psychologically well compensated. He had been able to make a new home in Hawaii and even to start a business. Oddly, I felt nervous, too, but of course, for different reasons and to a different degree. I was exhausted, but my trouble could be cured with a little sleep and relaxation. His was long-term, and, besides, he was worried that he might go suddenly out of control. A nurse opened the door, started to say something, and then closed it when she saw us talking.
"Do you have many friends here?" I asked.
"No, not really. I've never had very many friends. I prefer to stay home and read. I just don't enjoy going out and sitting in bars and drinking. It seems like such a waste of time. I guess I don't have very much in common with other people. I like to surf now and then, and I have a couple of guys I go surfing with, but not always. Most of the time I surf by myself..
That amused me for a moment. A schizophrenic surfer. But in some ways his style was a little like mine. "How about your mother? Where is she these days?"
"She's back in New York. She married that fellow she had been going with. My psychiatrist suggested I go away for a while. That's why I came to Hawaii. It certainly has changed my life for the better."
I got up and walked over toward the door. One of my legs had begun to go to sleep, and my foot was tingling. "What kind of business are you in?"
"Photography," he answered. "I'm a photographer, a free lance, but I also do some industrial work. That's what keeps me busy." He got up to stretch and walked toward the other end of the room, near the chair. I turned around, put my hands behind my back, and leaned on the door. He seemed a little calmer, slightly relieved of his anxiety.
"What about women?" I asked, a little hesitantly, wondering what had become of those latent homosexual tendencies he mentioned earlier.
He looked at me briefly after the words left my mouth, and then he sat down in the chair, looking at the floor. "Fine, just fine. Never better. In fact, I'm getting married very soon to a fine girl. That's why I want to be sure everything is all right with me. I don't want to spend any more time in the damn hospital. Not now."
I could understand his concern. By voicing it, he had suddenly moved the conversation to a more personal plane. Not that we hadn't been talking very personally already; but the fact that he connected a desire to get married with his mental difficulties made it easier for me to understand and empathize with him. After all, if he could pull it off and establish a real relationship with his fiancee, she might be the means to a permanent compensation. At least, it was a chance. Unlike many mentally disturbed people, this guy was really trying. I liked that. I sat down on the bed, near the chair he was in.
"That’s good," I said. "You're overcoming your basic problem."
"Yeah, it's wonderful," he repeated, without much emotion.
The fact that schizophrenics display blunted affects appeared in my mind from some dim psychiatry lecture. It gave me a momentary feeling of understanding and academic pleasure.
"When are you getting married?" I asked, to see if I could get any emotional response from him.
"Well, that’s one of the problems," he said. "She hasn't really set a date yet."
That comment set me back somewhat. "But she has agreed to marry you, hasn't she?"
"Certainly she has. But she just hasn't decided exactly when we should get married. In fact, I was planning to ask her again tonight if we could get married during the summer. I'd like to get married this summer."
"Well, why don't you?" I asked. I began to formulate a definite impression of a case of a schizophrenic's hypersensitivity toward any sign of rejection. Perhaps his anxiety had risen because he was afraid of being rejected by the girl. All signs led to it.
"I can't tonight," he said.
"Why not?" This was a crucial point. If things went smoothly, he could be golden; but if she rejected him, it could be devastating. He knew it, too.
"Because she called this morning and said she couldn't see me tonight. When I asked her why not, she just said she had something important to do. She does that every so often."
I knew he was in a difficult position. The more he pushed, the more he came to. depend on his fiancee for mental stability. I didn't know what to say. We had reached a sort of impasse, and I thought now might be the time to give him some Librium or something. Then he started talking again.
"Maybe you know her," he said. "She's a nurse in this hospital."
"What's her name?" I was curious.
"Karen Christie," he said. "She lives very close to the hospital, just across the street."
His words smashed into my brain, tearing down carefully constructed walls of defense and carrying everything away. I felt my jaw drop open involuntarily and a glaze cover my eyes, reflecting the confusion and disbelief inside. I struggled hard to regain my outward composure. He was sunk too deep in his own troubles to notice my discomfort. He went on, describing his relationship with Karen. Now, twenty seconds after the revelation, I was outwardly calm again, and listening, but inside, my own urgent messages robbed his words of all meaning. We were like two men discussing the same subject, but in different languages.
So here was the "boyfriend," the "fiance." I was sharing Karen with a schizophrenic who depended totally on her for mental equilibrium, whose world fell apart when that compensation was denied him, as it had been by Karen's decision to stay home with me tonight. In a grotesque but very real way, we had exchanged roles: he was now the therapist and I the patient. How fitting that I sat on the bed and he was in the chair. About a half hour earlier, I had felt rejected because Karen could only see me late at night, after eleven. At the same time, I had illogically blessed my luck that she had another man willing to take her out, but bringing her home in time for beer and sex with me. The fact that I had been sharing a role with a schizophrenic made it tempting to identify with him, to see myself in the same light. I wondered how much of my own personality was schizophrenic. But surely I wasn't schizophrenic; my grasp of reality was too good. I couldn't believe I had any delusions, because, if anything, I was the realist, especially about my role as a intern. Besides, I never hallucinated. I would have known, I thought. Wouldn't I have known?
It suddenly got through that he was looking at me as if expecting an answer. With my eyes, I asked him to say it again.
"Do you know her?" he was repeating.
"Yes," I said mechanically. "She works days."
We began to speak and think in different languages once more, as he went on drawing out the story of his half life with Karen and I retreated into my speculations. No, I most certainly was not schizophrenic, but perhaps was tending toward schizoid. Searching back through lectures and pages of textbooks, I tried to remember the characteristics of schizoid personality. Most such cases, I remembered, avoided close or prolonged relationships. Did that fit me? Yes, most definitely, of late. Certainly no one would describe my associations with Karen, Joyce, or even Jan as close, or characterized by respect and affection. They were more in the realm of reciprocating conveniences in which I — and perhaps the girls, too — hadn't invested much genuine emotion or attachment. I had to admit that to me they were more like walking vaginas than whole people, serving not as a means to move close, but as a method of escape and further withdrawal. It was the same with my patients. Over the months my attitude toward them had chang
ed. Each case had become an organ, a specific disease, or a procedure. Since Roso, I had avoided all close contact, intimacy, and involvement. Even that seemed schizoid now. Suddenly, vile, sick thoughts flooded through my brain, poisoning me, and I realized that I had to leave this room quickly and get away from the hospital, to some place where I could breathe. Mustering my thoughts, I concentrated on the reality in front of me. "What kind of tranquilizer have you been taking?" I asked hurriedly.
"Librium, 25 mg. size," he answered, a little confused. Evidently I had interrupted him.
"Fine," I said. "I'll give you a supply, but I recommend that you contact your doctor tonight or tomorrow. Meanwhile, I'll prescribe an injection of Librium to give you an immediate effect."
Before he could say anything else, I rose quickly from the bed, opened the door, and stepped out into the fluorescence and bustle of the ER. Mechanically, I wrote a prescription for "Librium 25 mg., sig: T tab P.O., QID, disp. 10 tabs," my mind going back over the absurdity of patient becoming therapist. That in itself seemed an almost schizophrenic delusion. A nurse tried to give me another chart, but I waved it away. I told another nurse to give the patient in the psych room 50 mg. of Librium intramuscularly. I was only half aware of the activity around me. Then, before leaving, I just had to go back and look in on that schizophrenic once more, to make sure he wasn't a hallucination. I opened the door. He was there, all right, staring out at me.
