Exhaustion clouds the mind. Forty-eight-hour shifts turn the world into a waking dream, while sleep itself, in fragments snatched here and there on a lucky night, becomes a dreamless coma. A man begins to doubt his senses. At four a. m., why do all those around me – nurses, patients, fellow interns, janitors mopping linoleum floors with pine-scented detergent – look like cadavers, their faces gaunt and pocked with shadow? Why do my hands shake? Do I need to take a pill?
The old-timers assured me it used to be worse. During my neurosurgery rotation, the admiral, as we called our senior attending, boasted that when he was an intern, nights off duty were rare and precious as diamonds.
“The word ‘intern,’ ” he explained, “is derived from the French interne, ‘to confine, as in a prison.’ We worked ‘round the clock, seven days a week. Half of us got a day off on Christmas and Easter, the other half on Thanksgiving and New Year’s Eve. Two days, plus a week’s holiday a year – that was it.”
The admiral puffed on his charred meerschaum pipe, sending clouds of blue smoke drifting toward the ceiling of the hospital cafeteria. This pipe aroused controversy. Ron and I found it pleasant, redolent of cedar chips, but some of the nurses compared it to smoldering cow dung. The admiral snatched the pipe from his mouth and gestured with the stem.
“Back then, they paid interns fifty dollars a month. We slept four to a room in a stone barracks out behind the old San Francisco General. If you stayed on as a resident – not many did back then – you got a double. The chief resident had his own room and a private bath with one of those cast iron tubs mounted on feet shaped like tiger claws. The damn thing must have been eight feet long.”
The admiral smiled and winked at me, glorying in my amazement. No doubt about it, I was mollycoddled – paid $ 837 a month, with two weeks of annual vacation and call every third night – while this old warrior had been on call almost every night of the year. Ron Goldstein, our senior resident, had heard the admiral’s war stories before.
“But admiral,” he said, “how many times a night did they haul you out of bed for a code?”
“You know damn well – back then, we didn’t have codes.”
“What,” I said, “your patients never arrested?”
“Don’t be silly,” the admiral said. “Of course our patients died, but that was the end of it. Since there were no cardiac monitors, the nurses didn’t know someone was dead until they came to take vital signs. By then, likely as not, they had gone stone cold. At morning rounds, we found an empty bed, and the head nurse made a discrete announcement – ‘Mister Jones has left us,’ or something like that.”
“Yeah,” said Ron, “and what about IV’s? How many times a night did they drag you out of bed to restart an infiltrated IV?”
The discussion proved enlightening. The institution of house officer – an intern or resident who worked, ate, and slept in a hospital 24 hours a day for months on end – arose at a time when cardiac arrests were shipped straight to the morgue, and fluids were infused by hypodermoclysis, a subcutaneous needle any nurse could handle on her own. The troublesome gadgetry of modern medicine lay years in the future. Without the burden now imposed by respirators and defibrillators and endotracheal tubes, house officers worked hard all day, but at night they got plenty of sleep. Then, decade by decade, gadget by gadget, their nights turned into a frantic rush to pierce and pound and intubate what back in the good old days were considered warm corpses.
At lunch a few days later, the admiral was puffing on his pipe and telling another war story when an angry shout filled the cafeteria.
“Jesus, man, I’ve been looking all over for you! Didn’t you hear my page?”
Everyone in the cafeteria turned to look. A resident had discovered his intern slumped over, dead asleep, his head resting on folded arms. By his elbow lay an untouched sandwich and a cup of coffee. Mumbling, eyes glazed, tousled hair standing on end, the intern followed his resident out of the room. I noticed the sleeve of his white coat was wet with drool.
* * *
When my month on neurosurgery ended, I began my second ER rotation, but this time I copped the swing slot. Instead of six twelve-hour shifts, I would work two twelve-hour day shifts followed by three twelve-hour night shifts, an arrangement that gave my fellow interns their one day a week off. It sounded like paradise – only sixty hours a week, the cushiest job an intern could get except for the newborn nursery – but the assault on my biorhythm proved more brutal than I had expected. How does a man command himself to sleep in the sunshine Monday through Wednesday, then in the dark of night Thursday through Sunday? My house was six blocks from the hospital. Off duty on a summer afternoon, I stretched out on a lawn chair in my back yard, looking up through the leaves of three acacia trees and listening to ambulance sirens while I struggled to sleep. Struggle – not a good word when it comes to sleep.
The sirens rose out of the distance, faint at first, pulsing up and down against a hazy summer sky. Jangled nerves. No sleep. On my nights off duty, evenings brought more sirens, an endless procession that wailed off and on until dawn. I ground my teeth, tossed in bed, counted my pulse into the thousands trying to calm my racing mind. I paced in circles, read medical journals, stared out a window at the darkness of night. No sleep. When at last I lay in bed, drifting down toward slumber, an anxious thought caught my weary mind at the cusp. I hovered, half asleep and half awake, suspended a fraction above blessed oblivion until a flash of anxiety exploded in my brain, jolting my limbs with electrical shocks. All hope of sleep was lost.
This wasn’t a relapse of my hypochondria, but a devastating combination of insomnia and panic attacks. A man needs courage to tap a spine or thrust a trocar into a swollen abdomen, and courage, I soon discovered, leaks out through the cracks of an exhausted mind. How long before I miss a terminal arrhythmia or prescribe a fatal dose of coumadin? Every time I thrust a subclavian needle beneath a patient’s collar bone, my mind’s eye sees the sharp tip ripping a hole in his innominate artery.
A fellow intern sends an eighty-year-old preacher home from the ER with a prescription for gas pains, but while the old man waits in line at the drugstore to fill the prescription, he keels over from a ruptured abdominal aneurysm. The scandal races through the Valley Medical Center. After that, in my sleepless, feverish brain, every wailing ambulance carries a dead patient I sent home from the ER a few hours before.
Ellen Stevens was the ER director, a kind mentor and a skillful physician, but she called interns into her office for a chat if their hands shook and they ordered too many consults because they were afraid of killing someone.
“What’s wrong, John? You did fine when you worked here last summer, but you don’t seem to be your old self. Maybe you should have a talk with Gallagher.”
Sam Gallagher, the director of the mental health clinic. He had gray eyes and a solemn, avuncular voice. His curly white hair always needed a trim, but he was a good man. He didn’t make me feel like a freak.
“It’s ok,” he told me. “You’d be surprised how many docs have the same problem. We’ve got to get you some sleep. Here, take one of these four times a day.”
An hour after my first dose of Librium, a siren became just another noise. I slept soundly, woke slowly, gazing through acacia leaves at fragments of a purpling sky. Languor settled in, a lovely indifference, but . . . where was the bouquet of honeysuckle that once drifted across my yard on the afternoon breeze? A steaming hot bath didn’t bring its usual pleasure, nor did the pastrami sandwich I ate for supper, or a glimpse of my wife as she stepped from the shower. To her relief, alas, that pale and perfect nakedness had lost its power over me. My libido vanished. Oh well, I thought, the price to be paid: no molecule is smart enough to block the pain and let the pleasure pass.
* * *
By the grace of Librium, I survived my ER rotation, but the reprieve was short-lived. On my next rotation, the medicine service, rounds began at six a. m. From the waning darkness of early dawn, I slogged my way through a ward full of bad livers, bad lungs, bad bowels. Nor was that the end of my labors. Every Tuesday and Thursday afternoon, no matter how much hell broke loose on the ward, I had to staff general medical clinic. GMC – a refuge for the ancient, the decrepit, the lost of the earth, shipped in by the dozen from nursing homes all over Santa Clara County. When the time came, I was always rushing about to get my ward patients under control. Infiltrated IV’s, stat blood gases, leaky chest tubes – all conspired to make me late.
The operator paged me through the overhead speakers: “Doctor Gamel, urgent to GMC,” repeating the message in ever more strident tones as the minutes passed. At last I rushed down to the GMC gauntlet, a hallway filled with mummies, their wheelchairs lined hub to hub as far as the eye could see. I walked fast lest one not blinded by age should recognize me, call my name, reach out a quavering hand to grab my sleeve. In the heat of summer, their upraised arms were bare, their liver-spotted flesh hanging in folds. On a bad day, Mr. Eakins sat near the entrance. His vision had been restored by cataract surgery. Behind thick lenses, his huge eyes caught sight of me. He reached out to grasp my arm. He called, “Doctor Gamel.´ The Word spread down the line. “Doctor Gamel . . . Doctor Gamel . . . Doctor Gamel . . . ”
Their voices called my name, but their eyes said so much more: Oh Doctor, please stop and chat. I’ve not been out of my nursing home since our last visit three months ago, and it would be such a lovely thing if you could stand beside me for a moment. Smile down at me. Take my hand. You would do this, Doctor, surely you would do this if you knew how long it’s been since anyone touched me.
But I was late. Always late. Arriving at last, I ran back and forth between two cubicles as nurses shuttled patients in and out with the cruel rhythm of a metronome. Hurry hurry hurry. The instant I entered a cubicle, the wheelchair-bound soul waiting within began her lamentations: phlegm, gas pains, shortness of breath, a roommate who spat on the floor and sucked her teeth all night.
I said, “Oh, my . . . sorry to hear that . . . you poor thing . . . ” as I peered into their eyes, their nose, their throat, percussed and auscultated their chest, then scribbled prescriptions and chart notes. Finally came that awful moment.
No, no, Doctor, not yet. They said it with their eyes. Please, Doctor, can’t you give me just a little more . . . a little more . . .?
Time – the currency of life?
More time? No, I can’t.
* * *
The innocents among us see death as an event rather than a process. Sometimes it works that way. A bullnecked handball player clutches his chest and falls face down, breaking his nose on the hardwood floor. Perhaps he’s the lucky one, a DOA rushed to the ER on a slow afternoon, his t-shirt damp with sweat and his arteries pulseless as a stone. Five-o’clock shadow darkens his jowls. Not much blood from the broken nose, just two streaks drying on his upper lip.
But for most of us, death comes in tiny slices. We rot slowly, our tissues withering year by year, leaving only wrinkles and decrepitude and – for my GMC patients – a loneliness cruel and parching as the desert sun. I touched those lonely people, gave them hugs and pats on the knee, but every instant I felt time’s hot breath on my neck. Five-thirty. Six o’clock. My god, what’s happening up on the ward? I imagine my resident – frantic, hollow-eyed, rushing from disaster to disaster and cursing my absence.
Finally, after weeks of GMC torment, the bottom dropped out of my world. Up on the medical ward, two alcoholics were hemorrhaging from their esophageal varices. An overdose of potassium sent an ICU patient into ventricular fibrillation. The page operator began calling me at one-fifteen, her voice blaring through the overhead speakers, but it was almost two o’clock when I made my way down to the GMC inferno, where a nurse found a bloodstain on the tail of my white coat and sent me back upstairs to change.
The first patient was scrawny as a stick, an ancient, cheerful nun with dyed blue hair. She lifted my spirits, but her garrulous, sleeve-plucking affection put me further behind. My next two patients were demented, one of them in the terminal stages of a brain tumor. Their filmy eyes and corpse-gray faces sent me over the edge.
Three days before, hoping to escape my peaceful prison, I had stopped taking Librium, and now the price of my foolish courage was upon me – a panic attack. My hands trembled. Sweat poured down my face and soaked the collar of my white shirt. I rushed to the lavatory to swallow a Librium, but an hour would elapse before the philter began to work its magic, and in the meantime I had to keep up the rhythm: force a smile, choke out my words through a raw, tight throat, examine the patient, scribble notes with a trembling hand, announce my farewell, then rush to the next cubicle, where another desperate mummy awaited my healing touch.
Then all was lost. There sat the patient, but where was the wheelchair? And my god – the patient! I saw a girl with glossy dark hair down to her shoulders. I saw a sleeveless aqua mini-dress, a golden expanse of bare arms and legs. Audrey Hepburn? No, not quite, a little too broad in the face. And overdone. She wore pancake makeup, heavy eye shadow, lashes matted with mascara – a painted doll redolent of lilac and musk. Some miracle, perhaps a warp in the space-time continuum, had transported a Vogue model to my cubicle.
“Hello,” she said, smiling. “My name’s Linda Baker.”
Linda had perfect white teeth and full, red lips. There was elegance in the angle of her crossed legs, the poise of her thin, squared shoulders, her hands folded modestly in her lap. Had I lost my mind? Was this an hallucination? The young, the rich, the beautiful – they never came anywhere near general medical clinic, yet here was a sylph dressed like a fashion plate. At last I spoke.
“What . . . uh . . . brings you here today?”
“My face,” she said.
“Your face?”
“Yes. It gets numb. Sometimes. Numb, and a little tingly.”
“When does this happen?”
“Oh, sometimes . . . sometimes . . . at dinner . . . ”
Her face remained calm, but she began wringing her hands.
“Do you have any other symptoms?” I said.
“Oh, yes,” she gasped. “I get lightheaded. Things spin around like I’m going to faint. My heart thumps so hard I can feel it beating inside my head.” She squeezed her eyes shut, pressed her fingers to her temples. Her lips trembled. “I just . . . can’t . . . sleep.”
Linda blotted her eyes. Streaks of mascara crept down her cheeks. The tissues I handed her collapsed one by one into soggy wads. My own panic had begun to wane. Perhaps I wasn’t insane, but what was this creature doing in GMC?
“It sounds to me as if you’re under a lot of stress,” I said.
“Stress? Oh, certainly not. I’m fine. Just fine. Got married two months ago.”
She sniffed, smiled, blew her nose, then held up her left hand to show the diamond ring and matching circlet. A small diamond, less beautiful than the slender, honey-gold hand it adorned. I struggled to clear my mind, focus on her problem. My voice quavered but remained loud and full of authority. Surely she had a clue, I insisted, some hint of where this panic monster was coming from?
“No,” she said, raising her chin. “You should send me to a brain surgeon. I think I’ve got a tumor.”
I was running late, desperately late. The clinic nurse had twice cracked the door of the cubicle to give me a glowering rebuke. Again, panic came upon me – what to do with this peculiar girl? I had long since mastered the subtleties of hemorrhoids and emphysema and congestive heart failure, but this was a new game, and that lovely, expectant face left me stupefied.
Ah, I remembered at last – this was not a new game for me, and what was good for the doctor might be good for the patient. I didn’t have the time or the training to sort through Linda’s psyche, but perhaps Librium might work the same magic for her it had worked for me. Once her anxieties were quelled, the poor girl could find their cause and sort out her own problems.
My plan worked. Almost. Linda missed her follow-up appointment, but a week later, the pharmacy called to report that she wanted more Librium. Absolutely not, I said – tell her if she wants more, she’ll have to see me in clinic.
When she returned, her hair was bobbed, and she wore a black silk dress that came below the knee. The mascara and pancake makeup had been restored. My houri was her old self, fetching and poised as ever, but this time she remained dry-eyed throughout the interview. Her tingling and numbness had vanished. She slept soundly, her nerves calm as a glassy pool. Well, yes, a faint mist seemed to float in front of her eyes, and sometimes she saw halos around peoples’ heads, but that didn’t bother her. Nothing bothered her.
But the stress, the terrible anxiety attacks she had suffered – what was all that about? The topic didn’t interest her. She sighed, grimaced, said, “What’s the point of talking about all that stuff?” She said it three times, but I persisted, until finally the story came out.
Linda was seventeen, the only child of a wealthy lawyer who had been widowed since her birth. She was also a high-school dropout, married to a twenty-eight-year-old pothead who watched TV soap operas all day and couldn’t find a job. Linda’s father, a closet alcoholic, had forbidden the marriage, and her defiance had provoked an outrage that only grew worse when she turned off the burglar alarm in their Los Altos Hills home so her new husband could haul away two trunks filled with her designer clothes. After that, the father refused to give her a cent. She was in GMC because her health insurance card had expired; when she returned home to ask her father for a new card, he caught sight of her coming up the sidewalk and pitched two andirons through the living-room window.
Now Linda and her husband lived on welfare in a hovel they shared with his family in a seedy section of San Jose. What kind of people were they? Well, they threw food at each other across the dinner table. When Linda refused to eat her mother-in-law’s boiled turnip greens, the woman screamed obscenities and dumped the plate on the floor. The two sisters-in-law pulled Linda’s hair – not in jest, but with vicious jerks that raised knots on her scalp. She parted her hair to show me a wheal the size of my thumb.
A stressful life indeed. After Linda finished her story, we sat in silence for a long time. My judgment was clouded by pride: no doubt she wanted to thank me. I waited for grateful tears, a gush of praise, perhaps a warm embrace for the clever regimen that had calmed her anxieties and helped sort out her life. But her face. . . that expression. . . what was it? Sitting with her back straight, one arm akimbo, half turned in her chair, Linda kept staring at me.
Was she expectant? Angry? Something had gone wrong. The stern face melted into a smile. The black dress ascended, revealing a golden expanse of thigh. After several moments of her silent, come-hither gaze, the slippery black hem inched higher still. Her legs were flawless, long and smooth and tanned, but my dead libido saved the day. Her performance didn’t arouse me. It alarmed me. What did this strange woman want?
“I need more Librium,” Linda said.
“More Librium? But . . . no, you need to do something about your life, get away from that awful place, those terrible people you live with.”
“Do what? I have no money, nowhere to go. Besides, the medicine you gave me – that’s great stuff. I can live with anybody, long as I can get some sleep and keep my nerves from tearing me to pieces.”
A horrifying proposition: Linda wanted me to save her from the agony of change, cast her in a perpetual Librium trance so she could endure her misery. She read the shock in my face. Her smile vanished. Now she was rigid, defiant, her chin uplifted.
“You started it, doctor. You gave me the pills.”
“But your father . . . you could ask him for help . . . ”
Her eyes blazed. The pancake makeup cracked into ugly furrows across her brow. She snarled, “Why that . . . that miserable bastard! I’d rather rot in hell!”
* * *
I never saw Linda again. No doubt she soon got all the happy pills she wanted from other doctors. Perhaps to this day, the poor woman sleeps soundly in her house of pain, and if she does, she’s not alone. The summer after my freshman year of college, I worked as a file clerk at Ford Motor Company’s distribution hub in Doraville, Georgia, a northern suburb of Atlanta. In a cinderblock shed dreary as a tomb, surrounded by acres of tarmac and two thousand Ford Fairlanes, my stout, red-nosed boss began each day with a sight gag. He slammed the door behind him, filled a paper cup from the water cooler, announced, “Seven years, four months, two days” – the time left before his retirement – then tossed a Miltown capsule into the air and caught it in his mouth.
Miltown was the tranquilizer of choice in that era. Years later, Roche Pharmaceuticals discovered Librium, which dominated the sedative market until displaced by Valium, the ultimate happy pill. Within a decade, millions of men and women the world over immersed themselves in a Valium cloud, grazing their way through life like so many contented cows.
When my GMC houri appeared, I was hooked on happy pills myself. It would make a good story if her pharmaceutical seduction had given me an epiphany; if, in a flash of insight, I had thrown my Librium into the trash. It didn’t happen that way. For years, I never left home without a hand-carved ivory pillbox tucked in my pocket. Yes, like many of my fellow physicians, I was a tranquilizer freak, but I stood above the hoi polloi by carrying my pills in an artistic receptacle. I never overdosed, kept away from hard drugs, stayed alert and bright-eyed. Like opposing electrical charges, my anxieties neutralized the soporific molecules flowing through my bloodstream, allowing my competence to remain unimpaired. But my memory of Linda – her painted face, her hard, desperate eyes – worked on me, even as I took Librium, then Valium, with the faithfulness of a diabetic taking his insulin.
Such reliable, magical medicine. Take one now and peace will descend. Take one now, and nothing – your mistaken diagnoses, your heartbroken patients, even your cold, unhappy wife – will disturb you in the least. And yet, despite their magical powers, I would give up happy pills. It was not a sudden decision, nor one inspired by a soul-searching struggle. No, my salvation came from images. During my months in the GMC, I saw the withered faces of men and women nearing the end of their mortal tether. Those faces stayed with me. They wandered through my dreams, through my waking thoughts, and over the years they taught me this: only a man who lives forever can afford to squander his days in a joyless stupor.
Death comes to most of us in tiny slices, but in the end, I decided it would be best not to cut those slices with my own hand.