These thoughts rumbled chaotically through my head as I went to the elevator and hit the button hard, half hoping to break the whole contraption. Returning to the hospital, down those sleepy corridors toward distant points of light, I tried not to wake up completely.
I once told a friend who was not in medicine the various reasons I got called out of my bed at 4:30 a.m. He didn't believe them. It was too disquieting for him; it shattered his colorful image of the intern awakened suddenly, all eager in white, flashing down the corridors, up the stairs by threes and fours, to save a life. Here was the real me, feeling shitty and stumbling down a hall swearing under my breath, on my way to say, How are you, patient?… Fine, Doctor… That's wonderful…Have a good rest, and please don't fall out of bed again.
When the phone rang again it was daylight, five-forty-five. Feet over onto the floor, sit up sideways, use my hands to push up. That slightly sick feeling again, and a momentary dizziness until the cold floor knocks it out of me. Over to the sink, hands on its sides, lean on it for a second. In the mirror my eyes are like aerial views of hot lava running into a muddy lake. The only reason the bags under them don't meet the corners of my mouth is that I can't smile. Ah, a trickle of water meanders out of the faucet. Holding on with one hand, I raise a few drops to my face.
Nothing about this morning was particularly noteworthy or different. It was just a morning, like other mornings. In two weeks I had worked up such a deficit of sleep that even when I did get six hours straight I felt the same way. The razor blade, much sharper than I was, left several points of blood on my throat. Mixing with the water on my face, it seemed like a lot of blood and, combined with my eyes and the dark under them, made me look like a Mafia heavy.
After thirty seconds or so I felt together enough to dress. Stethoscope, little flashlight, several different-colored pens, notebook, comb, watch, wallet, belt, shoes — on through the mental check list. Make sure socks are the same color. Mustn't spoil the tone of the place. One last visual sweep around the room to make sure there wasn't something else, some piece of paper, a book. Satisfied, I left, descended in the elevator, and stepped out into the morning air.
It had always been a point with me to walk around in front of the hospital on my way to the cafeteria. Somehow it lifted my spirits. This morning the sky was a pale faraway blue dotted with small clouds, half bathed in the east in golden tones of red; toward the west the colors faded off into pink and violet. The grass sparkled, still damp from the night air, even the trees sparkled, and birds were everywhere, producing an incredible din. Two types of birds predominated, the mynas, who strutted about gesturing awkwardly and making unharmonious, scolding squawks, and the less noticeable doves, moving more slowly, almost politely, some of them seeming to bob up and down as they fanned out their tail feathers and cooed in melodious voices. I liked that short morning walk. It was only a few hundred feet, but it made me feel happy.
Six o'clock in the morning is not my idea of the perfect time for a big breakfast, particularly after a sleepless night. But I forced myself to eat, stuffing the food into my mouth and relying heavily on water to take it down. By experience, I knew that if I didn't eat I'd be hungry in an hour or so, when it would be impossible to get food. Besides, I missed lunch about half the time because of the operating schedule. Another meal might not come my way for eight or ten hours.
After breakfast, I had about thirty minutes to see my patients before rounds started at six-forty-five. It was important to have everything in order before then, to know all the latest changes. The ICU was first. I never minded going there in the morning, or anytime during daylight, for that matter. Having other doctors around diminished that feeling of being alone on a high wire. Mrs. Takura was sleeping peacefully after her preoperative medication; the tube hung still in her nostril, wrinkling her nose from the tension. Pulse, urine output, blood pressure, breathing rate, temperature, electrolytes, BUN, protime, proteins, bilirubin… all the recent tests were back and recorded. Pausing to write a note about her status in the continuation sheet, I hoped she was ready.
Back in one corner Mr. Smith's machines were still beeping away, showing an EKG that looked pretty normal, although I was no ace at reading them, especially from the oscilloscope. He was sleeping, too. I went down to the wards.
On the ward, the name of the game was numbers and variety rather than crisis. I had several dozen patients, representing as many different types of people and problems. Most of them had had their surgery and were progressing well at various stages from postoperative, through having stitches out, to discharge. The length of their drains was usually a good indication of how many days had elapsed since they'd left the operating table. Drains are a somewhat awkward but quite necessary part of surgical practice. Planted deep with the wound at the end of the operation, they serve as an outlet for any unwanted fluid and help to keep down infection. The idea is to pull the drain out, inch by inch, beginning on the second postoperative day, thereby letting the wound heal slowly from the inside out.
Patients never understand these drains. To them, the dangling pieces of pale rubber are a source of endless conversation and discomfort, mostly mental. Mr. Sperry was two days postoperative for gastric ulcer, and it was time to begin pulling his drain. Grabbing it with a clamp, I gave the tube a good tug. But it held fast, just stretching a bit, so that it looked somewhat like a Chinese noodle. From his sitting position, propped up on two pillows, Mr. Sperry watched in dismayed fascination, his eyes as big as almond cookies and his hands gripping the sheets. Pulling at it again, I began to wonder if the drain had accidentally been stitched into the wound when gradually it let go and moved out a couple of inches. A bit of serosanguineous fluid escaped with the drain and was quickly soaked up with gauze.
"Doctor, did you have to do that?"
"Well, you don't want to go home with this drain hanging out, do you?"
"No."
I put a safety pin through the drain just above the skin to keep the tube from dropping back into the wound and then, with sterile scissors, I cut off the excess tubing. It was important to follow the right order in this simple procedure. Once, before I knew better, I had cut the drain off prior to placing the safety pin. The patient had been holding his breath all the while, and when he finally inhaled, the drain disappeared into his abdomen. Visions of a new operation crashed in my head, but fortunately a resident had retrieved the drain after taking out three skin sutures and fishing around with some forceps.
"Why don't you put me to sleep when you pull it?" Mr. Sperry looked at me, questioning.
"Mr. Sperry, putting you to sleep is not as easy as you think it is. Besides, anesthesia always carries a risk, but there's no risk in pulling out your drain."
"Yes, but then I wouldn't know about it."
"Did it really hurt when I pulled your drain?"
"A little, and it felt funny inside, like I was coming apart."
"You're not coming apart, Mr. Sperry. "You're doing great."
"Did you have to pull so hard?" he pressed.
"Look, Mr. Sperry, tomorrow I'll put these gloves on you, give you the clamp, and you can pull it out. How's that?" I knew that would get a response.
"No, no, I didn't mean that I wanted to do it."