Looking at this fellow as he lay there crying and cursing, I knew all those things. Figuratively, I had my hands in my pockets, not knowing what to say or do. What would I want if I were twenty and lying in that contraption with everybody saying take it easy, you'll be all right, and knowing it was a lie? I thought maybe I'd like someone strong, who wasn't trying to fool me, who acknowledged the bald truth. So in an effort to be firm, I told him he had to take the antibiotic, that we knew it was tough, but still he had to take it. He had to take the responsibility of being human.
Sometimes we surprise ourselves, talking out of unknown places inside us. I didn't know whether I believed what I was saying or not, but out it came. While I stood there the boy stopped crying long enough for the nurse to give him the injection. It suddenly became important for me to know whether he was relieved or only furious, but I couldn't see his face, and he didn't say anything. Neither did I. The nurse broke the silence and told him to try to get some sleep. Since I couldn't think of anything to say, I put my hand softly on his shoulder, wondering if he could feel my touch and my sorrow.
I knew I had to get away from the ward now or collapse. At any time, in any hospital, a thousand small chores are there to be done, like looking at someone's drain, checking an incision, responding to a complaint about a stiff neck, restarting an intravenous. Actually, the nurses in Hawaii were pretty good about starting IV's; back in medical school it had been a primary job for the student. Neither rain nor snow could spare us from being called at three-thirty in the morning to trudge off across the deserted New York streets to restart an IV. One winter night I had braved the elements only to be confronted by a veinless man. I had poked and cursed, and finally started an infant scalp-vein needle on the back of his hand. Then back through the rain, eventually sliding into my bed after being up for more than an hour, whereupon the phone rang again. It was the same nurse, half apologetic and half aggressively defensive. While putting on some more tape to reinforce the IV, she had accidentally cut the tubing.
In any case, there is always a lot to be done on any ward. Although the nurses will normally cope, if a doctor is around he's sure to be kept busy, and I was fading fast. There was only one job I wanted to do before going back to my room — to see Mrs. Takura in intensive care. I hoped that Jan had had enough sense to crawl under the covers before going to sleep. It was well after midnight.
We never called the intensive care unit by its full name, just ICU. Of all the names, initials, abbreviations, and jargon an intern hears, none can make him jump like ICU, because this is where the action is, a room in perpetual crisis. The chances of being called to the ICU at least twice a night were very high, and the chances of not knowing what to do were impossibly higher. That the nurses were efficient and knowledgeable only made it worse. You began to wonder what you had learned during those four expensive years of medical school. Schwartzman reaction, that's what we had learned. Two lectures on that, and no one was even sure it existed. Something's screwy when a doctor knows all about a disease that might not exist, but less than the nurse about any ICU situation. Of course, if the patient happened to have a Schwartzman reaction, I'd be an instant success: I could discourse at length on what the distal convoluted tubule of the kidney would look like under a light microscope, among other things. As for practical measures, however, we hadn't had time in medical school, nor had the pathologist cared, a fact that truly bugged me. The nurses had mostly carried bedpans through their three years of training. That's not fair, I realize, but, still, their training was trivial compared to the stacks of mechanism, enzymes, and Schwartzman reactions we had to memorize. Yet in the ICU I might as well have been carrying the bedpans. I often felt I'd better get the hell out of there before something happened that required an intelligent response.
An intern is supposed to pick up the practical stuff as he goes along, but if he got more of it in medical school he'd be a lot better off and so would the patients. In a working hospital nobody cares what you know about the Schwartzman reaction. The surgeon looks at your knots. "Weak," he says, "awfully weak." The nurse wants to know how much isuprel to put into 500 cc. of dextrose and water. "Well, how much have you been using on this patient?" "Usually 0.5 mg." "Hmmm, that should be okay." You don't have the guts to ask whether isuprel is the same as isoprotemol. Would she like to know about the thalamic radiations of the ventral nuclei of the cerebellum? No, and rightly, for it wouldn't help a single person in the ICU. What a way to live.
These thoughts were very much with me as I walked through the swinging doors of the ICU, as usual hesitating in wonderment at this strange mixture of science fiction and stark reality. Weird instruments hung from the walls and ceiling, adorned with their thousand buttons and switches and oscilloscope screens. Sonarlike beeps mingled symphonically with the rhythmic dick-clack of the respirators and the muffled sobs of a mother hunched over a bed in one corner. Moving and flickering as they stood guard over life, these machines often seemed more alive than the patients, who lay immobile, covered with bulky mummy like dressings and connected by plastic tubes to dusters of bottles that hung from the tops of poles. The mixture formed an alien and mysterious environment.
Nonmedical people react strongly to the ICU. It is the solid, physical incarnation of their fears about death and of the hospital as a place of death. Cancer, for instance, is certainly the most feared disease of our time, but unless you are the victim or a close relative or friend, it hardly exists outside hospitals. In the ICU, cancer hangs in the air like a sickening, primeval smog. If you work there a lot, you can easily forget that the hospital is a place where life begins as well as ends. But babies are not born in this room, and most people, with reason, associate it with the ominous, the unknown, and the final, where life hangs by its fingertips.
Although the normal human being does not enjoy a visit to the hospital, once he is in the ICU it holds him with its magnetic fascination, despite the morbidity, or perhaps because of it. His eyes dart around absorbing the fantasy, building monuments in imagination to the abstract power of medicine. Medicine must be powerful indeed, with all those machines. Otherwise, why have them? An observer, however, always senses the undercurrent of fear that mingles with the visitor's respectful awe, catching him in the conflict of wanting to be there and wanting to flee at the same time.
I felt the same ambivalence, for a different reason. I knew that most of the machines did almost nothing. Some of the smallest ones, though unimpressive to look at, did all the work. Those little green respirators, for insistence, clicking and clacking as they breathed for the people who needed them, were worth all the others put together. The complicated ones, with their screens and electronic blips, were not doing anything unless they were being watched. Medical school had taught me how to read these oscilloscopes. I knew that an upward sweep on the screen indicated millions of sodium ions rushing into the muscle cells of the heart. Then came a bump on the screen as the cells contracted while the cytoplasmic organelles worked like crazy to pump the ions back into the extracellular fluid. Fantastic to think about; but this scientific wizardry was only half the job. On the basis of these curves and sweeps, a doctor still had to make the diagnosis and then a prescription. That’s what pulled me apart, wanting to be there because I could learn a lot in a short time, yet always terrified that I wouldn't know what to do when total responsibility fell on me because I was the only doctor around.