Archives of The Cheerful Oncologist, Volume 2

Call me irresponsible but sometimes I can’t help but marvel at cigarette smokers who attempt to rationalize their years of pure smoking pleasure with their newly diagnosed lung cancer. Taking up the coolest habit of the cool all those years ago must have left them trembling with excitement as they learned how to light up and hold a Marlboro like Robert DeNiro. Now they sit humbly on an exam table in my office while I lean into the x-ray viewbox, silently despairing at the grotesque blotches of metastases splattered all over the CT scan. Peering at the black and white shadows I can see their future slip away like a capsized rowboat sinking slowly under the waves.

Part of the initial interview is to determine the patient’s history of smoking - calculated by multiplying the number of packs smoked per day times the number of years smoked. This result, called pack-years of smoking gives oncologists an idea of a patient’s risk for developing tobacco-related cancers. For example, four packs smoked per day times 50 years (200 pack-years of smoking!) pretty much guarantees a patient will develop a malignancy - if they should live so long (cf. coronary artery disease). When I ask a patient about their smoking history I do it in a straightforward and non-judgmental manner. I don’t see any point in scolding someone about the reason why they are visiting me today - they know the truth of the matter. What is amazing is some of the answers I get from smokers as they try to wiggle out of the desperate situation they find themselves in, as if one could extricate oneself from a barbwire coffin without receiving a scratch.

The Cheerful Oncologist would therefore like to inform all smokers that one does not get a kinder, gentler form of lung cancer for having been less than a full-blown chain-smoking Humphrey Bogart. For example, I have heard the following comments when asking about a patient’s love of Nicotiana tabacam:

“Doc, I only smoked short cigarettes.” (Is this the same thing as using only a small caliber revolver?)

“I quit smoking years ago.” A variation of this answer is “I only smoked on and off.” (Achtung! Cancer, once on the scene, doesn’t give out warning tickets to reformed smokers!)

“I only smoked in social situations.” Or, “I only smoked when I was drinking.” (Hey, this is America - last time I checked every man, woman and child was jabbering with friends!)

“I never inhaled them.” (I’ve heard this before somewhere…)

And of course, that all-time favorite: “Doc, I just laid ‘em down and let ‘em burn up in the ashtray.” (This seems to be a variation of the “Gee, Officer I have no idea how fast I was going” excuse).

Feeling magnanimous, let me also inform smokers that we oncologists don’t give a hoot when we hear that Uncle Jesse smoked three packs a day his entire life and is 92. Uncle Jesse ain’t here in the room wheezing like a chimpanzee playing a violin, and no partial credit is given to lung cancer patients who have smoking relatives who look like James Bond! All this braggadocio means is that your favorite uncle will likely be around when it comes time to don his Sunday best and climb into a black limo while you are taking a horizontal ride to the grassy knoll.

So, dear lovers of what the beloved Wodehouse character Bertie Wooster calls “gaspers” - don’t try to kid yourself about smoking. Even if you smoke “just a little“, you can get cancer. Please keep that in mind the next time someone offers you a cigarette, or the next time you feel the urge to light one up, or the next time you see a pack of ultra-lights in the grocery store, or the next time you see someone on the silver screen dangle one from the lips, or the next time you smell smoke on your teenage son or daughter.

This has been a public service announcement from your friendly neighborhood doctor.

While joyfully skipping along from hospital to hospital during a bout of weekend call recently I was asked to consult on an inpatient. This should not come as a surprise since that is exactly what on-call doctors do, compared with scrambling an F-18 and streaking off into the wild blue to vaporize a squadron of mustache-stroking evildoers. The trouble with this consult was that I had already been slaving away all morning and was looking forward to paying a visit to the local hot dog stand for some grub of perhaps dubious nutritional value. Unless I was about to renounce my vows for duty and humanity lunch would have to wait. Therefore I soon stood at a nurse’s station absorbing the minutiae of this chart in question. The consult seemed straightforward to me - a malignant tumor had been resected and the surgeon wanted to know if adjuvant chemotherapy should be given. Aiming the chassis toward the patient’s room, I rumbled on over to begin the interview. My only concern at that time was that the patient was well into her eighties. Would she be able to tolerate these treatments? Would she even want to consider taking them? My stomach emitted a gurgle of disapproval as I knocked and entered.

Behind the door rested a wizened woman with a proud look on her face, sitting high enough up in bed to allay any fears that she had faltered during her recuperation [the sicker the patient, the lower the head rests according to the C. O., but what does he know? -Ed.]. In fact, she was in the act of polishing off what appeared to be either a bowl of lemon sherbert or the dregs of her facial cream. As I began my spiel, also known as establishing rapport with the patient she asked me to sit down. Before any formal inquiries could be launched she quickly gave me a look like a vacationer who has just bitten into a rotten mango.

“I don’t know why on earth I agreed to let them operate on me,” she barked. Before I could even produce a soothing phrase or two she launched into a breathless diatribe about how miserable she was while imprisoned here, peppering her comments with crisp exhortations for the Lord to shine the Flashlight of Mercy downward toward our little room. After a couple of minutes of listening to her I half expected to hear the rumblings of giant corpse-filled wagons in the street and the cry of “Bring out your dead!” Surely her hospital stay wasn’t all bad, I suggested. She turned to me and recited a heartfelt comment that could be interpreted by the skeptic as expressing a noticeable level of insensitivity in my choice of careers.

Uh Oh, I thought - better hang on for dear life and jump in when the foot seems to ease up on the accelerator. For the next act of our little drama I sat silently while she complained, nodding my head so much I looked like a sufferer of rampant titubation. My mind and eyes began to wander - even a rant if continued long enough can induce tedium in the poor listener. I was desperate to either form a bond with this patient, allowing me to get on with the consult (and then on to lunch), or fake a catastrophe that would permit a sudden exodus from the room - the bite of the black widow spider came to mind.

Amazingly in all this consternation over her lamentation I had missed a prominent display placed next to this woman’s bed - two large framed color photographs of her standing next to a distinguished white-haired gentleman in a dark suit. The happy couple beamed from their glass frames, and this gave me a idea. What better way to bring the bluebird of happiness back into the room than to fill her senses with praise for the man in her life? Ignoring the kettle-drum concert emanating from my stomach I interrupted her with the compliment, phrased in the form of a question:

“Who is that handsome man in the picture with you?”

My luncheon that day was particularly satisfying - the bread of my sandwich was (mirabile visu!) only slightly soggy, and the reverse-osmosis cleansing of my bottle of water gave me a sense of peace found only previously while standing on the rim of the Grand Canyon during sunset. As I polished off the last few remaining crumbs a smile deigned to appear on my lips. My consult was finished and I was free to enjoy the remainder of a Saturday that turned out to be too hot for wives to order the chain gang of husbands and sons back outside to clear brush. I thought of my newest patient as I zoomed off toward home. Bless her heart, she not only gave me one answer but a double response to my query. She replied:

“That’s my husband! Who do you think it is?”

Then she added: “He’s worthless and useless - doesn’t lift a finger to help me and is losing his mind.”

Ah, there’s nothing like rekindling fond family memories to ease the heartache of a hospitalization. It’s comforting to know that my conversational skills are still as refined as when I was asking girls in mini-skirts to dance to the beat of The Carpenters. I’ll bet those photographs find their way safely home and will soon rest once again on the piano or the bedroom dresser. I regret that I couldn’t stick around to hear the saga hidden within them but we doctors know when it’s time to hold hands, and when it’s time to saddle up the sturdy steed and give out a hearty “Hi Yo, Silver!” before some poor nurse finds us sound asleep in a corner of a room, drooling into a wastebasket. I’ll keep this in mind the next time I find myself barging into someone’s life - which should be in about twelve hours.

An old familiar feeling hit me today. It started with a spurt, from the heart I assume (the fons et origo of emotion according to experts), then messily sprayed the rest of the corpus with layers of turmoil both scalding and icy.

The result was me holding a patient’s chart in two benumbed hands while burning with humiliation at the note attached to the front: “Patient has decided to change oncologists.”

I suddenly had a vision of myself as a young teenager in a swimsuit covered with peace signs, pressed up against a chain link fence surrounding the city pool on a crepuscular summer evening as I watched my long-haired girlfriend walk through the grass toward me. I held my breath as she approached but before I could speak she produced the ring I had bestowed upon her just a fortnight ago and handed it through the cruel links, along with a note. “Here” she replied, then said no more. I stood stupified against the coming night. The silence was unbroken, and the stillness gave no token. I cried:

“I scarce was sure I heard you!” while running for the entrance. Here I opened wide the door - darkness there and nothing more.

Nothing more, because I had just been jilted - and today’s breakup hurt just as much as it did back in those days when the radio poured out summer songs that melted young hearts as fast as a Bomb Pop left on the sidewalk.

I guess it is a sign of vulnerability but I have never become inured to being fired by a patient. It bothers me that someone would prefer another doctor’s wisdom, another doctor’s beside manner, another doctor’s eyes for the future. After all the time I had spent counseling him, why did this new patient abruptly want to leave me? As I stood over my desk, re-reading the request to send records to a rival oncologist I made a mental list of possible reasons, wallowing in what the psychiatrists call projection as I steamed over this incident. I considered a few causes:

1. The patient was in such profound denial about the diagnosis that he was exhibiting what the headshrinkers call displacement - that is, instead of becoming angry at the disease cancer he was angry at me for being the bearer of bad news about the ugly details of treatment and prognosis. This is known in businesses far and wide as “kill the messenger.”

2. The patient found my personality shall we say unappealing, and thinking it would clash with his own, decided to switch rather than fight (cf. Bernard Law Montgomery vs. George Smith Patton, Jr.).

3. I’m an abject failure as an oncologist and should be summarily executed cometh the dawn.

Of course I assumed that the answer to my being cashiered was behind door number 3, and proceeded to twist my mind into a barbwire of self-doubt and rationalization. I tried to recall what it was about his demeanor or statements that augured this rejection, but could not find any clues. If I had pranced into the exam room dressed as Groucho Marx, or slurped a Big Gulp while reciting a soliloquy about my recent holiday in Antigua, or had peppered my interview with such interjections as “Have you selected a funeral home yet?” I could understand why one might have considered my leadership to be less than inspiring. No matter how much I pondered I still could not explain the dismissal. I could see myself trying to sleep tonight, holding a contest between this rejection and the stiff-arm I got from my old sweetheart to see which one would fuel my insomnia. I was so ashamed I almost hid the chart from my staff but then decided like a forlorn lover to confront my heartache directly. I marched up to my secretary and demanded to know why this patient had fired me.

“Oh, he liked you but wanted to get his radiation closer to home, so he asked for a medical oncologist in the same town.”

They say it’s going to be hot for the next several days - some real afternoon scorchers that will put the pant back in the dog and take the pants off of the swimming-hole gang. I think a dip in a shimmering blue pool might be just the cure for the bright red cheeks I sported as I heard the truth as to why I was minus one patient. Maybe I’ll take the rest of the day off and head on down to the nearest oasis for a little quiet time. They might even play a dreamy old song over the loudspeakers and carry this overwrought oncologist back to the days when love stretched its suntanned legs by the water and the storm clouds of adulthood stood far off, too distant to be seen by adolescent eyes.

Ah, what a glorious duty it is to be the king! One delightful day last week as I paraded around the palatial rooms of my imperial domain, stethoscope in hand, I could not help but reflect on how pleasant the office is when running smoothly. Patients were moving from room to room with fluid precision like a snake gliding across a cool river. Telephones were being answered promptly, the “blood machine” (we do use the vernacular in medicine, you know) shimmied and hummed, spitting out lab results as if it had no prior recollection of past meltdowns, and my dictations were crisp and articulate, if not artificially enhanced by a tasty cuppa from some exotic valley. In short it was a good day at the office. Taking a last look around, I went to my desk and fired up the computer.

Little did I know that the mystic seismograph labeled “Crisis Alert” was about to start oscillating like a Tilt-A-Whirl on a Saturday night.

As I reviewed some research data I had been searching for I became aware of some vague hollering in the back of the office where the treatment room was located. Suddenly a nurse burst into my room and cried out “We need you in the back now!”

In this era of new and powerful chemotherapy and biological therapy every oncologist in the world knows what that command means - it is the bugle call of a sudden complication called a hypersensitivity reaction. I ran back with the staff and found one of my patients sitting bolt upright in a treatment chair, red-faced and clutching his chest. Was he having such a reaction, or was this a sign of something more ominous, like a myocardial infarction? Was it a pulmonary embolus? Aortic dissection? Especially funny joke?

It is predicaments like this that give doctors their reputation of grace under pressure, not to mention changing a few hairs from blond to ash. Fortunately I remembered my superior training and the first thing I did was to take my own pulse. Next I interviewed and examined the patient, which I have always thought was a nice way to break the ice during an emergency compared with say, standing on a chair and yelling out “Rampart! Start IV with LR!” or other dubious comments. The precious seconds ticked by and my patient still moaned and grimaced. I had to make a decision now on whether to treat him here, or transport him to the hosptial emergency room. The facts in the case could be catagorized as follows:

Symptoms of a hypersensitivity reaction: chills, flushing, dyspnea, wheezing, nausea, hypotension.

Symptoms of a major coronary event: dyspnea, chest pain, back pain, wheezing, hypotension, nausea, arm/jaw pain, syncope.

Symptoms my patient was exhibiting: chest pain, back pain, dyspnea, generalized distress.

It didn’t take a session with an IBM mainframe to place the puzzle pieces together and come up with a plan. Let’s remember folks - we doctors are skilled in the art of leaving no stone unturned when it comes to finding a diagnosis. Why is that, one might ask? Well, given the menacing cloud of litigation that doctors practice under these days, one would understand with Zeus-like clarity why I rushed this patient to the emergency room. The decision was justified if one notices the overlap between my patient’s symptoms and those of a major perturbation of the old ticker. Hypersensitivity reactions that are minor can be managed at the bedside by turning off the infusion and treating with Benadryl, corticosteroids, oxygen, IV fluids. Major hypersensitivity reactions (called anaphylaxis) are treated like a cardiac arrest - no head-scratching over that diagnosis, eh? My patient’s symptoms were atypical for an allergic reaction, and rather than assume that the most likely diagnosis was the actual diagnosis, I checked for other serious problems that could have lethal consequences if undiscovered.

In this case all’s well that ends well. After a thorough work-up in the hospital we determined that my patient was not having a myocardial infarction but just an unusual manifestation of a hypersensitivity reaction. La de da! So what if I went into supraventricular tachycardia as we raced down the hallway like Dale Earnhardt (requiscat in pace), flattening little old ladies on the way to the E.R.? Who cares if the doctor is scared out of his size 36 boxers as long as the patient has a full recovery? Am I right? Of course I am - the patient is the one with the disease, remember?

The only problem is - these darn reactions are making me a nervous wreck. My nurses are beginning to comment that my countenance reflects a certain lack of sangfroid normally found neatly stacked within. The next time I hear shouting don’t be surprised if I drop the dishes and run like the dickens - to the crisis, of course. We oncologists are hardy stock. We just don’t like surprises.

…they serve him best. -John Milton

“How was your week, Doc?”

How was my week? Me? Little ol’ me? You want to know how my week was? Gee, thanks for asking! I’d love to tell you how my week was! But first - did you know that 99% of all Americans are not only willing but eager to talk about themselves? One can’t blame them, when asked how their week was, for setting down the scholarly journal they were perusing on the coffee table and turning to the questioner with a sparkle in their eyes before unloading the hebdomadal news report entitled “An In-depth Look at My Fascinating Life”. I may be wrong, but a closer look at someone’s fascinating life certainly beats some of the other entertainment choices offered in this modern world. Well, since you asked here’s the scoop:

It is with a long face that I begin by saying that my week was not off to what I would call an auspicious start - in fact, if I were a racehorse I would be petrified every time my owner loaded me into the trailer, if you know what I mean. I was suffering [suffering? rather melodramatic, n’est ce-pas? -Ed.] from mishaps and annoyances flung from all corners of the world. First my wireless keyboard died a cowardly death, without even a spark of defiance. Then before the last of the day’s efforts could be tossed into the hayloft a telemarketer slipped through the elaborate screening process my secretary uses to shield me from such scalawags. His offer sounded intriguing but I just couldn’t see myself taking a trip to Nigeria on such short notice. The next day was no better - between running late, spilling tea on my lab coat and hobbling around with a weak back (don’t ask me how long I’ve had it), I was in no mood for gratuitous checkout-line-type delays or other obstacles. Unfortunately the stars were aligned malignantly for this benign medico, for I had to dash over to the hospital for a bit of the act that insurance companies ascribe to anonymous individuals called “providers”. Part of my dashing and flitting about routine required that I ask a favor from a certain hospital employee, and I dreaded the encounter. For reasons known only to his Maker this individual was armed with not one but two of the most lethal personality traits ever designed to bring doctors to their knees: apathy and whatever word describes the polar opposite of bonhomie. Having suffered [that word again? Wah wah wah! -Ed.] silently through several previous collisions with him I sighed and made my request. I began to count the perforations on the ceiling tiles as I awaited his decision re: springing into action versus withdrawing into the bowels of the hospital. I regretted not bringing a racing form to help pass the time.

While waiting for the muttering and drawer-slamming to subside let me make a confession: some of us in the medical profession are rather impatient. This of course speeds up things like having one’s gallbladder removed, or getting to the point of an office visit, also known as the “He walked in and walked right out” appointment. Being guilty to the ninth degree of such restlessness I naturally burned with humiliation at the treatment I received from this worker but maintained a cool disposition, and eventually received the vital information. I exited stage right as softly as a mouse tiptoeing over Marie Antoinette’s coiffure.

This turned out to be a smart move.

As my week dragged on the end slowly floated into sight, like a passing ocean liner appearing to a shipwrecked beachcomber. I glanced at the final few patients left to see and read a comment placed next to the name of a new patient on the list: “hospital employee”.

What can be described as a perfect example of foreshadowing rocketed into the proximal ear and promptly out the distal, which in itself became a perfect example of what the psychologists call “obtuseness”. Not until I fox-trotted into the exam room did I realize who was waiting for me within.

Saints preserve us - it was him! My bete noire sat before me stricken with cancer, here to seek relief from none other than lil’ ol’ me! He had the same blank look on his face as when asked to perform some official duty, but this time when queried he responded with bland but complete sentences. The man whose mission in life it seemed was to torment me was now on my exam table having his enlarged liver massaged and measured like a butcher preparing a choice cut of beef. He left our visit with this remark: “I know you can help me. I am ready to whip this.”

Before I get accused of the cardinal sin of schaudenfreude let me state with conviction that no devil appeared on one shoulder ready to throw the pitchfork at his heavenly adversary perched on the other. I admit I was walloped by the irony of the situation, but remembering that we oncologists don’t earn the weekly envelope from our modeling engagements, I strapped on the armor and did what I do best - come up with a plan to kill the loathsome disease and return my friend to his occupation. This is my only reason for justifying the shingle hanging outside in the boulevard. As that urbane, Noel Coward of comedy would admonish me, if he were leaning against the doorway in a tuxedo, martini in hand:

“Git ‘er Done!“

I guess the lesson learned this week is this: anyone can get cancer. Wise oncologists realize this and treat all they meet with the same respect they afford their current patients. This is how reputations get built and how people get excellent care.

Besides, now I have a new friend to rely upon whenever I need that favor in the future. The way I see it, it’s up to me to ensure that he has a future.

Gang aft agley,
An’lea’e us nought but grief an’ pain,
For promis’d joy!

Last night, wrapped in a dark, wispy heat left over from one of those egg-frying-on-sidewalk summer days, I spent a quiet hour or two out on the screen porch trying to absorb some cast-iron tome written to better one’s education. I believe it was on page 342 when I suddenly stood up and cried out “Enough!” My furry faithful companion, who was in her usual spot on the chair next to me, gave me a look like a bull trying to be milked. I quickly reassured her that my mental status was immaculate and we both hitched up our shorts and wandered inside to watch a bit of television before retiring. The first program I came upon was a highlight show from a previous Super Bowl in which my beloved St. Louis Rams lost as time expired.

I watched the program with about as much glee as Charles I felt when espying the lumberjack assigned to fell the royal tree. How painfully obvious it was to me that numerous strategic and tactical errors were made during the game that clearly cost us the championship. While my loyal consort drifted over to her favorite spot I grabbed the remote and began violently channel-surfing, only to stop on a World War II documentary on Operation Market-Garden. The narrator did a fine job chronicling the mistakes made by the Allies that probably cost us control of Berlin. Should we have poured more men and materiel into that attack or abandoned it completely? Should the Rams have blitzed on every play during that last Patriot drive? Should Monty have blitzed on September 17, 1944 instead of using one narrow road to the bridges?

It’s easy to find fault when using the proverbial retrospectoscope to examine tough decisions from the past that led to bitter outcomes. It’s daunting to make these choices in the here and now and then wait for the reports to come in with messages of either victory or despair. If one is overly cautious the enemy may survive long enough to become invincible; on the contrary if the troops are sent in recklessly they may fall like prairie grass before the scythe before critical adjustments can be made.

I picked up my snoozing sidekick and carried her with me upstairs, ostensibly to hit the hay. Something about those shows stuck in my mind though, and as lay beneath the sheets I realized that forming a treatment plan to kill cancer is sometimes like forming a battle plan. Patients present with life-or-death problems and doctors, like head coaches or pistol-packing generals, must devise a strategy to remove the invader without injuring the star quarterback, or destroying the village. The difficulty in creating a treatment plan is that doctors are never completely certain that their patients will survive the toxicity of chemotherapy, let alone achieve a response.

My dilemma therefore is this: do I go with the standard dose and schedule each time I start someone on treatment, as patients who are enrolled in clinical trials receive, or should I take into consideration mitigating factors such as age, prior radiation therapy or performance status? If I modify the plan because I’m afraid the patient will get sick I could be accused of giving “Friday night chemotherapy”, which is tailored to be just enough of a dose to not cause any symptoms that could lead to a phone call during some important weekend function.

I guess this is what they call the art of medicine. My sleepy thoughts that night ended with visions of head coaches pacing the sidelines…of generals standing before a large map studded with pins representing hundreds of souls. In both scenarios as in the world of cancer treatment decisions are made with the best possible intelligence available, using the most favorable of plans. Thankfully that is reassuring - up until the point when the snap is taken, when the first bullet whistles past the ear, when the patient leaves the office full of chemotherapy. From that point on:

…The game’s afoot:
Follow your spirit, and upon this charge
Cry ‘God for Harry, England, and Saint George!’

Hmm….I must already be dreaming….

…when heated in the chase,
so longs my soul, O God, for thee
and thy refreshing grace - or least two hours of uninterrupted sleep.

Let’s cut to the chase here: doctors who spend their apprenticeship not following some colorful Dr. Johnson-like character around the bustling alleys of London but toiling every third or fourth night away from home, awake most if not all of the night endeavoring to make at least a token attempt at keeping patients under their care safe from the Grim Reaper’s midnight rounds, become cranky over time. I say cranky, which is the most euphemistic description I could think of - other more truthful adjectives could have included dejected, sloppy, deceitful and angry. The graveyard shift is a trial by fire for young doctors. It can stretch the limits of fortitude by the nefarious way it insinuates into the daily schedule, viz.: after working all day to manage their patients’ “health care concerns” (as the glossy HMO pamphlet might say), these interns and residents stay at the hospital, usually without a fresh change of clothes, and work all night. Then as the first peach-and-champagne-infused rays of the morning sun sift through the window shades of their patients’ rooms, they get to relive the thrills of yesterday by raising the curtain on the same show just finished a few gongs of the clock earlier.

Some readers forced by great aunts to digest the classics will discern a pattern in this marvelous schedule designed to mold young mushy medical students into sharp, killing machines - oops! Sorry, must have been thinking of the movie “Tribes” rather than that one with George C. Scott in it, that influenced this budding paleontologist to decide to preserve old fossils rather than dig them up.

As those who labor under the full moon delivering everything from baby-to-mom or drunk-to-emergency-room know, strange and disturbing events occur during the night shift. Arguments between patrons of beloved taverns turn ugly, grudges are settled - sometimes with imaginative efforts of improvisation. I remember some of the outcomes of these scuffles, such as the woman who signed in wearing a carpet knife as a left earring, or the man who, after receiving a blast of 20 gauge shot point blank, could have auditioned for a role in the next Batman comic as the villain “Half-Face“.

Gruesome memories, these - but that is just the eruption from the graveyard hours, which occurs (thank heavens) infrequently. What really saps the spirit at 2-o’clock in the morning is the dull, continuous rumbling of interviewing sleepy patients. Let us recap - we know why the doctor is here, but why is the patient there? And why at such an annoying hour? I have fought to stay awake while admitting someone in the middle of the night, especially if they look upon this encounter as a golden opportunity to recite the mesmerizing details of their life, as if they were Scheherazade tickling the ear of the king of Persia. Not only does such loquacity drag out the mission of young doctors, it dulleth th’ edge of husbandry so much that sharp decisions are no longer automatically made, but are weighed against the attractive alternative to running down x-rays or performing a lumbar puncture, namely getting some shut-eye.

There is a way to combat this recurring nightmare of bad breath, greasy foreheads and slumping murder-victim-like into unit secretary chairs. It requires almost the same amount of foresight and discipline that got our boys up the cliffs at Pointe du Hoc, plus a little bit of that wonderful good luck floating around the universe. The secret is to design and follow a crisp routine faithfully - never wavering from it unless trapped in a firestorm of patient crises. The schedule varies from team to team, but can be outlined basically as follows:

5:30 P.M. Eat a hearty dinner, at least one worthy of praise from Lief Erickson and company.

8:00 P.M. Go to bed. Yes, that’s what I said - provided the patients are all tucked in and no black cloud looms on the horizon, don’t waste time watching the latest spectacle of televised tommyrot, or hang around the nurses’ station drooling over the Clara Bartons assembled there. Go to sleep, my lovely child - for who knows what pandemonium lurks ahead. The night is young - make good use of the sheets while you can.

1:00 A.M. Do what is commonly called the “lightning admission” - get the patient worked up and tucked away but fast, then jet back to the call room. Hopefully the case will be a routine and uncomplicated one, such as WADAO (Weak and Dizzy All Over). Pleasant Dreams!

4:50 A.M. It’s too late, baby, now it’s too late - you’ll never get your work done in time to jump back into the bunk so switch to Plan B: start drinking that java now. Two or three cups ought to be enough to get the old nervous system out of the phylum Porifera and back to the challenges of the coming day.

The graveyard shift cannot be conquered unless one defenestrates the beeper, bars the door and takes a chainsaw to the telephone, which might lead to an avuncular visit from the chairman of the residency program followed by a transfer to possibly a less attractive residency program. The infernal shift can be managed, though. With a sense of self-deprecating humor combined with the elusive ability to put oneself in another’s shoes, anyone can get through the night of work and still be able to tuck into a piping hot fruhstuck without nodding off into the midst of the plate. And if the gods of darkness smile not upon thee - despair not! Those who rattle their brains all night caring for sick folks can greet the dawn (if not their relief help when they ask the familiar question “How’d it go last night?”) with the battle cry of the survivor:

BOHICA!!

There are oodles of synonyms for the word “naive”, each contributing in its own colorful way to paint a portrait of an individual unencumbered by sophisticated attitudes such as wariness, cynicism, perspicacity, or weltschmerz. Think of these few descriptive terms: gullible, ingenuous, childlike, unseasoned, simple-minded, wide-eyed, patsy. The words conjure up a vision of one who is friendly and honest, but unlikely to be given any position of weighty responsibility like sentry, or head of security in a nuclear power plant.

I know, because like many cherubs who flitted about the heavens during the pastoral days of youth I was somewhat of a rube. The transition from Little Jack Horner to the hard-boiled medical gumshoe (complete with stubble and trench coat) I am now began when I worked the graveyard shift. It wasn’t just the wrenching disruption of the sleep schedule that did it, though that alone is enough to turn any soi-disant “model citizen” into a mattress-label-tearing grizzly bear. It was the responsibilities of the job description that tended to stress me out. I earned a paycheck for doing one thing and doing it promptly, with a smile on my face. My job was to serve others - patients, nurses, interns, visiting dignitaries, even wandering minstrels could have asked anything of me. Hearing a request for a drink, I was expected to dash to the Nile for a refreshing pitcher. With such conditioning I soon became a skilled automaton, much to the delight of the nurses who began to look at me like a hungry Greek ogling the cornucopia. I didn’t seem to mind the workload - because I was (ahem) still somewhat naive.

It was with this valet-like servitude that I answered a call light at around one-o’clock in the morning and found within the darkness of room 214 a young man lying stiffly on his back. He registered his awareness of my presence by snapping his head toward me like a flag in a stiff wind. Before I could ask the question, he sat upright and began to criticize his accommodations vigorously.

“Listen - I want out of here! I want you to get the doctor to let me go!” His unwashed hair lay smashed against his right ear, defying gravity. I was shocked - he was the youngest patient I had encountered in my brief period of employment. Although paler than me, he reminded me of myself, and I thought of that short story by Poe that had unnerved me last semester. Trying to recall how to address someone not a septuagenarian, I issued some standard there-there-everything’s-all-right blabber. He suddenly rolled over onto his stomach and showed off what turned out to be a textbook display of catatonia. It appeared that a friendly game of gin rummy was not in the offing, and I crept out of the room. The charge nurse gave me the details of his admission - PCP overdose from the E.R., no immediate family available, attending physician left few orders. She floated off down the hall, and I slowly turned toward the new sounds of moaning and laughing…coming from room 214.

What else but innocence could make me believe that I could reason with a lunatic? I went into his room again and again and tried to calm him down, only to break out in a sweat each time he confronted me. He had the glare of the striking cobra and the laugh of the mythical Yeti. After presenting my case for sending in the Marines, the nurse made a guest appearance in his room and tried to give him an injection. Our patient looked as if he had the jawbone of an ass hidden in his gown, and since I knew the outcome of the old Bible story I high-tailed it out of there, followed by the sister of mercy herself. I half expected the patient to come storming out into the hallway crying “Though ye have done this, yet I will be avenged of you!” - real fire-and-brimstone rhetoric.

The night dragged on. It seemed that rosy-fingered Dawn was out night-clubbing somewhere, for I thought my shift would never end. I pleaded with my compatriot to remain calm, but he wouldn’t listen. Just when I had finished making the morning pot of coffee I heard a hugh crash inside his room. Although I ran to the door, a sixth sense told me to open it with the same caution one sees being taken in those slasher movies - just before an unsuspecting head is lopped off. I peered into his chamber - and my skin crawled.

He was sitting at the foot of the bed holding a light bulb in a bloody hand. His lamp lay in pieces on the floor, and he chanted something like “it’s-time-it’s-time” or some other phrase designed to work as a laxative on authority figures like me. Now back in those days the rules for restraining patients were about as strict as the rules against enjoying a Lucky Strike at the nurse’s station - there weren’t any. This fact was not lost on me as we circled round his bed like two cowboys confronting a rattler. Why the heck didn’t we have him in a Posey vest if we knew he was unstable? How were we going to get that weapon out of his hand? Who’s running this insane asylum anyway?

The most pertinent questions always get asked at the most inopportune times, and as I tried to disarm him I kicked myself for not predicting this outcome - leaving a deranged drug addict to his own devices in a room laden with objet pointu. Necessity being the mother of improvisation, I decided to fight him on his own terms, and within the minute he was sans lightbulb and back in bed - soon to be enjoying the comfy-cozy feeling of four-point leather restraints. How did I do it? Easy - I started jabbering, Hamlet-like, in gibberish to him, calling him “fishmonger” and accusing him of breeding maggots. When he heard the same nonsense he was spewing coming from his fellow man he seemed to realize even in the throes of an angel-dust delerium he was acting ridiculously. Chalk one up to fast thinking and belief in the power of human understanding.

My experience working the night shift was invaluable as medical school began. I no longer feared sleep deprivation or strange patients. Soon I was crossing the stage of a large auditorium, mortarboard and hood in proper place, receiving the diploma that gave me the opportunity of a lifetime to work with cancer patients. I had only one hurdle to jump before I could hang out my sign and load up the closet with long white lab coats - the residency and fellowship. As I stood on the hill overlooking the school, the red sun setting behind me, I felt as if the world was mine to command. My internship in St. Louis started in ten days, and I was ready.

Somewhere in the far reaches of the galaxy my name was being called, followed by the sound of uncontrollable laughter. Not only did I still have a debt to pay to the graveyard shift, it had saved its biggest surprises for the upcoming years. My nighttime duties were about to take a leap forward - into the abyss.

Next: The Graveyard Shift, Part 3: Night of the Living Dead