Blast | April 12, 2024

BLAST, TMR’s online-only prose anthology, features prose too vibrant to be confined between the covers of a print journal. “The Red Button” takes place in Southern California in 1974, when Jim Steck spent a year as a psychiatry resident at the University of California, San Diego. Part of Steck’s training involved a stint in the ER, where he found he had a natural aptitude for handling emergencies. A portrait of the doctor as a young man, “The Red Button” is an essay about the serendipitous and sometimes fateful process of discovering one’s true calling.

The Red Button

Jim Steck

 

In September 1974 I drove into La Jolla for the first time, in a rental car. I came from inland, from the Mojave Desert. Unlike most people, whose first day in the desert makes them worry about dying from thirst, I loved the Mojave right away. I loved the spaciousness and the regular arrangement of plants, like squares on a quilt. I loved the dry smell of mesquite. I stopped for lunch in Palmdale, and I commented to the teenage waitress how lucky she was to live in such gorgeous country. She looked at me as if I were insane and said, “It’s a godforsaken desert.”

When I crested the Torrey Hills, because I’d traversed dry country, the shore was all the more beautiful. Palm trees—the icons of the Biblical paradise—red-tiled roofs, and the tin-sparkling ocean. I had seen the village of La Jolla on maps, and I’d heard about “La Hoya,” the site of the University of California, San Diego, but it wasn’t until I arrived there for the start of my psychiatry residency that I realized the two places were the same.

I’d studied philosophy in college. I spent many hours debating the existence of God, of free will, and even of that most accessible of college objects, the chair. If only I’d first read Dr. Samuel Johnson, who, to disprove immaterialism, kicked a large stone and said, “I refute it thus.”

I gravitated towards psychiatry in medical school, partly to find out why I had been so fascinated by philosophy. The invention of psychoactive drugs was another reason I gravitated that way. This was the height of the hippie era, and we really did take drugs for spiritual reasons. During one winter vacation a friend and I went cross-country skiing in the Santa Fe National Forest, on psilocybin, and the juniper trees spoke to me, and I wasn’t surprised. I simply assumed I was communicating with some sort of Buddhist god.

 

I had always wanted to be young someplace warm. Orientation for the psych residency was held in a large conference room furnished with pastel stack chairs that held smudges nicely and flimsy tables that folded up like burning insects. Three walls were decorated with bland scenes of nature but the fourth had floor-to-ceiling windows looking out on a rooftop volleyball court, the Pacific Ocean, and patches of mist that came and went like guardian angels. I turned my chair towards the view and only half listened to the speaker, Dr. Nathaniel Hoffman, a short guy with a sharp chin and elfin ears.

“With the right combination of medicines,” he began, “You can be anyone you like. Personality is the sum of neurotransmitters, and every day modern psychiatry is discovering new transmitters and how to manipulate them. For example, I notice you there”—he indicated Dennis, one of the new residents—“you’re twirling your hair. You may imagine that you’re doing so voluntarily, but the truth is that twirling your hair, like cracking your knuckles and sewing-machine legs, is the result of excess dopamine. I could give you a dopamine antagonist like Haldol and stop your hair-twirling in its tracks.”

Dennis seemed miffed that he’s been singled out as a victim of his neurotransmitters. He was young-looking, with curly brown hair. His clothes—khakis, a tie, and a striped button-down shirt—were suitable for a high school graduation. He was the sort who was eager to be first to answer a question in class.

During Hoffman’s talk, half a dozen psychiatric patients wandered out to the volleyball court. Because it was a locked ward, the rooftop court was surrounded by a chain link fence, and there was netting over the top. The patients’ first volley lasted only until one of the players retreated into his own thoughts and ignored the ball.

“During your residency you will be making patients take many psychoactive medicines,” Hoffman was saying. “It’s only fair, therefore, that you see what these medicines are like. So, I’m going to distribute a different medicine to each of you, so that you can appreciate their effects.”

We residents looked at each other. We’d never heard of such an experiment, even in rumor.

“Of course, any of you have the right to refuse,” Hoffman said. I recognized, though, that Hoffman’s suggestion, like many activities in the residency, was mandatory.

I got Thorazine. Dr. Hoffman handed it to me in a little beige envelope, like a party favor. For about twenty minutes nothing happened. I got up to walk around, but when that seemed like too much trouble, I sat down in another stack chair a few feet away. I noted that the original chair was light blue and the second, yellow. At moments I began to worry about various things, primarily about having taken an unfamiliar medicine, but each time I started on a spiral of worry, my train of thought immediately cut off. I could almost hear a click, like the sound of a circuit breaker.

I headed toward the outdoor court, slowly, because now I felt as if I were walking through syrup. Six of the inpatients had managed a semblance of a game. They immediately struck a deferential pose; two of them muttered, “Doc.” A frazzled woman sidled up to me. She was evidently on a gradual withdrawal from “downers,” and asked if I could raise her dose. “They calculated the dose wrong,” she said.

I was handed the volleyball and I served. The ball went fitfully back and forth. When I rotated to the front I got it into my head that I would block a shot. When the opportunity arose, I tried to jump. My legs buckled, and I barreled into the patient across the net, who spent the rest of his hospital stay limping. I was singularly unconcerned. I hoped it was the effect of the Thorazine. “Our point,” I said.

 

I found a place to stay in downtown La Jolla, three blocks from Marine Street Beach. I didn’t have a car, and so every morning I walked to a bakery where I bought three croissants from a hippie who got up at four AM, served myself coffee in a Styrofoam cup, extracted an LA Times from a newspaper box, and took the bus up Torrey Pines Road to the campus. I didn’t at first realize how eccentric bus transportation was in Southern California, nor how unreliable.

My first patient, Anne, was a depressive, a fiftyish woman, a practicing Catholic, whose children had left home and who had been spending her days lying in bed, smoking and reading old magazines.

I admitted Anne to the ward and then discussed her with my supervisor, Dr. Matt Blankin. Dr. Blankin was a rival to Dr. Hoffman. He was a psychoanalyst, a Freudian, who had spent years in New York City listening to recumbent patients whine in an office with a clanking radiator and steamed-up windows, and he was having trouble adjusting to a more casual city. We met in his small office, which smelled of pine freshener and was decorated with posters by Klee and Magritte.

“I’m an analyst,” he announced. “That explains my perianal beard.”

I wished he hadn’t said that, because from then on I couldn’t think of anything else when I found myself staring at his goatee and mustache combination.

“What did you tell Anne?” he asked.

“I started her on Elavil,” I said.

“Antidepressants!” he said. “Chemicals! We have to get to the root cause.”

“I think it’s ‘empty nest syndrome,’” I said. “I suggested that one day a week she volunteer at the church’s daycare. I know that Catholic churches have opportunities like that.”

“What were her parents like?”

“I don’t know. They’re dead.”

The rest of our consultation continued along the same parallel tracks, though he did helpfully point out, in regard to Anne, that depressed people hate to be cheered up.

The next Monday the Torrey Pines Road bus was late. This was the sort of thing that happened randomly in Southern California, a reminder of the randomness of life. I arrived at the very end of medication rounds. Afterwards, Dennis, wearing one of his striped button-down shirts, took me aside.

“You weren’t here to prescribe Anne the prednisone for her asthma. I did it for you.”

Anne had chronic asthma, and I had put her on a week of prednisone for an exacerbation.

“Thanks, Dennis. My bus was late.”

“You come here on a bus? Who would do that?”

I shrugged. “Prednisone doesn’t need exact timing.”

“Sure. And if it was delayed enough, she’d be dead.”

That afternoon I met with my supervisor, Dr. Blankin, again. We first discussed Anne, but he seemed distracted. At length he put his palms down on his desk and said, “I received a complaint about you today.”

“Yes?” I said.

“Another resident noted that you were late.”

I could see that he’d made a mistake naming the complainant.

“My bus was late…. Sorry.”

“I have an assignment for you. I want you to read the chapter of my textbook entitled ‘Passive-Aggression.’”

“Okay.”

 

After two weeks, to tell the truth, Anne had not improved much. Enough time had passed for the antidepressants to kick in, and, following Blankin’s advice, I had avoided cheering her up. She sat unmoving in the common room, facing away from the television, responding to questioners only with a polite smile, as if she were a teenager dying to get away from a formal dinner. I’d been unable to find anything wrong with her parents, her weening from breast milk, her toilet training, or her eighth-grade confirmation party.

While I was detailing her plight to my supervisor, Dr. Hoffman knocked and came into the office.

“Sorry, Matt,” he said. “I thought you were alone.”

“We were discussing Anne Wright.”

“That prim, mopey woman whose children left her?”

“That’s the patient, yes.”

“Jeez, Matt. Just buzz her…. I’ll catch you later.”

“Buzz her?” I said to Blankin, after Hoffman left.

“‘Shock therapy.’ Electroconvulsive therapy. Dr. Hoffman’s big on it.”

Blankin eventually conceded Hoffman’s suggestion about Anne. It was the first time I’d administered shock therapy. I asked Dennis for his advice, thinking that his meticulousness would be advantageous in this setting.

“Just push the red button,” he said.

At ten AM on a Monday the anesthesiologist showed up on the ward to assist in the procedure. He started the IV and prepared the sedatives without fuss, except to ask me, “Does that front door lock from the inside?”

“Yes, of course,” I said. “A nurse will let you out.”

“Which nurse?” he said.

“Any one.”

At Anne’s bedside a young nurse, Lindsay, did most of the work. She swaddled the patient in a blanket and applied electrodes, like headphones, over Anne’s head and kindly brushed her hand against Anne’s cheek.

I noticed that there was indeed a red button on the console.

“Ready?” I asked Lindsay and the anesthesiologist.

“Yes, please, let’s get on with it,” he said.

I pushed the button. Anne stiffened and her eyes darted from side to side like a doll’s. Then she relaxed and after ten seconds moaned and tried to sit up.

The anesthesiologist quickly excused himself.

“Good job,” Lindsay said. I couldn’t tell if she were being ironic or not. “I’ll take care of her now,” she added.

When I left, I glanced at her from behind and noted that she had the sort of corn-fed figure that boys from the snowy Midwest dream about.

Electroshock therapy has had a bad reputation ever since Randle McMurphy underwent it, but orthodox psychiatrists are much in favor of it when antidepressants fail. They maintain that it causes no more memory loss than the depression itself does. Ernest Hemingway resented shock therapy, but David Foster Wallace and vice presidential candidate Thomas Eagleton didn’t mind. In Zen and the Art of Motorcycle Maintenance, Robert Pirsig decried electroshock, claiming that it wiped out his personality, but in real life he appreciated it.

 

I picked up another inpatient, a young woman in her twenties named Allison. The police had arrested Allison after she shoplifted a cheap umbrella. They were about to take her to jail until she explained that she needed the umbrella because there was a radiation beam aimed at her.

She was a skinny brunette whose looks may well have not changed since eighth grade. She was dressed in a tan midi dress with puffy sleeves, fashionable but un-San Diegan. She had attended an all-woman’s college in North Carolina for two years and then quit and relocated on her own to San Diego.

Her drug test came back negative. I asked her about the radiation beam.

“Oh,” she said. “I didn’t mean that.” Her voice was juvenile too.

“You made it up?”

She looked at me as if it were a trick question. “It was nothing,” she said. “It’s in the past.”

“What made you move to San Diego?” I asked.

“I wanted to learn to surf.”

“Me too,” I said. “I’m here because of the Beach Boys.”

She smiled uncertainly.

“I live right near the ocean,” I said. “I noticed some really big waves this morning.”

I didn’t know what to make of Allison. She seemed spookily solitary. I described her to my supervisor.

“Sounds like a borderline personality,” he said. “The mini-psychosis is typical.”

I knew Blankin would say something like that. “Borderline personality” was a newly described syndrome, characterized by “chronic feelings of emptiness, shifting self-image, fear of abandonment” and other traits that, as Dr. Hoffman pointed out, couldn’t be seen. Dr. Hoffman didn’t believe the syndrome existed.

 

I bought a car, a 1968 Austin America whose original cranberry tint had turned the color of dead leaves. The reverse gear gave out completely after a month, and so from then on I had to carefully plan which way I was going.

It was lucky that I’d bought a car, though, because after the holidays I was assigned to County Hospital, just north of Balboa Park. Like all county hospitals, its original progressive architecture—balconies, a big atrium with curved lines—had steadily deteriorated, resulting in rusted railings and cigarette stains on the windowsills.

My first week there I ran into Lindsay, the young nurse, again. For a few moments I watched her from a distance, humming and efficiently fashioning hospital corners on a patient’s bed. I tried to think of something clever to say to her, but she suddenly stood up straight and caught sight of me in that always-puzzling trick of peripheral vision. She wore green surgical scrubs that were a size too small for her.

She waved me over and said, “Come with me. I’ve got something to tell you.” She led me to the supply closet, flicked on the bare bulb, and closed the door. She seemed unaware that this would become a clichéd scene a decade later in shows like St. Elsewhere. I studied the rows of metal baskets holding syringes, rubber tourniquets, IV bottles, and gauze pads.

“I don’t know you very well,” she said, “but you seem like a nice guy, and I’ve got a proposal for you.”

“Sure.”

“Well, the head of our nursing program, she’s sort of old-fashioned, and maybe a little bit of a perv, but anyway she’s offering a hundred dollars for the first nurse to, you know, ‘get together’ with a doctor, and I want that money.”

“Well, sure, that sounds like something…. Here?”

“No, silly. I have to get to know you first. Over dinner at The Prado. Your treat. Saturday.”

I finally smiled. “Okay.”

She handed me a packet of gauze with her phone number written on it and the proposed time: 7:00.

I couldn’t tell how serious Lindsay was. Nothing like this had happened to me before, but I knew that she was from LA, and I had the idea that being from LA made a person more sophisticated—or rather, more advanced, more attuned to the future.

 

Blankin excitedly announced that Dr. Jack Nathan was coming out from New York to lead our next grand rounds. Dr. Nathan was a psychoanalyst and a national authority on the treatment of male homosexuality.

The subject patient was a short guy in his thirties. He had a pointed chin, jug ears, and a sallow complexion. He worked as a dishwasher. He looked like someone who’d been continually bullied in his youth, back when that was allowed. He came to the authorities’ attention when he stopped cars in front of his restaurant to warn the drivers about some unspecified threat. The police arrived, breathalyzed him for alcohol, and when they detected none took him to the ER.

All this happened before laws about medical privacy, and all of us residents knew the salacious details of this patient’s story; in particular, that in lieu of rent he provided some sort of homosexual services to the man whose house he stayed at, with both participants covered with a bedsheet. We heard that he attributed his behavior the night of his arrest to adulterated marijuana.

The patient sat in the middle of a particularly big circle because everyone wanted to see this expert analyst in action. Dr. Nathan began by nodding and smiling at the patient and then paused for so long that the squeaking and scraping of our chairs took over our consciousness.

“Tell me about your childhood,” Nathan said at last.

The patient grew up in a poor neighborhood in LA. His father was a long-distance trucker but perfectly fatherly when he was home. When the patient was four, his mother moved for a few months to Las Vegas to work as a card dealer and he was left in the care of his grandmother.

Nathan sat forward and seized on this revelation. “Did your mother phone you when she was in Las Vegas?” he asked.

“Naw. Maybe once or twice. It was long distance. Too expensive.”

“When she returned, did she have a gift for you?”

“I don’t remember. I was four years old.”

Nathan leaned forward even more. “Were you angry with your mother?”

“I don’t know. Probably. I was four years old. Probably I stayed mad for a day.”

Nathan smiled to himself. “Let’s move on to another topic. What do your regard as your sexual orientation?”

“My what?”

“Your sexual orientation. Do you have sex with women or men, or are you bisexual?”

“I’m trisexual. I’ll try anything.” He looked around to see if anyone appreciated the joke. A couple of people smiled.

“This sex under a blanket? Or bedsheet. Or whatever. You’d better get that behavior treated or you’re going to find yourself doing stranger and stranger things.”

The patient shrugged, unembarrassed.

Nathan blathered on about the interruption of the Oedipus Triangle and the patient’s early developmental arrest. Then Blankin asked the patient to return to his room and said they’d be discussing how best to help him.

Nathan said, “I welcome any questions from the residents at this time.”

One of the residents raised his hand and spoke: “So the patient wasn’t able to cathect the mother fully, and his bisexuality indicates he has an infantile libido?”

“Yes,” Dr. Nathan beamed. “You have it exactly.”

I raised my hand. I don’t know why I felt it was important for me to say what I was about to say, but it was like Samuel Johnson kicking the rock. I felt as if I were pointing out some obvious detail, like the windows being open during a rainstorm.

“Might this not,” I said, “be simply an example of the landlord exploiting the patient? I mean, he’s not paying any rent.”

Nathan surveyed the room, as if afraid that he was the object of a joke. Then he said, “I suppose. If you’re not looking at the case very closely.”

After grand rounds Dennis took me aside. I flinched because Dennis, who was becoming the star resident, usually contacted me only to criticize me. He grabbed my hand with both of his and said, “Thank you. I don’t think that patient could help being gay, and I don’t think it was his mother’s fault.” Then he abruptly walked away.

I considered what had just happened—being a psych resident I was always considering what just happened. To be honest, I hadn’t meant to make a statement of sexual politics. I had spoken up mainly because I didn’t like Nathan and I didn’t like authorities. Maybe I should have read that chapter about passive-aggression after all.

 

Anne continued to receive shock treatments at the other hospital, with someone else pushing the red button. One Sunday morning she showed up unexpectedly at County while I was on call. She wore a long brown dress with a subtle shamrock pattern. She brought along her two teenage daughters, also in long dresses. All three wore white gloves and little white hats pinned to their hair.

“I came by to thank you,” she said. She smiled. I’d never seen her smile before. I wanted to ask whether she thought it was the shock treatments that cured her, but then I feared that if I asked, she wouldn’t remember.

She sensed my dilemma and laughed. “Yes, it was probably the shock treatments, but it was you who decided to give me them.” The two daughters nodded in agreement.

Allison, the alleged “borderline,” was more problematic. We met back at University in Blankin’s office. She wore the same tan midi dress she wore when she was admitted to the ward. Her eyes went immediately to the Magritte poster.

“His head is an apple,” she said.

I glanced at the poster. “Yes,” I said. “So, how have you been doing?”

“That must be difficult,” she said. “How does he eat?”

“Uh, it’s just a picture. Someone made it up.”

“Oh.” She smiled benignly. “I’ve been doing about the same.”

We talked about La Jolla Shores, where she spent most of her days. She must have used a lot of sunscreen, because her face was as pale as the moon, so pale that occasionally I doubted that she really went to the beach. For some reason my conversation with her often veered towards earth science: the tides, the state of the morning fog, the cloud cover. She listened like a child whose parent was explaining why the sky was blue.

At one point she excused herself briefly to use the “ladies’ room.” When she returned her face was even paler. “What happened to that woman?” she asked.

She described a woman who’d just had shock treatment.

“She doesn’t know anything,” Allison said.

We talked about other things, but from time to time Allison shook her head, still thinking about the woman.

As if to cheer herself up, she announced, “I’ve got a boyfriend now.” Her voice was melodramatic, like that of an actress badly failing a screen test.

“Tell me about him.”

“He was with a bunch of his friends at the beach and he looked over at me and winked.”

I waited to hear more and then I said, “So, what’s his name?”

“Charles…. I think.”

“It must be early in the relationship.”

“Yes, that’s it.”

 

The Saturday of my date with Lindsay arrived. I parked several blocks away from The Prado so she wouldn’t spot my car. As I walked to the restaurant it occurred to me that her proposal might be a trick, and I waited outside until she actually showed up. I didn’t want to sit alone at a table, crunching tortilla chips and looking around for her.

Lindsay arrived wearing a black mini skirt, white keyhole blouse, and big hoop earrings. “I love this place,” she said, as if it were her vacation home. The Prado was indeed impressive, a white castellar building with a lot of filigree, perhaps the brainchild of a haciendado who’d inherited a thousand cattle. We sat outside under a red umbrella and took in the smell of butter and shellfish.

“Relax,” she said, “I’m not going to bite you…. What ever happened to that woman Anne who you buzzed?”

“Anne? Oh, that really straight woman. She got a lot better. She didn’t even complain about her memory. She stopped by with her daughters to thank me…. You seem to like psych.”

“I just like being a nurse.”

“Why did you choose…”

The waiter brought some sculpted vegetables as an appetizer.

“My father gave me three choices. I could be a secretary, but my spelling wasn’t great. I could be a schoolteacher, like my sister, but I just hated babysitting. So I chose nursing. I liked the uniform ever since I was a little girl.”

We talked about medicine, San Diego, and LA. It was fascinating to talk to someone who regarded LA life as normal—the smog, the traffic, the anomie. Lindsay was either insensitive or she’d achieved a Zennish tranquility.

We had a good dinner—paella—and then at Lindsay’s suggestion walked to her apartment, about seven blocks away. We walked alongside some undeveloped land that smelled of sage and it occurred to me that I was finally in the West of my adolescence, the West of Red River, Bonanza, and Riders of the Purple Sage.

“Birth control?” Lindsay said.

“Uh.”

She pointed to a 7-Eleven across the street. I scurried across and bought a pack of condoms, vainly hoping that the impassive clerk would regard me as a player.

Lindsay’s bedroom had a king-size bed with Christmas lights and plastic ivy strung along the backboard. We had wonderful sex. When we were done, she set a Polaroid camera with a timer on the dresser, posed us in bed with the sheet drawn up below our bare shoulders, and took a picture.

“That ought to do it,” she said.

“Do we share the money?”

She smiled. “I don’t think so. But we can do it again free.”

 

Like all psych residents I spent two months in the ER, where, after an initial orientation, I was to be treated like a physician from any specialty. I had to sew up lacerations, diagnose biliary colic, treat heart attacks, and stop kids from convulsing. The idea was that we psychiatrists should know enough general medicine not to mistake somatic illnesses for psychiatric ones. I supposed I was more up to the challenge than other residents, though not as prepared as “hand-up-in-the-air-to-answer-the-question” Dennis.

The ER was bedlam. There were gurneys in the halls and patients on the gurneys with their gowns askew, leaning over side rails to vomit. Cardiac monitors buzzed and dinged, and there were continual overhead pages, punctuated by “stat.” The place smelled like bodily effluvia and coffee. Nurses and doctors rushed to and fro, calling loudly to each other as if in a crowd at a football game.

I sat in the workroom waiting to be told what to do. One doctor strode in and said to no one in particular, “Where’s the record book?”

Another doctor pointed to a high shelf without looking up from his paperwork. A third doctor, standing at the light box and studying a chest X-ray, said, “Hey, do you think there’s a pneumonia here?” The paperwork doctor turned momentarily and said, “Right lower lobe.”

The first doctor took down a stained black composition notebook and turned to a page in the middle. “Hey, I think I’ve got a new glucose record. One thousand fifty-one.”

The overhead speaker interrupted, “Code Blue, ICU. Bed fourteen.” All the doctors paused, like crows on a road. Paperwork doctor said, “I knew it. That’s the guy I sent up with septic shock. I knew he was circling the drain.”

He noticed me for the first time. “You’re the new guy,” he said. “Psych?” He pointed the fingers of one hand at me and wiggled them—the traditional sign for psychoanalysis. “Let’s get you a patient.” He ducked out the door of the work room and picked up two hinged metal charts. When he stood up I noticed that he was tall and thin and had the carefully balanced posture of a heron. He glanced at the first chart and put it aside. “Not that one. She’s got hemodynia.”

“Hemodynia?”

“Pain wherever the blood goes…. Take the other one.”

I walked into the room in full imposter syndrome mode, but my white coat did the trick. The patient apparently believed that I was competent, maybe because I had taped over the phrase “Psychiatry Department” on my name tag.

The patient, a burly man with a military haircut left over from World War II, complained of abdominal pain but, as was customary with males, noted that “The wife made me come in.” I listened to him at some length—what else would I have learned in psychiatry? When it came to examining his belly I remembered a trick from one of my medical school professors: You don’t have to press hard, he said. I tapped on the patient’s belly lightly and discovered that he was exquisitely tender in the right lower quadrant.

I went back to the workroom to report to the paperwork doctor, Dr. Morrison.

“What’s he got?” he said when I finished reciting.

“Appendicitis, I think.”

“Call surgery,” he said and returned to his writing.

The surgeon on call didn’t notice that I was an imposter.

“Send him up to the OR in an hour,” she said.

This isn’t too bad, I thought.

 

My first weeks in the ER my supervisor was Dr. Morrison, a fifth-year surgical resident. He asked a few hesitant questions about psychiatry, but I could tell that he was puzzled by the existence of my specialty. More than once I presented a patient with a vague complaint, one that made no scientific sense, and he said, “Sounds supratentorial,” meaning that its origin was above the membrane that supported the brain, i.e., in the patient’s imagination.

At the end of my first week, however, I rose in his estimation. He was about to sew a laceration on a baby’s face, and he’d ordered a shot of a narcotic to pacify the kid. I passed by the patient’s room and the mother tentatively signaled me through the glass window.

I detoured into their room.

“Is my baby all right?” she asked. “I think there’s something wrong with her breathing.”

I didn’t know much about babies, and this one at first glance didn’t seem distressed. She was sleeping, the cut on her chin wasn’t bleeding. Maybe her cheeks were pale, but because the mother seemed like the sort of person who “didn’t want to bother anyone,” I accepted her observation. I stepped into the hall and gestured to Morrison. He came into the patient’s room and glanced at the infant.

Addressing me rather than the mother, he said, “It’s the Demerol. They always look pale like that.” And he hurried away.

I started to elaborate what Morrison said and I noticed that the kid’s lips and fingertips had turned a cerulean blue. My mind snapped into a detached but sharp-witted state. I pressed the red emergency button by the intercom. I unwound the oxygen tubing, applied the plastic mask to the child’s face, and started the oxygen.

I heard people running. Two nurses arrived, politely took the infant from the mother’s arms, lay her on the bed, and set about starting an IV on either arm. Morrison arrived and immediately ordered a third nurse to draw up Narcan, the antidote for Demerol.

The baby didn’t react to the nurse’s sticks. She was at an age when IVs are difficult, and both nurses failed at their first tries. One of them made a disappointed clucking sound.

“What’s the oxygen at?” Morrison asked. The third nurse returned with the Narcan. The only sound was the oxygen hissing. The mother stood at the bedside with her hands over her face.

I remembered another trivia from medical school: Narcan can be administered intranasally. “You can squirt the Narcan up the kid’s nose,” I said.

“What?” Morrison said.

I repeated what I’d said.

“Okay,” Morrison said to the third nurse. “Do it.”

She did, and within ten seconds the infant woke up and started crying.

In my hyper-perceptive state I heard several sighs of relief. The rest of the hospital people filed out.

“We’ll figure out some other anesthesia,” Morrison remarked on his way out.

“Thank you,” the mother mouthed to me, as if she didn’t want anyone else to hear.

Later, in the workroom, Morrison, without looking up from his charts, said, “Thanks. No one likes a dead kid.”

 

Allison was still troublesome. Most of our sessions were devoted to practicalities: how to find a job, how to meet people, how to keep occupied. Her purported boyfriend came up in conversation, and I asked her whether she still saw him and she said, “On the beach. He’s very shy.” One time she told me that she was thinking of having sex with her dog. My reaction was embarrassment rather than anything therapeutic. I mentioned this to Dr. Blankin and he said, “Crazy people say all kinds of things.”

Another time she said she’d seen me downtown. “You were at Alberto’s with your wife.”

“My wife?”

“A pretty woman with long, curly blonde hair.”

It was Lindsay. “Oh, that was a friend of mine,” I said.

Learning about this chance encounter, my supervisor talked about “transference.” “This is positive transference,” he said. “You remind her of a male whom she feels close to. Play up the transference to get her to take your advice.”

 

One of the psych residents arranged a party in the rec room of his apartment complex. It was a sizable room with big white and black linoleum squares and the odor of laundry detergent. The host served fruit punch and homemade canapés based on Ritz crackers. All the psych residents were male but several of us brought female companions.

“Who are you seeing?” a short fellow in a gray cardigan asked me.

I nodded toward Lindsay, who was twenty feet away. She wore a blue halter top fashioned from five cowboy bandanas.

“No, no,” he said. “I mean, for therapy.”

“Uh, no one.”

“Robinson’s good, if you haven’t picked anyone yet.”

The host put on a dance tape and two couples hesitantly began dancing.

“Well,” the short resident said, “we hope to see you around more.”

Several people watched our conversation. I got the impression that the short resident was an emissary from the psych department. I hadn’t been aware of how estranged I was. Lindsay and I circulated, overhearing phrases like “You’re just projecting” and “She’s so OCD.” Lindsay rolled her eyes. I don’t know why I had departed from our usual habit of eating well, having sex, and taking a walk in Balboa Park in order to attend this party.

Near the end of the party I was having another inane conversation with a psych resident. The music had been turned up and become more danceable: “Brown Sugar,” “My Sharona,” “Maggie May.” Someone grabbed my right hand and pulled me onto the dance floor. Dennis. He led me into a jitterbug whirl with a look that said, Please go through with this. And I did. Dennis, after all, was the one resident I’d had much contact with, and I’d felt embarrassed for him when we hosted that “expert” in homosexuality. Besides, dancing with him gave me that Hollywood liberal feeling, the same feeling you get from liking the movie Green Book or Driving Miss Daisy.

 

I settled into the ER. I liked it that patients talked fast rather than rambling and whining. I didn’t mind that their stories were scrambled, because I was a good listener and could organize their observations while they talked. It was as if the chaotic environment—the overhead pages, the groans and yells, the excitable machines—made me concentrate better.

I was allowed to see patients with less supervision. We were primarily triage doctors and diagnosticians. We enjoyed solving medical puzzles without the responsibility of making sure that patients came out all right.

Emergency physicians made no distinction between holidays and weekdays or between days and nights. Fluorescent lights were our sun. I worked several night shifts and the only difference from days was that my supervisor was maybe in the sleeping room and the cafeteria was closed, though the vending machines, whose arrangement of items I can recall even now, were still open.

One night around one AM we got a ring down from an ambulance about an old man who’d fallen off a ladder and was now unconscious. “What was he doing on a ladder in the middle of the night?” the nurse said.

The patient was a Mexican man whose driver’s license said he was in his seventies but who looked quite fit. He wore a blue western shirt with pearl buttons. The paramedics had put him in a plastic neck brace. The hair on the right side of his head was matted with blood and yellow paint. I dug my knuckles into his breastbone, as I was supposed to do. No reaction. I pried open his eyelids on each side and found that his gaze was as empty as an abandoned gas station.

I shone a pen light into each eye and discovered something. His left pupil was huge and didn’t react at all to the light.

“Jeez,” I said to the nurse. “Better wake up Dr. Chu. And call neurosurgery.”

The patient had a “blown pupil.” A blood clot was expanding next to his brain, and it was tilting his brain against the tentorium, the inflexible membrane beneath it, and strangling the nerve that ran along the bottom of the brain, the nerve that operated the pupil. Before the era of CT scans a blown pupil was the first sign of a major brain injury—and generally the last sign of life.

I skipped sharp-wittedness and went straight to fright. I went into the workroom to take the call back from the neurosurgeon. I kept wrapping and unwrapping the phone cord around my forearm while I described the situation.

“By the time I have coffee and drive to the hospital,” the neurosurgeon said, “he’ll probably be dead. You’re going to have to drill a burr hole.”

“I’ve never done that.”

“Have you ever seen it done?”

“Yes. Once.”

“You’ll be fine.”

The nurse came into the workroom. I held the phone and asked for a cranial drill. Her eyes opened wide. “The neurosurgeon said I could do it,” I said.

Dr. Chu, who was in his last year of internal medicine, appeared, rubbing his eyes, and I told him the situation. “I don’t do that procedure,” he said. “I’m going back to bed.”

Over the phone the neurosurgeon explained the procedure, step by step. He explained that the drill would automatically stop when it punched through the skull, and he advised me not to let up on pushing the drill, because if I did, the drill would get stuck in the bone. When he finished, I asked him what I should do with the circle of bone that the drill excised.

“I don’t know,” he said. “Throw it in the waste basket.”

I did it. I succeeded. I drilled a hole in the patient’s temple and the congealed blood oozed out like strawberry jelly from a broken jelly jar. I stood at the bedside holding the drill up like a trophy. The patient stirred, which under the circumstances was a positive sign.

 

My next shift, Morrison supervised. “I heard you saved a guy with a burr hole,” he said.

I admitted that I had.

“You ought to seriously consider emergency medicine for a career,” he said.

I took up Dr. Morrison on his recommendation. In May I sent a resignation letter to the psych department. I met no resistance.

One of my final tasks was handing over three outpatients. Dennis was assigned to replace me. Two outpatients were no problem, but Allison was troublesome. I’d been seeing her since late October and I can’t say I’d made any progress. She still spent most of her days hanging out on the beach. Her imaginary romance with Charles wasn’t going anywhere.

Allison, Dennis, and I met in Blankin’s office. I explained that I was leaving and that Dennis was actually the most accomplished resident.

“It smells like a pine tree in here,” she said.

Dennis listened politely to Allison’s account of her life, an account I’d heard a hundred times. I had to force myself not to glance at my watch.

 

A few days afterwards a fellow resident summoned me from the ER. “Dr. Blankin wants you to go to the M & M conference tomorrow,” he said. The “M & M,” or Morbidity and Mortality conference, was where doctors reviewed their mistakes.

Dr. Blankin presided. “Last night,” he said, “a patient, A. D., wrapped a pillow around her head and shot herself fatally in the brain. She’d been an outpatient on our service for several months and carried the diagnosis of borderline personality. Reviewing her recent visits, it’s evident that she was showing symptoms of depression: hypersomnia, feelings of emptiness, trouble making decisions.”

I knew immediately who it was.

“Was she on antidepressants?” a doctor asked.

“No. It was felt that she, being a borderline, wouldn’t have benefited,” Blankin said.

Another doctor asked, “What is the significance of the pillow?”

After the conference Dennis came up to me. “I’m so sorry,” he said. “I’ve already told the family.”

I’d been completely mistaken. I’d been regarding Allison in one way, and the truth was different. She had not been a colorful character, but a young woman playing dress up, and I had looked away, the way you look away when firewood bursts into flames.

I think about Allison two or three times a year now. At first I thought of her death as a product of my incompetence at psychiatry. Later I learned that it’s typical for a young psychiatrist to lose an occasional patient and that Dr. Blankin’s bland report wasn’t merely a rationalization but reflected the way that hardened professionals spoke. When I imagine Allison’s life now, as I somehow failed to do then, I could indeed detect “symptoms of depression.”

Now I see, to use a term from the era, that Allison was collateral damage. In 1974 I was a nomad, but by the next year I had found a place to be. In 1974 I was a floundering intellectual, but by 1975 (and ever afterwards in the ER) I’d achieved a clumsy compassion, whereby I behaved as if I were on a quiz show and my emergency patients would benefit, sometimes by staying alive. I found myself but I lost Allison.

***

Jim Steck graduated from Stanford’s writing program a long time ago. Since then he’s published dozens of reviews and essays. This is an excerpt from his first long work, a memoir of his working life as an ER doctor, tentatively entitled People Who Are Trying to Die.