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So I'm on my way to work and I stop to watch a pigeon fight a rat in the snow, and some fuckhead tries to mug me! Naturally there's a gun. He comes up behind me and sticks it into the base of my skull. It's cold, and it actually feels sort of good, in an acupressure kind of way. "Take it easy, Doc," he says.

Which explains that, at least. Even at five in the morning, I'm not the kind of guy you mug. I look like an Easter Island sculpture of a longshoreman. But the fuckhead can see the blue scrub pants under my overcoat, and the ventilated green plastic clogs, so he thinks I've got drugs and money on me. And maybe that I've taken some kind of oath not to kick his fuckhead ass for trying to mug me.

I barely have enough drugs and money to get me through the day. And the only oath I took, as I recall, was to first do no harm. I'm thinking we're past that point.

"Okay," I say, raising my hands.

The rat and the pigeon run away. Chickenshits.

I turn around, which rolls the gun off my skull and leaves my raised right hand above the fuckhead's arm. I wrap his elbow and jerk upwards, causing the ligaments to pop like champagne corks.

Let's take a moment to smell the rose known as the elbow.

The two bones of the forearm, the ulna and the radius, move independently of each other, and also rotate. You can see this by turning your hand from palm up, in which position the ulna and radius are parallel, to palm down, where they're crossed into an "X."¹ They therefore require a complicated anchoring system at the elbow, with the ligaments wrapping the various bone ends in spoolable and unspoolable ribbons that look like the tape on the handle of a tennis racket. It's a shame to tear these ligaments apart.

But the fuckhead and I have a worse problem right now. Namely that while my right hand has been fucking up his elbow, my left, having somehow come into position by my right ear, is now hooking toward his throat in a knife-edge.

If it hits, it will crush the fragile rings of cartilage that keep his trachea open against the vacuum of breathing in. Next time he tries, his windpipe will clench shut like an anus, leaving him at ReaperTime minus maybe six minutes. Even if I ruin my Propulsatil pen trying to trache him.

So I beg and plead, and coax the trajectory of my hand upwards. Past the point where it's aiming for his chin, or even his mouth -- which would have been disgusting -- to where it's aiming for his nose.

Which caves in like wet clay. Wet clay with twigs in it. The fuckhead crashes to the pavement, unconscious.

I check to make sure I'm calm -- I am, I'm just annoyed -- before getting heavily to my knees down next to him. In this kind of work, as in every kind of work, probably, planning and composure are worth a lot more than speed.

Not that this particular situation requires much planning or composure. I roll the fuckhead onto his side so he won't choke to death, and bend the arm that isn't broken under his head to keep his face off the frozen sidewalk. Then I check to make sure he's still breathing. He is, in fact with a bubbly joie de vivre. Also the pulses at his wrists and ankles are reasonably strong.

So, as is usual in these situations, I imagine asking the Great One -- Prof. Marmoset -- whether I can leave now.

And, as is also usual in these situations, I imagine Prof. Marmoset saying No, and What would you do if he was your brother?

I sigh. I don't have a brother. But I know what he's getting at.

I put my knee into the guy's fucked-up elbow and pull the bones as far apart as the tendons feel likely to bear, then let them come slowly back together into their positions of least resistance. It makes the fuckhead groan in pain in his sleep, but whatever: they'd just do the same to him in the ER, only by then he'd be awake.

I frisk him for a cell phone. No such luck, of course, and I'm not about to use my own. If I did have a brother, would he want me getting hassled by the cops?

So instead I pick the fuckhead up and fold him over my shoulder. He's light and stinky, like a urine-logged towel.

And, before I stand, I pick up his handgun.

The gun is a real piece of shit. Two pieces of pressed sheet-metal -- no grips, even -- and a slightly off-center cylinder. It looks like something that began life as a starter pistol at a track meet. For a second it makes me feel better about there being 350 million handguns in the United States. Then I see the bright brass ends of the bullets and am reminded how little it takes to kill someone.

I should throw it out. Bend the barrel and drop it down a storm drain.

Instead, I slip it into the back pocket of my scrub pants.

Old habits die harder than that.

In the elevator up to Medicine there's a small blond drug rep in a black party dress, with a roller bag. She's got a flat chest, and the arch of her back boosts her ass, so she's shaped like a sexy, slender kidney bean. She's twenty-six after a bit too much sun exposure,² and her nose is the kind that looks like a nose job but isn't. Freckles, I shit you not. Her teeth are the cleanest things in the hospital.

"Hi," she says like she's from Oklahoma. "Do I know you?"

"Not yet, no," I say. Thinking: Because you're new on this job, or you wouldn't have such shitty hours.

"Are you an orderly?" she asks.

"I'm an intern in Internal Medicine."

An intern is a first-year resident, one year out of medical school, so typically about six years younger than I am. I don't know what an orderly is. It sounds like someone who works in an insane asylum, if there are still insane asylums.

"Wow," the drug rep says. "You're cute for a doctor."

If by "cute" she means brutal and stupid-looking, which in my experience most women do, she's right. My scrub shirt is so tight you can see the tattoos on my shoulders.

Snake staff on the left, Star of David on the right.³

"You're from Oklahoma?" I ask her.

"Well yes I am."

"You're twenty-two?"

"I wish. Twenty-four."

"You took a couple of years off."

"Yes, but oh my God that is a boring story."

"It's okay so far. What's your name?"

"Staaaaacey," she says, stepping closer with her arms behind her back.

I should say here that being chronically sleep-deprived is so demonstrably similar to being drunk that hospitals often feel like giant, ceaseless office Christmas parties. Except that at a Christmas party the schmuck standing next to you isn't about to fillet your pancreas with something called a "hot knife."

I should also maybe say that drug reps, of whom there is one for every seven physicians in the U.S., get paid to be flirtatious. Or else to actually fuck you -- I've never been quite clear on that.

"What company do you work for?" I ask.

"Martin-Whiting Aldomed," she says.

"Got any Moxfane?"

Moxfane is the drug they give to bomber pilots who need to take off from Michigan, bomb Iraq, then fly back to Michigan without stopping. You can swallow it or use it to run the engine.

"Well yes I do. But what are you gonna give me in return?"

"What do you want?" I say.

She's right up under me. "What do I want? If I start thinking about that, I'll start crying. Don't tell me you want to see that."

"Beats going to work."

She gives me the play slap and leans over to unzip her bag. If she's wearing underwear, it's not of any technology I'm familiar with. "Anyway," she says, "it's just things like a career. Or not having three roommates. Or not having parents who think I should have stayed in Oklahoma. I don't know that you can help me with that."

She stands up with a sample pack of Moxfane and a pair of Dermagels, the Martin-Whiting Aldomed eighteen-dollar rubber gloves. She says, "In the meantime, I might settle for showing you our new gloves."

"I've tried them," I say.

"Have you ever tried kissing someone through them?"

"No."

"Neither have I. And I've kind of been dying to."

She hip-checks the elevator "stop" button. "Oops," she says.

She bites the cuff of one of the gloves to tear it open, and I laugh. You know that feeling where you're not sure whether you're being hustled or in the presence of an actual human being?

I love that feeling.

"The ward is a fucking nightmare," Akfal, the other intern on my service, says when I finally show up to relieve him. What "Hello" is to civilians, "The ward is a fucking nightmare" is to interns.

Akfal is a J-Card from Egypt. J-Cards are graduates of foreign medical schools whose visas can be rescinded if they don't keep their residency directors happy. Another good word for them would be "slaves." He hands me a printout of current patients -- he's got one too, though his is marked up and heavily creased -- and talks me through it. Blah blah Room 809 South. Blah blah colostomy infection. Blah thirty-seven-year-old woman for regularly scheduled chemotherablah. Blah blah blah blah blah. It's impossible to follow, even if you wanted to.

Instead I'm leaning back against the nursing station desk, which is reminding me that I'm still carrying a handgun in the inside pocket of my scrub pants.⁴

I need to stash the gun somewhere, but the locker room is four floors away. Maybe I should hide it behind some textbooks in the nurses' lounge. Or under the bed in the call room. It doesn't really matter, as long as I can focus enough to remember where I put it later.

Eventually Akfal stops talking. "Got it?" he asks me.

"Yeah," I say. "Go home and get some sleep."

"Thanks," Akfal says.

Akfal will neither go home nor get some sleep. Akfal will go do insurance paperwork for our residency director, Dr. Nordenskirk, for at least the next four hours.

It's just that "Go home and get some sleep" is intern for "Goodbye."

Rounding on patients at five thirty in the morning usually turns up at least a handful of people who tell you they'd feel fine if only you assholes would stop waking them up every four hours to ask them how they're feeling. Other people will keep this observation to themselves, and bitch instead about how someone keeps stealing their mp3 player or medications or whatever. Either way, you give the patient the once-over, keeping a particularly sharp lookout for "iatrogenic" (physician caused) and "nosocomial" (hospital caused) illnesses, which together are the eighth leading cause of death in the United States. Then you flee.

The other thing that sometimes happens when you round early on patients is that none of them complain at all.

Which is never a good sign.

The fifth or sixth room I enter is that of Duke Mosby, easily the patient I currently hate least. He's a ninety-year-old black male in for diabetes complications that now include gangrene of both feet. He was one of ten black Americans who served in Special Forces in World War II, and in 1944 he escaped from Colditz. Two weeks ago he escaped from this very room at Manhattan Catholic Hospital. In his underpants. In January. Hence the gangrene. Diabetes fucks your circulation even if you wear, say, shoes. Thankfully, Akfal was on shift at the time.

"What's going on, Doc?" he says to me.

"Not much, sir," I tell him.

"Don't call me sir. I work for a living," he says. He always says this. It's some kind of army joke, about how he wasn't a commissioned officer or something. "Just give me some news, Doc."

He doesn't mean about his health, which rarely seems to interest him, so I make up some shit about the government. He'll never find out differently.

As I start bandaging his reeking feet, I say, "Also, I saw a rat fighting a pigeon on my way to work this morning."

"Yeah? Who won?"

"The rat," I tell him. "It wasn't even close."

"Guess it figures a rat could take a pigeon."

I say, "The weird thing was that the pigeon kept trying, though. It had its feathers all puffed out and it was covered with blood. Every time it attacked, the rat would just bite it once and throw it onto its back. Go mammals, I guess, but it was pretty disgusting." I put my stethoscope on his chest.

Mosby's voice booms in through the earpieces. "That rat must have done something pretty bad to that pigeon to make it keep on like that."

"Doubtless," I say. I push his abdomen around, trying to elicit pain. Mosby doesn't seem to notice. "Seen any of the nurses this morning?" I ask him.

"Sure. They been in and out all the time."

"Any of the ones in the little white skirts, with the hats?"

"Many times."

Uh huh. You see a woman dressed like that, it's not a nurse, it's a strip-o-gram. I feel the glands around Mosby's neck.

"I got a joke for you, Doc," Mosby says.

"Yeah? What's that?"

"Doctor says to a guy, 'I got two pieces of bad news for you. First one is, you got cancer.' Man says, 'Lordy! What's the second one?' Doctor says, 'You got Alzheimer's.' Man says, 'Well, at least I don't have cancer!' "

I laugh.

Like I always do when he tells me that joke.

In the bed by the door of Mosby's room -- the bed Mosby had until the ward clerk decided he'd be less likely to escape if he was five feet farther from the door -- there's a fat white guy I don't know with a short blond beard and a mullet. Forty-five years old. Lying on his side with the light on, awake. When I checked the computer earlier, his "Chief Complaint" -- the line that quotes the patient directly, thereby making him look like an idiot -- just said "Ass pain."

"You got ass pain?" I say to him.

"Yeah." He's gritting his teeth. "And now I got shoulder pain too."

"Let's start with the ass. When did that start?"

"I've already been through this. It's in the chart."

It probably is. In the paper chart, anyway. But since the paper chart is the one the patient can request, and that a judge can subpoena, there's not much incentive to make it legible. Assman's looks like a child's drawing of some waves.

As for his computer chart -- which is off the record, and would contain any information anyone actually felt like giving me -- the only thing written besides "CC: Ass pain" is "Nuts? Sciatica?" I don't even know if "nuts" means "testicles" or "crazy."

"I know," I say. "But sometimes it helps if you tell it again."

He doesn't buy it, but what's he going to do?

"My ass started to hurt," he starts up, all resentful. "More and more for about two weeks. Finally I came to the emergency room."

"You came to the emergency room because your ass hurt? It must really hurt."

"It is fucking killing me."

"Even now?" I look at the guy's painkiller drip. That much Dilaudid, he should be able to skin his own hand with a carrot peeler.

"Even now. And no, I'm not some kind of drug addict. And now it's in my fucking shoulder, too."

"Where?"

He points to a spot about midway along his right collarbone. Not what I'd call the shoulder, but whatever.

Nothing's visible. "Does this hurt?" I say, poking the spot lightly. The man screams.

"Who's there!?" Duke Mosby demands from the other bed.

I pull the curtain aside so Mosby can see me. "Just me, sir."

"Don't call me sir --" he says. I let the curtain fall back.

I look down at Assman's vitals sheet. Temp 98.6, Blood Pressure 120/80, Respiratory Rate 18, Pulse 60. All totally normal. And all the same as on Mosby's chart, and on the vitals sheets of every other patient I've seen on the ward this morning. I feel Assman's forehead like I'm his mother. It's blazing.

Fuck.

"I'm ordering you some CT scans," I tell him. "Seen any nurses around here lately?"

"Not since last night," he says.

"Fuck," I say out loud.

Sure enough, a woman five doors down is flat-out dead, with a look of screaming horror on her face and a vitals sheet that reads "Temp 98.6, Blood Pressure 120/80, Respiratory Rate 18, Pulse 60." Even though her blood's so settled at the bottom of her body that it looks like she's been lying in a two-inch pool of blue ink.

To calm myself down I go start a fight with the two charge nurses. One's an obese Jamaican woman busy writing some checks. The other's an Irish crone cruising the Internet. I know and like both of them -- the Jamaican one because she sometimes brings in food, and the Irish one because she has a full-on beard she keeps shaved into a goatee. If there's a better Fuck You to the world than that, I don't know what it is.

"Not our problem," the Irish one says, after I've run out of things to complain about. "And nothing to do about it. We had that pack of Latvian cuntheads on the overnight. Probably out selling the lady's cell phone by now."

"So fire them," I say.

It makes both nurses laugh. "There's a bit of a nursing shortage on," the Jamaican one says. "Case you haven't been noticing."

I have been noticing. Apparently we've used up every nurse in the Caribbean, the Philippines, and Southeast Asia, and now we're most of the way through Eastern Europe. When the white supremacist cult Nietzsche's sister's founded in Paraguay re-emerges from the jungle, at least its members will be able to find work.

"Well I'm not filling out the certificate," I say.

"Sterling. And fuck the Pakistani, eh?" the Irish one says. Her face is remarkably close to the computer screen.

"Akfal's Egyptian," I say. "And no, I'm not leaving it for him. I'm leaving it for your Latvian shitheels. Stat."

The Jamaican one shakes her head sadly. "Won't bring the lady back," she says. "You ask them to do the certificate, they're just going to call a code."⁵

"I don't give a fuck."

"Párnela?" the Jamaican one says.

"I neither," the Irish one says. "Dim bitch," she adds, sort of under her breath.

You can tell by the way the Jamaican one reacts to this that she knows the Irish one is talking about me, not her.

"Just tell them to do it," I say, leaving.

I feel better already.

But even after that I have to take a slight break. The Moxfane I chewed up half an hour ago, along with some Dexedrine I found in an envelope in my lab coat and ate in case the Moxfane took too long to kick in, is making it hard for me to concentrate. I'm peaking a little too sharply.

I love Dexedrine. It's shield-shaped, with a vertical line down the middle so it looks like some vulvae.⁶ But even on its own, Dexedrine can sometimes make things too slippy to focus on, or even look at. On top of a Moxfane it can make things start to blur.

So I go to the medicine residents' call room to chill out, and maybe take some benzodiazapines I've got hidden in the bed frame.

The second I open the door, though, I know there's someone in there in the darkness. The room stinks like bad breath and body odor.

"Akfal?" I say, though I know it can't be Akfal. Akfal's aroma I will take to my grave. This is worse. It's worse than Duke Mosby's feet.

"No, man," comes a weak voice from the corner with the bunk bed.

"Then who the fuck are you?" I snarl.

"Surgery ghost,"⁷ the voice says.

"Why are you in the Medicine call room?"

"I...I needed a place to sleep, man."

He means, "Where no one would look for me."

Great. Not only is the guy stenching up the call room, he's using the only available bunk, since the upper one is covered by a complete run of Oui magazine from 1978 to 1986, which I know from experience is too much of a pain in the ass to move.

I consider just letting him stay. The room smells unusable for the foreseeable future anyway. But I've got that Moxfane Edge, and there's always deterrence to think about.

"I'll give you five minutes to get the fuck out," I tell him. "After that I'm dumping a bottle of urine on your head."

I turn the lights on as I go.

I'm feeling slightly more focused now, but still not focused enough to talk to patients, so I go and check labs on the computer. Akfal has already copied most of them into the charts. But there's a pathology report on a patient of Dr. Nordenskirk's who actually has insurance, so Akfal hasn't touched it. Dr. Nordenskirk doesn't let anyone who's not white or Asian interact with patients with insurance.

So I scan the report on-screen. It's a bunch of bad news for a man named Nicholas LoBrutto. The Italian name alarm in my head goes off, but I'm pretty sure I've never heard of this guy. And anyway mobsters -- like most people with options -- don't come to Manhattan Catholic. It's why I'm allowed to work here.

The key phrase in the pathology report is "positive for signet cells." A signet cell is a cell that looks like a ring with a diamond (or a signet, if you're still sealing your letters with wax) on it, because its nucleus, which is supposed to be in the center, has been pushed to the wall by all the proteins the cell can't stop making because it's cancer. Specifically, either stomach cancer or cancer that was stomach cancer and has now metastasized, like to your brain, or your lungs.

All stomach cancers suck, but signet cell is the worst. Where most stomach cancers just drill a hole through your stomach wall, so you can have half your stomach cut out and conceivably live, just not be able to shit solid, signet cell cancer infiltrates the stomach along the surface, producing a condition known as "leather bottle stomach." The whole organ has to go. And even then, by the time you're diagnosed it's usually too late.

The CT scan of Nicholas LoBrutto's abdomen is inconclusive about whether his cancer has spread or not. (Although, helpfully, he now has a 1 in 1200 chance of contracting some other form of cancer just from the radiation of the scan. He should live so long.) Only surgery will say for sure.

And in the meantime, at six thirty in the morning, I get to go tell him all of this.

Mr. LoBrutto? There's a call for you on line one. He didn't say, but it sounded like the Reaper.

Even for me, it's early to be wanting a drink.

LoBrutto is bedded down in the Anadale Wing, the tiny deluxe ward of the hospital. The Anadale Wing tries to look like a hotel. Its reception area has wood-patterned linoleum and a schmuck in a tuxedo playing a piano.

If it really were a hotel, though, you'd get better healthcare.⁸ The Anadale Wing actually does have hot 1960s nurses. I don't mean they're hot now. I mean they were hot in the 1960s, when they first started working at Manhattan Catholic. Now they're mostly bitter and demented.

One of them shouts out to ask where the hell I'm going as I pass the charge desk, but I ignore her on my way to LoBrutto's "suite."

When I open the door I have to admit it's pretty nice for a hospital room. It's got an accordioning wall, now mostly retracted, that divides it into a "living room" -- where your family can come eat dinner with you at an octagonal table covered with vinyl that looks easy to clean vomit off of -- and a "bedroom" with the actual hospital bed. The whole thing has floor-to-ceiling windows, with a view, at the moment, of the Hudson River just starting to catch light from the east.

It's dazzling. They're the first windows I've looked out since I got to work. And they backlight LoBrutto in his bed, so he recognizes me before I recognize him.

"Holy shit!" he says, trying to crawl away from me up the bed, but held back by all his IV and monitor lines. "It's the Bearclaw! They sent you to kill me!"

__________

1. And you can compare this to your lower leg, where the same setup is vestigial. The two bones of the lower leg, the tibia and fibula, are locked in place. The outer one, the fibula, doesn't even support weight. In fact you can take most of it out -- to use as a graft or whatever -- and as long as you don't fuck up the ankle or the knee, it won't affect the patient's ability to walk.

2. Doctors always know how old you are. We use it to tell whether you're lying to us. There are various formulas for it -- compare the creases of the neck to the veins on the backs of the hands and so on -- but they're not really necessary. If you met thirty people a day and asked them how old they were, you'd get good at it too.

3. The tattoo on my left shoulder -- winged staff, two snakes -- turns out to actually be the symbol of Hermes, and therefore of commerce. The symbol of Asclepius, and therefore of medicine, is a nonwinged staff with one snake. Who knew?

4. Scrub suits are reversible, with pockets on both sides, in case you need to run anesthesia or whatever but are too tired to put your pants on correctly.

5. "Stat" is short, though not very, for statim. "Calling a code" is what you do when you want to pretend you don't know someone's already dead.

6. In fact, the medical word for pubic hair, "escutcheon," means "shield," although in free-range humans only women's pubic hair is shield-shaped. Men's is naturally diamond-shaped, pointing up toward the navel as well as down toward the groin. Which is why women who shave their pubic hair into a diamond shape subconsciously skeeze you out.

7. This is an actual job, though it's not interesting enough to go into.

8. Think more money can't buy you worse healthcare? Forget the endless studies showing that the U.S. spends twice as much per capita as any other country, with results outside the top thirty-six. Take a look at Michael Jackson.

Copyright © 2009 by Josh Bazell