Orphan

During my first month as resident, I was assigned to the oncology service. I hated it. Any service on which patients routinely die during morning rounds upsets me. And there were always too many patients, most of them being treated for some terminal process with drugs that made them sick to just this side of death and not infrequently beyond. Some doctors enjoy this kind of challenge; I’m not one of them. It scared me. I was 20 years older than the rest of the residents in the hospital, and it shook me in some way I wasn’t able even to name. As if some vulnerability within me were waiting to declare itself. Something that, like cancer, I would discover only after it was too late.

Which may have been why, that month at least, I tended to leave the routine business of the service to my competent intern, Mike, and on the weekends didn’t mind looking after my orphan. “Orphan” is the name given to any intern admitting patients when her resident isn’t around; on weekends when I was admitting, one of my responsibilities was to supervise the orphan also admitting that day.

The current orphan’s name was Virginia; she went by Virgie, and she was assigned to the gastrointestinal, or GI, service. This is another subspecialty the house staff tends to regard with distaste, but compared to oncology it seemed to me a clean, well-lighted place. True, the patients include a fair number of GI bleeders, who require close watching but never quite buy the transfer to, say, a surgical bed that would get them off your census. You usually also have two or three patients in the final stages of liver failure, who are generally delirious, capable of taking sudden nasty turns, and infected with viruses you don’t want to bring home to your family. Add to that the pancreatitis patients (unstable alcoholics who withdraw under your care), the inflammatory bowel patients (unhappy), and the occasional fecal impaction (don’t ask), and you can understand why, when Virgie returned my page that morning, she sounded a little harried.

“Just checking in,” I said. “How’s your day going?”

“It’s horrible,” she cried. “We just finished rounding and I’ve got three discharges to get out and a float down in the ER I haven’t even seen yet.”

As problems go, I thought, this wasn’t bad. Discharges were a good thing. And the patient in the ER was probably stable. But for the sake of form I asked.

“I think so,” Virgie said. “Some bogus abdominal pain thing. But I don’t know when I’m going to see her. Could you go? I’ll get there as soon as I can.”

“Take your time,” I said soothingly. “Happy to help out.”

“Thank you thank you thank you,” she cried, and hung up.

I was happy, I realized as I made my way down the quiet back stairs to the basement. Somebody else’s patient to see. Already worked up. Probably not dying. More of a social visit than anything else.

Ten-thirty on a Saturday morning, and the emergency department was already busy. Most of the bays were occupied, and the noise was enough to make ordinary conversation difficult; there were shouts coming from one of the trauma bays on my right. I ran my eye over the bank of monitors suspended above the front desk, checking the list of patients for anything that looked like it might be coming my way. The one good thing about oncology was that it tended to get its admissions from clinic, and the clinic wasn’t open on weekends. But sicklers, intractable pain, clotting problems of various sorts, and the occasional blast crisis could come in at any time. And once the other services filled up, we would be in line for whatever needed admitting. But the board seemed clear for now, so I looked for the name Virgie had given me. I found her on the first screen, bay 7: “Stanley, A.,” her name in pink to indicate her sex. Her time of arrival the night before (10:42) was highlighted in orange, a token of the emergency department’s outrage at her continued presence here. This probably accounted for some of Virginia’s urgency about her pending discharges: she was undoubtedly getting pressure from bed control to free up space for incoming admissions.

I pulled the chart for bay 7. This is a bed at the front of the ER, where they like to keep the unstable ones. I wasn’t sure what there was about Stanley that merited this. I registered this question, like most questions in the hospital, as a pang, a surge of doubt that distracted me as I thumbed through the untidy stack of papers on the clipboard.

A. Stanley was a float—a patient worked up by the night shift and handed over to an intern the next morning for ongoing care. Floats are notoriously iffy: the system has too many cracks where orders, lab results, sometimes entire patients can get lost; and the workup, conducted by a resident whose internal clock is even more messed up than usual, can vary from merely sketchy to outright delusional. It had been drummed into me early in my training: always eyeball the float.

The admission note told me little. This was a 22-year-old female who had come in with a one-day history of nausea, vomiting, and abdominal pain. No significant medical history, no drug allergies, no sick exposures except to a dog known (how, I could not begin to guess) to harbor parvovirus B-19. It was clear this was a red herring included in the history in a display of mere thoroughness: factual, obscure, irrelevant. Ms. Stanley had endured her nausea, vomiting, and abdominal pain for approximately 12 hours, at which point she had attempted to treat it with a few Tylenol Sinus tablets. When those failed to bring relief, she came in to the ED.

As stories went, it sounded odd. Twelve hours of a bellyache don’t usually bring otherwise healthy young people to the hospital. I was left with a familiar mix of annoyance (this was wasting my time), relief (nothing horrible was going to happen), and dread (what was I missing?). According to this script, the lady shouldn’t have come in. But she had. And they’d put her up front in bay 7 where they could keep an eye on her. Why?

I scanned the rest of the note. The review of systems—that laundry list of symptoms with which we catechize admissions (“Anyfeverschillsnightsweatsweightlosschestpaincoughorchange-
inthecolorofyourstools?”)—added nothing to the history. Physical exam ditto: mild abdominal tenderness. Meaningless. The labs and x-rays seemed to rule out any specifically abdominal pathology. But there were two false notes that got my attention. Her white count was slightly elevated, indicating a possible infection. And her serum lactate was high. This was the one that made me stop and look up for a moment.

An elevated lactate accompanied by a high white count explained why they had lodged her in the front of the ED rather than stashing her in the back room with the sore throats and bladder infections. Lactic acid is a byproduct of cellular metabolism gone astray. In company with a high white count, it signals sepsis: infection at large in the circulation, and a patient hours away from the ICU.

None of which fit the innocuous history of A. Stanley.

I scanned the admission note again, wondering if there was anything I’d overlooked. But there was nothing there; the only other lab value remotely notable was the serum Tylenol level. We check Tylenol levels pretty frequently: it’s at once an extremely common and very nasty drug. Toxicity can occur at less then twice the recommended dose. And when somebody, in a suicidal gesture or simple confusion, downs an entire bottle, there isn’t much time to get help. If the antidote isn’t started within 12 hours of ingestion, the patient is basically dead (although the dying can go on for weeks). But given Stanley’s history and the time they had drawn the sample, the level they had gotten wasn’t worrying: it was consistent with a reasonable dose taken at the time she had reported, about four or five hours before. But they had thought to check: that was interesting.

The history didn’t do much for me except to rouse vague fears of doom—and what day in the hospital doesn’t do that? Abdominal pain and infection: the possible causes of such a pairing make a long list, and some of them can be serious trouble. Fortunately for my orphan the common ones—appendicitis, gall-bladder disease—are surgical issues. And until A. Stanley developed signs or symptoms of needing transfer to surgery, there wasn’t much for Virgie to do. Time would tell. We would watch her, and wait (as the saying goes) for her to declare.

That should have been all. But I thought again about the Tylenol, and I saw that the ED had been thinking about it too. They had started her on N-acetylcysteine, the specific antidote for Tylenol, around 6 a.m. Her levels didn’t warrant it, but it’s an innocuous drug (except for the taste), so I could see their logic. Not knowing what to treat, they had treated what they could.

When I look back at those years in the hospital, I can see that this kind of nervous second-guessing might seem, to anyone on the outside, hysterical. At the time, however, for me and I think for most of the house staff, it was simply a way of life. During those years, I always felt that I knew nothing. And no matter how much you did know, there was always more you didn’t. In that vast desert of ignorance always lurked that one detail waiting to kill somebody. Which was bad enough if you were prone to worrying about such things. What made it worse was that you were required—by the patient, the family, the intern—to look as if you knew what you were doing. You couldn’t turn and ask someone else. And you couldn’t count on second chances. I’d learned that years before.

So it must have been an irrationally optimistic impulse that made me look around again, hoping to find somebody who could tell me anything else about A. Stanley. But there was nobody. The nurse said only, “She’s a flake. When are you going to get her out of here?”

I knocked on the door, pausing briefly before pushing through. The room was dim. The bed occupied the back half. Curled up in it was a slender, pretty young woman under a cotton ER blanket and a tangle of sheets. She wore a hospital gown. The inevitable bag of saline hung over her, dripping through an angiocath taped to her left forearm. In the far corner, the usual pile of clothing, shoes, and purse lay heaped on a chair. The patient was already awake, watching me. In the other corner, behind the door, a long male figure sprawled half out of a chair, stirring as I entered.

I introduced myself. A. Stanley stretched slowly, propped herself up on one elbow, and took my offered hand.

“I hope you won’t think I’m bad,” she drawled. She said this with a sly half-smile, waiting for a reaction.

It was such an odd thing to say that I paused.

“Why would I think that?”

She shrugged, still smiling. “I don’t know.” And slowly she slid back down to the bed. She was still looking at me.

Somewhere over my right shoulder I was aware of the male form coming upright in its chair. It belonged to a skinny guy, also in his 20s, with scraggly chin hair and eyeglasses with fashionably small lenses, through which he peered with the expression of clueless concern common to young guys in hospitals with sick young women.

The oddness of her opening gambit hovered in the room. I didn’t know what to do with it, so I set it aside, plunging into the ritual. How did she feel? Not so good: her stomach hurt. When did that start? This morning—no, it’s yesterday now, isn’t it. She stopped with a giggle, and a girlish movement of the shoulders that made her seem ten years younger than she was.

We plowed on through, and I heard the same story I’d gotten from the admission note, minus the irrelevant dog. The repetition of the history should have been reassuring, but—oddly—it was not. I had been waiting foran inconsistency, something that might account for the strange atmosphere in the room, the opaqueness of her chart—waiting for anything, preferably something psychiatric and therefore harmless. But she wasn’t a nut. Her story was lucid, at least. And yet the strange atmosphere persisted. She giggled at odd moments, went shy at others, and generally carried on like a naughty teen. Something was off here, but I couldn’t figure it. She was a flake, I told myself. Her belly hurt. Watch her declare. I let the exam cement the story: a healthy young woman with normal active bowel sounds, slightly tender in the epigastric region.

Virgie came in, filling up the rest of the space in the room with her own awkwardness and hurry. I made the introductions, Virgie performed a perfunctory exam, and we excused ourselves.

Out in the ED it was getting on toward noon, and the noise level had gone up a notch; the hollering from the trauma bays had died down, but from everywhere else came the clamor of people speaking: words laid on words until they formed a resisting medium, a substance you could almost feel parting as you passed through. We retreated behind the counter and lodged against the cubbies, where I reshelved the clipboard.

“You’ve got to scan her belly,” I shouted over the din.

“Why?” Virgie spoke petulantly, out of the intern’s settled resistance to adding anything.

“Belly pain, white count. You’ve got to. And did you see her lactate?”

Virgie flustered. “She’s got a lactate?”

Then to cover her omission she started asking me all the questions you run through to find the cause of an elevated lactate. I knew the questions too. I just didn’t know the answers.

“You need to scan her belly,” I repeated. “Get it started down here.” I flipped through the papers on the board. “She’s written for a floor bed. She should probably be in stepdown, but the floor is all we’re going to get.”

“I can write her for frequent vitals.”

“Do that.” I handed her the clipboard. “But they won’t take them, you know.”

“I’ll keep an eye on her,” she muttered, as she scribbled orders.

I watched her, her hair astray, white coat grubby, clutching her pen between her teeth as she reached up to grab a new order sheet. There was a slightly wild look about her, an extra millimeter or so of white showing around her irises. The odds of Virgie keeping an eye on A. Stanley struck me as pretty slim.

“CT-abdomen-pelvis-w/contrast,” she wrote out. “Abd pain & ↑wbc/lactate.”

“Make it stat,” I added as an afterthought. “And tell her nurse.”

Despite what you may see doctors do on TV, I hardly ever order anything stat. You can get a bad reputation. Everyone knows that what you really mean is, I forgot to order this and I want to go home for dinner. Today it meant something else. Vague fears. Impending doom. Abd pain & ↑wbc/lactate.

* * *

Around four that afternoon, Mike, my intern, paged me to let me know we had two new admissions waiting in the ER: a young man with sickle-cell disease and joint pain and a chemotherapy patient who had been vomiting uncontrollably for several days. I told him to start on the sickler; sickle-cell pain crises are usually routine, and beyond the need to make sure the patient’s marrow and lungs are still working, management is a matter of ordering IV fluids and the narcotic of choice. I went to the nearest workstation to look up the records of the other patient, a young woman with metastatic breast cancer and a recent history of frequent admissions for nausea and vomiting. She had three young children and seemed to do better when someone took care of her for a change. We’d treat her and send her home; she’d take care of her children until she needed to come in again, and it would go on like that until one day she wouldn’t go home. Armoring myself dully against the implications of this, I lumbered down to the ER to talk to her, trying not to think about anything but the treatment of nausea.

I shoved the clipboard for bay 11 back into its slot and fished a blank order sheet off the top shelf. The shelf is a bit of a reach for me, and as I stood there, stretched high on tiptoe, I found myself staring at a pair of surgery residents a few feet away. I knew the senior, Sara Barnes, a fifth-year unusual among her kind for a businesslike civility with the other house staff. She was in earnest conversation with her intern, a sour-faced young woman who looked ready to quit. They were holding a large dark square of radiography print up to the overhead fluorescents. I recognized the patchwork of a CT scan. Sara gestured to a series of images on the middle third of the print.

“There, there, and there,” she was saying. “See it?”

“Yeah,” said the intern.

Sara ignored her tone. “It’s classic. They call it target sign: it’s pathognomic for intussuception.”

“Okay,” said the intern.

Medical-school facts surged up unbidden as my hand groped along a seemingly empty shelf. Intussuception: a surgical emergency; the bowel swallowing itself like a collapsible spyglass, cutting off circulation; deprived of oxygen, the tissue dies. And as it dies, produces lactate.

“We’ve got to find whoever ordered this,” Sara said, and her eyes started questing around the room.

My hand by this time had found the order sheet it was looking for, but I was no longer concerned with what my hand had found.

“Is that Stanley?” I called. “Is that Angela Stanley’s CT? I ordered that.”

It took Sara a moment to recall her gaze and focus on me. Then the two of them were around me, barking.

I let them go on, cherishing the growing warmth of my realization that they were talking about taking A. Stanley to the OR tonight. Even though this would ultimately benefit Virgie, not me, I couldn’t help but feel a flush of pride. Virgie would emerge from her call night with one fewer patient to round on in the morning. Good for Virgie. I was taking care of my orphan.

I still held the blank order sheet for 11 in my hand. Sara and her intern left, busy, satisfied. I placed a page to Virgie to let her know. And then I sat down to order ondansetron and ativan for the patient I’d just admitted in 11, whom I could still see, through a gap in the curtains, retching in a basin, a mauve turban askew on her hairless skull.

* * *

Around 8 p.m. I was up on 3 Central, passing through on my way from the ED, where our last two admissions of the day were still having the finishing touches added to their admission orders. I was on my way up to the cancer ward, where the patient in the turban was still vomiting. There was little purpose in my putting in an appearance, having ordered more ativan for her over the phone, but I felt the obligation. And the ER was making me weary. While admitting our full five patients, I had also helped Virgie with three more. She still had two scheduled transfers, both end-stage livers for transplant evaluation, coming in by plane from elsewhere, and both delayed by weather. I had no idea what weather might be conspiring outside to delay the air ambulance, but I was glad of it. My own intern had capped. We had survived. All that remained for me to do was to help Mike get his patients settled. Then I could scuttle off to my call room and try to sleep.

I ducked into the 3 Central nursing station and called up Virgie’s census. A. Stanley should be on her way off it, on her way to surgery. But you can’t take things like that for granted in the hospital, which is why transfers are dangerous; sometimes people fall into the cracks. I needed to check.

She was still on Virgie’s census,lodged inevitably in one of the rooms far down the hallway, at theend of a cul-de-sac. The back corner of 3 Central was not a goodplace to be. There was a (probably apocryphal) story about a patienton that hallway dialing 911: the nurse had ignored her call bell thatlong. The biggest threat to Angela Stanley, with her possiblygangrenous intussuception, was precisely this: an overburdened staffwho would not look in on a patient more often than the routine takingof vital signs. I wondered when Virgie had last looked in on her, andas I clicked through the workstation to get at labs, I punched inVirgie’s pager on the phone.

Stanley’s 7 p.m. labs were comingup on the screen just as the telephone rang.

“Virgie,” I said.She said something very fast and incoherent in return.

Or maybe itwas me. Certainly my own thoughts went suddenly too fast to follow asnumbers outlined in red seemed to fill up the screen.

“I just gota page from Core Labs,” Virgie was saying. I was forcing my eyes toattend to the numbers, forcing them to make sense. Two of Stanley’sliver chemistries, her AST and ALT, were over 10,000. The normalvalues are less than 50.

“Her LFTs?” I said. “I’m lookingat them right now.”

There was panic in Virgie’s voice.“What’s going on?”

The liver—that dense, strongly flavoredorgan that occupies the right upper quadrant of the belly—does agreat many things, most of which I could not recall at that momentbeyond a distinct sense that they were essential to life. Thetransaminases, AST and ALT, are chemicals the liver produces for usein its inscrutable tasks. When the liver is damaged, they leak intothe blood. What A. Stanley was demonstrating, as her transaminasesjumped from essentially normal levels on arrival at the ED the nightbefore to these sky-high values now, was fulminant liver failure.

I scanned the other chemistries, but nothing else was out ofline—yet: by morning, other numbers would start to waver and slideinto the red; the bilirubin the liver is supposed to clear from theblood would wind up circulating instead, tinting her eyes a muddyyellow; the coagulation factors the liver produces would start tofail, and she would begin to bleed. Then she would slip into a coma.And not long after that she would die.

And in a flash I knew whatwas doing it, as certainly as I knew where it would end. With onlyher transaminases out, it was unlikely that this was infection—theviral hepatitides don’t strike so quickly. Gall-bladder disease,ascending cholangitis—half a dozen other things I could think offailed to fit the presentation. And the intussuception? It was adistraction, irrelevant to the real issue. I knew what had destroyedher liver. I knew it as surely as I knew that, for all practicalpurposes, A. Stanley was already dead.

* * *

I stood upinvoluntarily, impelled by adrenaline. I had no purpose in mind, nonotion of anything I could do to change the course of things. It wastoo late to help A. Stanley; in a jumble of ugly images I imaginedwhat her next few days would be like. Just what I wanted as I stalkedtoward her room I had no idea: I wasn’t trying to do anything, orto learn anything as banal as why. I think I just needed to seeher.

The door at the end of the hall was ajar,light visible through the opening. I knocked once and went through.The bed in that room is wedged across the far end, the rest of theroom a long architectural afterthought. She was awake, her beddingdisheveled, the expression on her face inscrutable as she watched metraverse the floor. The boyfriend was not in evidence. The visitorchair was occupied by a well-dressed, older woman I took for themother. With a cursory nod at her, I knelt at the bedside.

“Ms.Stanley,” I said. I tried to sound calm.

“Hi,” she said. Shedid not giggle, but a smile flirted across her face, turning down topout at the end.

“How are you feeling?”

“Terrible. Thosehorrible doctors.”

“What doctors?” I remembered Sara Barnesand her intern. I wondered what they had said to her. If they hadseen the labs yet.

The pout became a look of frank distaste.“The surgeons.”

I glanced at her mussed bedclothes andsuppressed a smile. The surgical abdominal exam. “Mash on youpretty hard?”

“I thought they were going to cut me righthere.” She attempted a smile again.

“Did they tell you,” Ibegan, then stopped.

“That thing in my intestines? Do I reallyneed an operation?”

She looked puzzled, like someone who has beentold out of the blue she needs surgery. Nothing more.

I could feelat my back the mother shifting in her chair. I glanced at her. Shewas leaning forward, worried: her daughter needed anoperation.

“Ma’am?” I said finally. The mother cocked herhead. “Would you mind excusing us for a moment? I’d like to talkto your daughter.”

The mother, now more worried, told herdaughter she’d be right back, gathered up a large leather purse,and softly closed the door behind her.

I turned back to thepatient.

“Ms. Stanley,” I said.

“Yes?” A littlecoy.

“What did you do?”

The smile faded. Her eyes wentelsewhere.

“You know what I’m talking about.”

“No.” Shewould not look up.

“When did you take it?”

No answer.

“It wasn’t last night, was it?”

No answer.

“When didyou take it, Angela?” I never first-name my patients. But I calledher Angela, and I wasn’t sure if I was pleading or threatening.

Her hand made an angry shoving gesture, pushing a wrinkle acrossthe sheet.

“Angela, if you don’t tell me, you’re going todie. Do you understand that? You’re going to die. If you want anychance of living past the next three days, you have to tell me whatyou did.”

As if it matters, I said to myself, in that cynicalinner voice that kept me company throughout my residency. Butcertainly it sounded like it mattered. I was shouting. I was shakingwith something, some sensation so close to me I couldn’t identifyit. Did I really care? It is in the nature of the house staff tobecome uncaring (even though, in the hospital, not to care is to bebrutal). There is so much death and suffering and grief, and in themidst of it we still need to fill out forms, subject the sick toindignities and pain, try to eat and sleep and leave these needypeople as far away as possible. When I wasn’t too numb, I worriedthat I’d stopped caring. And now I was shouting, berating a dyingwoman because she wouldn’t tell me exactly what she’d done. MaybeI had too many feelings. Or none at all.

She didn’t speak,but she stopped the restless motions of her hands and held still onthe bed. I was still as well, and for a long moment neither one of usmoved.

“I’m hurting,” she said finally.

For a long timethere was another silence, a vast empty space,hurting.

“Where?”

“In here,” she gestured vaguely at herabdomen. And then her eyes turned up to meet mine. “Is that what itdoes?”

I nodded. She dropped her gaze back to the bedsheet, thefingers of her left hand spread over the fabric. A tear fell from hercheek to spot the linen beside her thumb. “I didn’t know,” shesaid.

Didn’t know what, I wanted to ask, but there were morepressing questions, and I never found out what she didn’tknow.

She told me, instead, how much Tylenol she had taken. Maybe30, maybe 40. She didn’t count. And not the night before. NotFriday night. She’d said last night when they’d asked her, but itwas Thursday she meant. Thursday night. Her voice was small,emotionless, tired. She had let her secret out, and it was much toolate to matter. I think she knew that without being told.

But Ihad to tell her anyway. I quietly explained to her the differencethat day made. It felt much more brutal than shouting. The Tylenollevel they had drawn in the ER was just a number: 15, I think it was.By itself, the number was meaningless. To interpret it, you had toknow how much time had elapsed between the taking of the drug and thedrawing of the blood. If it had been a matter of a few hours, then 15was a therapeutic drug level, and all was well. If it had been morelike 30 hours, then 15 was the tail end of a massive overdose,indicating a level that had peaked high in the toxic range more than24 hours before. And perhaps the worst of it was thatit didn’tmatter: her lie, her silence, made no difference to the story. Itwouldn’t have mattered if she had confessed right away. She hadcome to the hospital too late. The antidote the ED had given, out ofits characteristic pessimism, hadn’t been able to help her. Nothingcould. The only difference her lie made was to something far outsidethe realm of medicine.

I knelt there beside her while her tearsfell and her shoulders shook. I’d like to say that I held her, orsaid soothing words. But I don’t hold female patients, even whenthey cry, and I had no soothing words. I knelt there and watched her,and struggled to comprehend what I saw. But as I stared at her I knewthat it wasn’t her I was wondering about. She was pulling atsomething buried in me, something I did not want to recall.

Angelawas suspended, right here in front of me, between life and death. Herliver had failed. She would surely die. But just now, and for a whilelonger, she would lie here on her bed, her belly sore where SaraBarnes had poked it, and cry. She was alive and she was dead, somehowoccupying both states at once until the passage of time wouldcollapse them into one. And I knelt at her bed in some paralysis ofawe, powerless and hollow at the core.

I had felt that sensationonce before. Long before I went into medicine, back when I still hadhopes of making a living as a writer, my wife and I were invited to adinner party one oppressively hot Saturday in July. Our host, apleasant Swiss who taught German at my wife’s college, had prepareda meal of broiled fish preceded by a delicate, steaming soup—thekind of meal only a foreigner would think of preparing on a scorchingsummer day. But he was proud of it, and we had the sense toappreciate his cooking, and praised especially the soup, which wasthe least dense of the evening’s offerings, even if itsteamed.

“Wild mushrooms,” he said, explaining the subtleflavor of the broth. “My mother gathered them herself in theAlps.”

“Ah,” we said, and sipped the soup.

Thatnight around 2 a.m. we both awoke with belly pain. “The soup,” wesaid at once, aghast at the possibility even while we laughed anddismissed it, lying down to sleep again. But sleep would not come. Byhalf past two it was clear that something bad was going on, and tenminutes later it was equally clear that we could no longer laugh awaythe one idea that had seized our imaginations from the moment we hadvoiced it. I rose from bed to look up the number for poisoncontrol.

The voice at the other end of the line wasprofessionally calm, faultlessly polite. After a brief discussion ofour symptoms and the meal that had preceded them, the woman said tome, “It certainly does sound like the mushrooms. Unfortunately, ifthat’s the case, there’s very little that can be done: from thesymptoms you describe, I’m afraid it’s too late.” A briefsilence on the line, and then she spoke again. “But before you goto the hospital, you must call your host. He’ll need to contactanyone else who had the soup.”

I hung up the phone. I let my handlie on the receiver while a minute passed, looked at it as if it weresomething somebody had left there. It was three in the morning on asullen July night. Out the kitchen window I could see the full moonfloating in a brown sky. In a moment I would move again. In a momentI would go back down the hall and tell my wife what I had heard. In amoment.

I stood there for what seemed a long time, hearing nothingof the night noises, only a dull roaring in my ears, while I put offthe moment when I would move and time would begin again.

I pulledmy hand from the telephone and walked back through the darkenedhouse, stopping at the door of what we had wanted to be the baby’sroom. I stood there a moment and thought, So this is how itfeels.

That was all I could come up with: This is how it feels tobe dead. I stood at the door of the empty room for a long time,feeling nothing.

But we were not, of course, dead. Hans had beenjoking about his mother gathering mushrooms. He had bought them atthe Pathmark that afternoon. He was somewhat testy about this, alittle too annoyed with the 3 a.m. phone call to be properlyremorseful (I felt) about the spoiled fish he had served us after thesoup. My wife and I endured nothing worse than three days of nausea,a week of depressed appetite, and an aversion to mushrooms thatlingers to this day.

Nothing worse than that.

* * *

Asfor Angela Stanley, after she told me the time of her overdose, shebegged me not to tell her mother. Why not? I wanted to ask, but Irestrained myself. It was of a piece with whatever hurt she had beentrying to treat with Tylenol. And it no longer mattered. I told herher medical condition was nobody’s business but her own, and thatthe hospital would respect her privacy. It was up to her to tell hermother as much or as little as she chose. Then I left theroom.

I left under some sense of urgency, feelingthere were things I should do. But other than placing a few phonecalls, there wasn’t anything, really. The ED had already orderedthe antidote, and it was clear that wasn’t working. I let Virginiaknow what I had learned, and called the ICU to let them know theywould likely be getting a transfer before the night was over. Then Iremembered Sara Barnes, and called her as well. She was puzzled bythe information, liver failure and Tylenol toxicity not fitting intoher protocols any more than intussuception fit into mine, but sheconcluded that it didn’t change anything. The patient’s bowel wasstill a surgical emergency; her attending was on his way in; AngelaStanley was posted for the OR that evening. As for her liver: theconversation slid off into silence.

* * *

It didn’tend there. Even though Angela Stanley fell off my radar later thatevening as she was wheeled off to surgery, her mother following downthe hallway with an armful of Angela’s belongings to find her wayto surgical waiting, her story continued. I went home the nextafternoon, hearing nothing about Angela Stanley until several dayslater, when I learned that she had had an intussuception successfullyreduced before midnight Saturday. And that two days later she hadundergone a successful liver transplant. Her youth, her fundamentalhealth, the abruptness of her failure had all catapulted her to thehead of the list, and through another stroke of luck a suitable donorcame in on Monday morning, the helmetless passenger of a wreckedmotorcycle, and now she was in the surgical ICU, holding her own.

Over the next several months I continued to hearof Angela’s progress. There were the usual post-transplantproblems, and an episode of kidney failure that put her on dialysisfor a while. But the last I heard she was off dialysis and doing aswell as can be expected. Life with someone else’s liver is nevereasy: episodes of rejection, toxicities of immune-suppressing drugs,the threat of infection. But I lost eight patients that month, andAngela wasn’t one of them. A victory of sorts.

I’m left with alingering sense of satisfaction, one I know I’m not really entitledto, because my contribution, in the end, was to order a CT thatbought her an irrelevant surgery, and to force a confession, toolate, to something that was obvious anyway. But I’ll claim myvictories where I can. I’ll take my second chances when I findthem, earned or not. Maybe no one earns a second chance, anyway. Whowould be worthy of it? Angela’s out there somewhere, living herlife somehow, while others sicken and die waiting for transplantsthat never come. And we did have a baby, and even (God blessed us)another. I became a doctor. I’m writing again. I care again.Perhaps too much.

All victories are worth claiming, when we consider the alternatives. And when we recognize that all such victories are temporary, forestalling that dead moment in the middle of the night.