Robin Cook: Godplayer

“He’s a charmer all right,” said Jacob. “Cassi, you should have called me. What time did he come in?”

“Two-thirty A.M.,” said Cassi.

“I take that back,” said Jacob. “You did the right thing.”

Everyone laughed, including Cassi. For once there wasn’t that substratum of hostile competition that had colored all her years of training. And none of the half-respectful, half-jealous commentary that had surrounded her relations at Boston Memorial since her marriage to Thomas Kingsley. Cassi hoped she would be able to repay their support.

“Anyway,” she said, trying to organize her thoughts. “Mr. Bentworth, or I should say Colonel Bentworth, U.S. Army, presented with acute alcohol intoxication, diffuse anxiety alternating with a depressionlike state, fulminating anger, self-mutilating behavior, and an eight-pound chart of his previous hospitalizations.”

The group erupted with renewed laughter.

“One point to Colonel Bentworth’s credit,” said Jacob, “is that he has helped train a generation of psychiatrists.”

“I had that feeling,” admitted Cassi. “I tried to read the most important parts of the chart. I think it’s about the same length as War and Peace . At least it kept me from making a fool of myself and hazarding a diagnosis. He’s been classified as a borderline personality disorder with occasional brief psychotic states.

“On physical examination he had multiple contusions on his face and a small laceration of his upper lip. The rest of the physical examination was normal except for his recent self-inflicted burns. There were slight scars across both wrists. He refused to cooperate for a full neurological exam, but he was oriented to time, place, and person. Since the present admission mirrored the last admission in terms of symptoms and since amytal sodium was used on the previous admission with such success, half a gram was given slowly IV.”

At almost the exact instant that Cassi finished her presentation, her name floated out of the hospital page system. By reflex she started to get up, but Joan restrained her, saying the ward clerk would answer.

“Did you think Colonel Bentworth was a suicide risk?” asked Jacob.

“Not really,” said Cassi, knowing she was hedging. Cassi was well aware that her ability to estimate suicide risk was approximately the same as the man in the street’s. “Burning himself with his cigarette was self-mutilating rather than self-destructive.”

Jacob twirled a lock of his frizzed hair and glanced at Roxane, who had been on Clarkson Two longer than anyone else. She was recognized as an authority of sorts. That was another reason why Cassi enjoyed the psychiatry service. There wasn’t the stiff structure that existed elsewhere in the hospital, with physicians implacably at the top. Doctors, nurses, aides, everyone was part of the Clarkson Two team and respected as such.

“I’ve tended to ignore the distinction,” said Roxane, “but I suppose there is a difference. Still we should be careful. He’s an extremely complex man.”

“That’s an understatement,” said Jacob. “The guy had a meteoric rise in the military, especially during his multiple tours of duty in Vietnam. He was even decorated several times, but when I looked into his army record, it always seemed as if a disproportionate number of his own men were killed. His psychiatric problems didn’t seem to show up until he’d reached his present rank of colonel. It was as if success destroyed him.”

“Getting back to the risk of suicide,” said Roxane, turning to Cassi. “I think the degree of depression is the most important point.”

“It wasn’t typical depression,” said Cassi, knowing she was venturing out on thin ice. “He said he felt empty rather than sad. One minute he acted depressed and the next he’d erupt with anger and abusive language. He was inconsistent.”

“There you go,” said Jacob. It was one of his favorite phrases, and its meaning was related to how he stressed the words. In this instance he was pleased. “If you had to pick one word to characterize a borderline patient, I think ‘inconsistency’ would be the most appropriate.”

Cassi happily absorbed the praise. Her own ego had had very little to feed on during the previous week.

“Well, then,” said Jacob. “What are your plans for Colonel Bentworth?”

Cassi’s euphoria vanished.

Then one of the residents said, “I think Cassi should get him to stop smoking.”

The group laughed and her tension evaporated.

“My plans for Colonel Bentworth,” said Cassi, “are…” she paused, “that I’m going to have to do a lot of reading over the weekend.”

“Fair enough,” said Jacob. “In the meantime I’d recommend a short course of a major tranquilizer. Borderlines don’t do well on extended medication, but it can help them over transient psychotic states. Now then, what else happened last night?”

Susan Cheaver, one of the psychiatric nurses, took over. With her usual efficiency, Susan summarized all the significant events that had taken place since late afternoon the previous day. The only happening out of the ordinary was an episode of physical abuse suffered by a patient called Maureen Kavenaugh. Her husband had come for one of his infrequent visits. The meeting had seemingly gone well for a while, but then there were angry words followed by a series of vicious openhanded slaps by Mr. Kavenaugh. The episode occurred in the middle of the patient lounge and severely upset the other patients. Mr. Kavenaugh had to be subdued and escorted from the ward. His wife had been sedated.

“I’ve spoken with the husband on several occasions,” said Roxane. “He’s a truck driver with little or no understanding of his wife’s condition.”

“And what do you suggest?” asked Jacob.

“I think,” said Roxane, “that Mr. Kavenaugh should be encouraged to visit his wife but only when someone can be with them. I don’t think Maureen will be able to retain a remission unless he’s brought into the therapy in some capacity, and I think it’s going to be hard to get him to cooperate.”

Cassi watched and listened as the whole psychiatric team participated. After Susan had finished, each of the residents had an opportunity to discuss their patients. Then the occupational therapist, followed by the psych social worker, had a chance to speak. Finally Dr. Levine asked if there were any other problems. No one moved.

“Okay,” said Dr. Levine, “see you all at afternoon rounds.”

Cassi did not get up immediately. She closed her eyes and took a deep breath. The anxiousness engendered by the team meeting had hidden her exhaustion, but now that the excitement was over she felt it with a vengeance. She’d had only three hours of sleep. And for Cassi rest was important. Oh, how nice it would have felt to just lay her head down on her arm right there on the conference table.

“I bet you’re tired,” said Joan Widiker, placing her hand on Cassi’s arm. It was a warm, reassuring gesture.

Cassi managed a smile. Joan was genuinely interested in other people. More than anyone, she had taken time to make Cassi’s first week as a psychiatry resident as easy as possible.

“I’ll make it,” said Cassi. Then she added: “I hope.”

“You’ll make it fine,” assured Joan. “In fact you did marvelously this morning.”

“Do you really think so?” asked Cassi. Her hazel eyes brightened.

“Absolutely,” said Joan. “You even drew a compliment of sorts out of Jacob. He liked your description of Colonel Bentworth as inconsistent.”

“Don’t remind me,” said Cassi forlornly. “The truth is I wouldn’t know a borderline personality disorder if I met one at dinner.”

“You probably wouldn’t,” agreed Joan. “Nor would many other people, provided the patient was not having a psychotic episode. Borderlines can be fairly well compensated. Look at Bentworth. He’s a colonel in the army.”