Unstrung

Take but degree away, untune that string, And hark what discord follows.

—William Shakespeare, Troilus and Cressida

Call the police. I'm being held prisoner!" I could hear the shrieks from behind the curtain in the emergency room. Brian, my intern, could hardly mask his expression of distaste. I couldn't blame him; it had been a long night already. We had just finished admitting a guy from prison who had spent five hours banging his head rhythmically against the bars of the stretcher, screaming violently when we tried to examine him. We had to wrestle him for a head CT and spinal tap, both of which turned out normal. In the end, his urine tox showed cocaine. If the ER had just waited for the urine tox results before admitting him, they could have spared us the wrestling match.

Now here was another crazy patient to deal with. I didn't want to do another useless CT and spinal tap on this lady, but the ER had insisted on admitting her to us before any of the labs were back. This was what residency at Bellevue Hospital was all about: crazy patients turfed to the medical service.

I settled into an old wooden chair at the clerks' desk and sipped my midnight coffee. The curtained cubicles of the ER were close enough to the desk to smell and hear everything. I tried my best to ignore the pervasive foot odor ("toxic sock syndrome" to those in the know) as I scanned the history scribbled on the ER sheet.

Lydia Kowalsky was a forty-eight-year-old Polish janitor from Brooklyn, by all accounts unassuming in character and impeccable in health, who had suddenly begun screaming and ranting at work. Now she was admitted to our team with the diagnosis of "drug overdose vs. psychotic break." Brian was copying down her lab values from the computer while preparing the CT scan form. He had gotten the hang of internship in the organizational sense—he always had lab slips and X-ray requests filled out way in advance—but didn't seemed particularly concerned with my role as the team leader.

On morning rounds today I'd been reviewing cirrhosis with our interns and students. When I'd mentioned treatment with beta-blockers, Brian had somehow steered the discussion toward the use of beta-blockers in coronary disease. I was left with my mouth half open while he gave a monologue on how beta-blockers affected the heart. I didn't want to be impolite and stop him in the middle, but I was peeved. Over the course of the two weeks we'd worked together, I'd realized that his knowledge base was not as broad as he made it out to be. There were a few topics he knew a lot about, and he made it his business to divert every clinical discussion toward them.

Brian was short, good-looking in an overcompensating, suburban sort of way—crisply gelled hair, expensive, casual Ralph Lauren clothing, cocky gait that had probably served him well in a Long Island high school. With senior attendings present, he was unctuously deferential, simpering about beta-blockers so he'd get a good letter of recommendation when the time came.

"Get away from me, you people. I'm going to sue!" came frantic shouts from behind the curtain. I craned my neck and made out an agitated white woman through the crack in the curtain. She had disheveled blond hair and the corpulent body type charitably called "pear-shaped." Her face was scrunched and reddened from screaming.

Another Bellevue classic, I thought as I tried to massage the crick out of my upper back. Just like the last patient. Let 'em chill for twenty-four hours. If the urine tox is clean, ship 'em off to psych in the morning. If the ER would just wait for the urine tox to come back, we'd all be spared this work. I couldn't control the yawn that seemed to hijack my entire body as I hauled myself to my feet. The "Roach...