The Sleepers

John Gamel

Santa Clara County Hospital was built in 1836 to care for the indigent citizens of San Jose, California. It served this function until the 1960s, when the board of directors decided to cash in on the Medicare boom by luring paying patients through their doors. They built a new wing filled with well-appointed private rooms. They changed the name to Santa Clara Valley Medical Center and forged an affiliation with Stanford University Hospital, but their efforts achieved only modest success. It was a matter of status. The aristocrats of northern California still referred to Valley Medical Center as the county hospital. They imagined its doctors were all hapless students, and they wanted nothing to do with the riffraff that crowded its charity wards.
    As an intern at Valley Medical Center during the early 1970s, I saw this snobbery in action. It stole from me a patient who became a landmark in my career when I diagnosed his disease at twenty paces. Late one night, halfway through my shift, I watched a nurse lead Mark Cisko into the ER. He was a student at nearby San Jose City College, a thin young man of average height, with olive skin and dark hair. His flushed face suggested a high fever. Even more compelling was a grimace that contorted his mouth every time he lifted his right foot to take a step.
    A voice in my head said, I’ll bet that kid has appendicitis. The moment he lay down on a gurney, I introduced myself, explained what I was about to do, then pulled up his shirt and gently pressed my fingertips on the right lower quadrant of his abdomen. He screamed in pain. An ER nurse measured his temperature at 103. A half hour later, when a CBC confirmed a high white count, I started an IV, then paged Sam Watanabe, the surgery resident on call that night. Sam examined Mark, glanced through his chart, and gave me a wink and a nod.
    “Good job, Gamel,” he said. “It’s been a slow night. Talk to the family, and we’ll get him up to the OR when ortho finishes their case. It shouldn’t be more than an hour.”
    So there lay my patient, his lab work done and his IV in place, scheduled for surgery within the hour. The OR nurses all agreed Sam’s appendectomies were the best, a work of art from the first cut to the last stitch. But it was not to be. My phone call to Mark’s mother in Los Altos Hills woke her up. As soon as she understood what was happening, she launched a string of invectives, then warned me that if any so-called doctor at that goddamn county hell hole laid a hand on her son, she would sue our pants off.
    The battle-ax proved as good as her word. A half hour later she stormed into the ER, a scrawny, enraged woman in a black leotard. A rope of disheveled hair swung down her back. Judging by her tantrum, one might have thought we were about to mutilate her son rather than save his life. Poor Mark. Feverish and writhing in pain, he groaned as attendants loaded him into an ambulance that would bear him fifty miles to a private hospital where his workup would have to be repeated. In all likelihood, the mother’s snobbery delayed his operation for hours. I don’t know how it went, but I imagined his surgeon to be a doddering old coot with an office in Los Altos Hills, the scalpel trembling in his hand as he tried to remember whether to make the incision on the right or the left side of the abdomen.
    Despite scenes like this, Valley Medical Center held its own with the landed gentry. Every ambulance driver in the county knew where to take the victims of wrecks and knifings and gunshots. Most of these patients had no insurance, but now and then a rich burgher with a crushed chest or a bullet through his abdomen would end up at Valley Medical Center. However fat his wallet, a man with blood pouring through an open wound was damn glad to see two or three of our doctors rush to his assistance the moment his gurney rolled into the ER.
    We also had our share of nontrauma patients. True, the nearby private hospitals offered posh lobbies, catered meals, a battalion of well-paid nurses, but at night, alas, their doctors all went home. Thus the truly sick, no matter how much they paid for medical insurance, often found themselves trundled off to our humble wards, where round-the-clock doctoring came at no extra charge. It was always a treat to admit these members of the upper crust. Their families—frightened by their loved one’s illness, and frightened even more when that illness took a turn for the worse—looked on in wonder as ambulance attendants wheeled the patient into a room at the disparaged Valley Medical Center. Moments later, when an intern young enough to be their grandson came to take a history and examine the patient, some of those family members were ready for the smelling salts.
    Yet we always won them over. We were always there. One night out of three, the interns worked a thirty-six hour shift, roaming the wards until the early hours of the morning. On the other two nights, they would go home at ten or eleven, but only after introducing their patients to the colleague who was covering that night. That arrangement beat the hell out of the typical private doctor, a busy fellow who dropped by for a five-minute visit once a day, then drove twenty miles down the freeway to his office or his home. Around the clock, seven days a week, the families huddled outside the ICU saw our doctors rush again and again to the bedside of desperate patients. And when a page operator announced, “Code blue in room A 23,” half a dozen doctors crowded into that room before a minute had elapsed.
    True, most of these were interns and residents training for a medical or surgical specialty, but the chain of command was carefully supervised. As an intern fresh out of medical school, my brain carried only a meager scrap of knowledge, but I was seldom more than fifty feet away from a junior resident who knew twice as much as I did. He or she answered in turn to a senior resident with three or four years of on-the-job training. At the top of the pyramid were the attending physicians, board-certified faculty members with decades of experience. They conducted rounds every day and staffed all of the major surgeries. Looking back on my time at Santa Clara Valley Medical Center, I can reach only one conclusion: irony of ironies, that disparaged hospital provided the best medical care in the county. I would not have hesitated to place myself or a loved one on its wards.

Of all the patients I encountered during my internship, one group holds a special place in my memory. I call them the sleepers—patients who lay motionless for days or weeks at a time, their eyes closed and their arms resting peacefully at their sides. They were my greatest burden, yet caring for them gave a compelling sense of power. Day after day, I attended to their every need, with no clue from the people who dwelled inside those still and silent bodies.
    Maria Gonzales, the most beautiful of all my sleepers, was six-years-old when I admitted her to the neurosurgery service. The girl had dark eyes and jet black hair that hung down to her shoulders, but fate is seldom swayed by beauty. She complained of terrible headaches. My examination revealed choked discs, swelling of the optic nerves caused by high intracranial pressure. An angiogram captured what radiologists call a “tumor blush” at the base of her brain. I had taken an elective in radiology and knew this phrase translated into “incurable cancer.”
    Adrianna, the unmarried aunt who brought Maria to the hospital, sat alone at the bedside many hours a day, her eyes glowing with tenderness as she stroked the girl’s hair, straightened her pillow, or held a cup of water to her lips. I learned from a social worker that Maria’s parents had deserted her soon after her birth.
    During my rotation on the neurosurgery service, our team had only an intern, a resident named Ron, and a tall, gaunt attending who had retired from the navy some years before. Ron and I called him the Admiral. He carried a pipe and chewed on the stem, though the pipe was seldom lit. When Maria’s angiogram had been completed, the three of us walked to the radiology department, where Ron lined up her x-rays on a view box. After a long, morbid silence, the Admiral spoke.
    “Oh, Jesus, it’s a glioblastoma.”
    “Yup,” Ron said, “no doubt about it.”
    “We’d better start the Solu-Medrol,” the Admiral said.
    “How much?”
    “A hundred milligrams a day.”
    I said nothing. There was nothing to say. The girl was doomed. The Solu-Medrol, a form of cortisone prepared for intravenous infusion, would lower her intracranial pressure and relieve her headaches for a few weeks, but nothing known to medicine could stop the tumor’s relentless growth. Her fate remained as certain as it was horrific.
    Maria did have three weeks of the good life. Her headaches vanished. She ran up and down the pediatric ward, spent hours watching TV and trading soft toys with the other kids in the playroom. During the evening, Adrianna sat the child on her lap and read her bedtime stories. When the headaches returned, Ron and I worked out the dosage of IV morphine needed to control her pain, but this made her drowsy, and soon she took to her bed. Adrianna now kept a round-the-clock vigil at her bedside.
    The nightmare seemed to go on and on. One morning I discovered lumps in the girl’s neck. The Admiral shook his head in amazement.
    “I’ve never seen this before—a glioblastoma that metastasizes outside the skull.”
    A few days later, Adrianna gave us yet more devastating news.
    “Maria doesn’t wake up very often, but when she does, she says the headache is terrible, and she claims she can’t see anything.”
    The Admiral, his face grim as death, opened Maria’s lids with his fingers and shined a flashlight into each eye. The light did not rouse the girl, and her pupils remained fixed and dilated.     “Yes,” he said, “I’m afraid the child is blind.”
    Adrianna’s face was blank. She stared into space as though blind herself, silent tears flowing down her cheeks. The Admiral gave her a hug. He seemed ready to speak again, then shook his head and removed his arm from her shoulder. Ron and I followed him down the hall to a conference room, where he waited for us to enter, then closed the door.
    “Well,” he said, settling into a chair, “the Solu-Medrol doesn’t seem to be working. We might as well stop it.”
    “Yup,” Ron said, “that sounds like a good plan. I’ll write the order.”
    Something about the idea bothered me. I probed my memory, seeking a fragment retained from an old textbook or lecture.
    “Wait,” I said. “You don’t mean we should stop it all at once. She’s been getting a huge dose for over a month, and that will sure as hell shut down her adrenals. Why, if we just cut her off cold, her blood pressure will drop like a rock.”
    It was a proud moment. I had dredged up a gem, an erudite fact that would save my mentors from a lapse in their reasoning, but Ron and the Admiral did not thank me. They gazed at me in silence. Perhaps they were embarrassed by their lapse or surprised by my precocious knowledge. The Admiral lit his pipe, took a few puffs, grunted to himself, and shook his head. Ron turned red in the face.
    “Jesus Christ, Gamel,” he said. “How dumb can a man get? Did your mother have any children that lived?”
    The Admiral’s plan worked. Over the next thirty-six hours, Maria’s blood pressure fell lower and lower. She died without regaining consciousness.

Granny Simpson, a seventy-year-old widow, distinguished herself as my most bizarre sleeper. During the course of a week, she worked her way through a cascade of three life-threatening disasters, all the while urging us to stop the treatments and let her die. Even her family opted for death, arguing that Granny had suffered enough.
    It started one night when ambulance attendants pulled Granny from her wrecked Cadillac and brought her to our ER. She had ruptured her spleen on the steering wheel. Lancy Allen, my senior resident that night, scheduled her for emergency surgery, then typed and cross matched six units of blood, but getting Granny to the OR proved an uphill battle. She refused to sign the consent form, insisting that she was a worn-out old lady with nothing left to live for. Soon her two grown children showed up and gave Lancy the same story: Granny had been deeply depressed for months, insisting time and again she would be better off dead. Why not let nature take its course?
    Lancy was at his wit’s end. Since Granny smelled of liquor and had just suffered a major trauma, she could not make a rational decision on such an important matter. The family kept talking about how the old lady was worn out and ready to die, but before the wreck, she had been in perfect health except for her depression. When Lancy spoke to the hospital’s lawyer, he said we should go ahead with surgery. To do otherwise, he insisted, would be nothing less than a mercy killing.
    So Granny was hauled off to the OR kicking and screaming in protest. Her surgery proved a close shave. The ruptured spleen had dumped pints of blood into her abdomen, dropping her blood pressure to a critical level, where it stayed until the anesthesiologist had given her several transfusions. The attending surgeon thought her liver was enlarged, suggesting alcohol abuse. Lancy wouldn’t buy it. True, she had liquor on her breath, but she was well dressed and her children seemed to be solid members of the upper class.
    Indeed, Granny didn’t look like a typical alcoholic, but on the third post-op day, she went into florid delirium tremens. By the time I got her tremors and hallucinations under control with generous doses of Valium, she was cyanotic, gasping for breath. A stat pulmonary consult diagnosed shock lung, a disorder caused by the prolonged drop in her blood pressure.
    For any hope of survival, I had to put her on a respirator, but she would have nothing of it. After she pulled out her endotracheal tube the third time, an anesthesia resident helped me set up a curare drip that would keep her paralyzed twenty-four hours a day. This turned Granny into a sleeper, but of a special type. She was awake yet couldn’t move a muscle, couldn’t even open her eyes. She lay still as a corpse except for the rise and fall of her chest in rhythm with the hiss . . . clunk . . . hiss . . . clunk . . . of the respirator. Her children visited the ICU every day. Now their protests reached a fever pitch.
    “Poor Granny, why do you doctors keep torturing her like this? Why don’t you let the old lady have her way? She’s miserable and wants to die.”
    Every other day, Lancy was on the phone to the hospital’s lawyer, who still insisted that so long as there was any chance the patient might lead a normal life, we should do all we could to save her. It mattered not that she and her family fought our every move.
    A week after this cascade of disasters began, her lungs were healed. Rather than becoming the corpse she had hoped for, Granny was a healthy woman, sober and clear-eyed, with no tremors and a recovering liver. Best of all, we could stop the curare drip. The moment we took her off the respirator, allowing her to speak, Lancy and I were astonished to find ourselves heroes. Every time one of us came near her bed, she grabbed one of our arms.
    “Oh, doctor,” Granny said, “thank you so much. I just can’t tell you how grateful I am. You saved me, and I’m so happy to be here, never felt better in my life.”
    Her family was even more effusive. They brought a huge basket of fruit for the ICU staff and sent a card to Lancy and me, a flowery message thanking us for saving their beloved mother. Most memorable of all was the gratitude shown by one of the granddaughters, a young woman with long blonde hair. The night she caught me in the hall outside the ICU, she wore a halter top and tight denim shorts. The encounter was stunning, a provocative hug that cracked my ribs. She leaned close to whisper a message. Our cheeks touched. I felt her warm breath on my ear. She would do anything, anything in the world, to show her gratitude. I’ve forgotten what I mumbled in reply, but I remember Lancy’s reaction when he heard of the encounter from one of the ICU nurses.
    “You jerk,” he said. “I’m the surgeon. I’m the one who saved the old girl’s life. If you had a decent bone in your body, you’d tell that granddaughter she ought to be hugging up on me. Besides, I’m single, and you’re married.”
    In the end, the story fell short of the fairy tale one might hope for. I kept in touch with Granny’s daughter, the mother of the affectionate granddaughter, and she told me that after the old lady’s discharge, she seemed to have a new lease on life. She joined AA, took up golf, and began keeping company with a gentleman who lived next door to her in an upscale retirement community. But within a few months, Granny fell off the wagon. The last time I spoke to her daughter, she had been thrown out of the retirement community for disorderly conduct.

George Caraway was a forty-five-year-old airline pilot who lived in Cupertino, a few miles from the San Jose Airport. When he developed progressive nausea, fatigue, and depression, his private doctor admitted him to a local hospital. According to the records, the doctor found no abnormalities on physical exam, but he described the patient as “lethargic and confused.” He ordered a battery of tests, then went home for a good night’s sleep. The next morning, all the lab tests were normal, but he was horrified to find his patient obtunded, almost comatose. The doctor considered all the relevant details of the case, including the fact that Memorial Day weekend began the next day. He dispatched George to Santa Clara Valley Medical Center, where I admitted him to the medical ICU.
    The first time I saw George, he inspired a strange thought: how could any doctor give up such a fabulous patient? Not that he was so handsome, but, lying in deep coma, his arms resting at his sides, he seemed beatific, an embodiment of peace and repose. The ICU was an open ward, so the medical personnel could move about freely. I noticed the orderlies and nurses kept looking over at him. Indeed, when not attending other patients, they often stood by his bed, gazing in wonder at his seraphic face.
    I examined George from head to toe and found no abnormality except for his coma. Harvey Fitzgerald, my resident on the medicine service, had no better luck. Together we looked through the records sent over with George from the private hospital.
    “Damn,” Fitzy said, “here’s an EKG tracing, but there’s no report.”
    “Ah, too bad,” I said, but my own heart fluttered with excitement. During a cardiology elective, I had learned to read EKGs, and on the tracing I saw marked shortening of the QT interval and a prolongation of the T wave. These were the signs of hypercalcemia, an elevation of the serum calcium, which can lead to depression and coma. What a treat—Fitzy had missed the clue.
    Rather than tell him of my discovery, I decided to wait for cold, hard proof—a measurement of George’s serum calcium. Since the assay was complex and expensive, it was not included in the routine lab tests performed during that era. I received special clearance from the pathologist on call, and two hours later, I had my ace in hand. George’s value was grossly elevated, high enough to alter his EKG and put him in a coma. I hunted down Fitzy at the A-ward charting desk.
    “Take a look at this,” I said, handing him the lab slip. “George’s calcium is off the chart. That’s what put him in a coma.”
    Fitzy looked at the slip, then glowered at me. I was delighted to see that my coup, plus my obnoxious grin and triumphant tone, had pissed him off.
    “Well, smartass,” he said, “you got any idea what’s causing this?”
    “Uh . . . no, I don’t.”
    “And treatment—got any thoughts on that?”
    “Uh . . . no.”
    “Then you’d better get busy.”
    Despite our childish egos, Fitzy and I were pleased by what we found in the Merck Manual of Diagnosis and Therapy, a helpful volume the nursing supervisor kept on every ward. The section on hypercalcemia included a long list of possible causes, and most were benign or amenable to treatment. Perhaps George had overactive parathyroid glands. Perhaps he suffered from an inherited disease or had taken too much vitamin D or too many antacid tablets. Though the list also included bone cancer, we agreed that this diagnosis was unlikely, since all the data gathered so far revealed no hint of malignancy. But a few hours later, our optimism collapsed when a radiologist paged Fitzy with devastating news. George’s x-rays showed that his body was riddled with hundreds of lytic lesions, cancerous nodules that had dissolved his bones and released calcium into his blood.
    This left us with only one question: where had these tumors come from? The radiologist felt certain they were not from the lungs, so we requested consults from oncology, gastroenterology, and urology. In the end it was the urology resident who found the answer. After his first exam, he pronounced George’s prostate unremarkable, but the next morning I found him back at George’s bedside.
    “I lay awake half the night,” he said. “Couldn’t quit thinking about this guy. The book says those mets most likely came from his prostate, so I decided to take another look, and this time I convinced myself things don’t feel quite right. There’s no obvious lump, but I don’t like the texture of his prostate, especially the left lobe. I’ll be back this afternoon for a needle biopsy.”
    Bingo. The next day, I was at the ICU charting desk when a clerk delivered the pathology report from the biopsy. George’s cancer had come from his prostate. It was a terrible moment. Not twenty feet away, his wife and two teenage children stood beside his gurney, gazing down at his peaceful face. The wife was a thin, nervous woman with dark circles under her eyes. I rehearsed in my mind the speech I had to give: Ma’am, I’m afraid we’ve got some news, and it’s not good. No, I had a better idea. I paged Fitzy and told him about the biopsy.
    “Look,” I said, “I had to tell George’s wife about the mets in his bones. Now it’s your turn.”
    A few minutes later, he arrived in the ICU, gave me a look that said I was a rotten coward and would owe him big time, then led George’s wife down the hall to the hospital chapel.
    Would that this had been the end of George’s story. It was clear that we needed to do nothing. Which is to say, let the poor man die quietly, unaware of the horrible disease that consumed his body, but soon after the biopsy report, an enemy leapt upon us.
    During my years at Stanford University Medical School, the oncology department had an extraordinary reputation: it was both famous and notorious, a collection of brilliant lunatics. They won millions of dollars in research grants. They published hundreds of papers in prestigious journals. But at their worst, they tormented cancer patients with a consuming and irrational passion, a passion that often served only to prolong hopeless misery. Dr. X., the department’s long-standing chairman, was so frantic and aggressive in his treatments that a dark joke haunted him throughout his tenure. According to the joke, Dr. X. rushes to a graveside just as pallbearers lower the coffin. “Wait! Wait!” he shouts. “There’s still time for one more dose of 5-FU.” Five-fluorouracyl, or 5-FU, is a toxic drug used to treat advanced malignancies.
    When we discovered the cancers in George’s bones, an oncology fellow from Stanford had answered our request for a consult. Trained by Doctor X. and his minions, he did an excellent job. His report included a list of the organs from which the tumor might have spread and a list of the tests we needed to perform. It also included a treatment protocol for lowering serum calcium, but with no hope for a cure, we had decided against bringing George out of his coma. Our plan seemed obvious—the only compassionate thing to do—but two days later, Fitzy paged me to the ICU. When I found him at George’s bedside, he was fuming and red in the face.
    “What happened?” I said.
    “It’s that oncology fellow from Stanford. He came back for a follow-up consult and chewed me out. Called me a terrible doctor, threatened to sue me for malpractice.”
    “What?” I said. “Where’d that come from?”
    “He wants us to go after George’s hypercalcemia, pull out all the stops so we can wake him up.”
    “Wow,” I said. My spirits lifted in a surge of euphoria. “You mean they’ve got something new, a drug that might wipe out all of George’s mets?”
    “Oh, god no,” Fitzy said. “That moron made it clear—there’s nothing new for prostate cancer, nothing at all. They’re still stuck with 5-FU. This guy wants us to start pouring it in right now. Maybe it’ll shrink the tumors by 50 percent, but only if we give whopping doses. The best we can hope for is a few weeks, a month or two at most.”
    I stared at Fitzy. My brain struggled to take in this lunacy.
    “Wait a minute,” I said. “They want us to wake the man up so we can tell him he’s a goner, tell him he’ll spend the last weeks of his life writhing in pain from his tumors and puking up his guts from the 5-FU?”
    “Yeah, that’s pretty much it.”
    Despite the oncologist’s deranged ideas, in the end all went well. Fitzy sat down with the ICU director, a senior attending at Valley Medical Center, and together they worked out a scheme. We gave George intravenous diuretics and calcitonin, the standard treatment for hypercalcemia, plus a few milligrams of 5-FU, but the doses weren’t quite enough to do the job. I wrote a standby order for IV morphine in case he woke up screaming with pain, but it was never needed. For the next five days, George remained as calm and peaceful as a sleeping baby. He died without stirring a limb.

My most prestigious sleeper was Michael Burns, a ten-year-old whose father had served as the mayor of San Jose and the head of the county school board. The trouble began when a pediatrician treated Michael with aspirin for what seemed a typical case of influenza. Within hours, he developed intractable vomiting and was admitted to a private hospital for intravenous rehydration. At midnight, a nurse summoned the pediatrician from home. Michael’s urine output had dropped to almost nothing. Worse yet, he had become confused and disoriented. This deterioration in mental status gave the final clue: Michael had Reye’s syndrome, a mysterious affliction that devastates the brain and other vital organs. There was no proven treatment, but the pediatrician proved to be a clever fellow by shipping Michael to Valley Medical Center.
    At 3:00 am, as ambulance attendants transferred him to a bed in the ICU, I introduced myself to the parents. It was an awkward encounter. Among the three of us, not one had slept in the past thirty-six hours. We all sagged from exhaustion. Somehow they had managed to dress for the occasion in a suit and a stylish dress, as though they were going to church. I wore rumpled OR scrubs. Their faces were pale and blank, with staring eyes.
    Their son lay a few feet away, a beloved golden-haired child, but his body already had the urinelike stench brought on by liver failure. The father was so distracted, I had to repeat my questions two or three times before he could muster an answer. The mother was silent. Again and again they turned to watch the ICU nurses as they tucked the boy into bed and attended to his IV. He was delirious, screaming at the nurses, flailing his arms and legs in a wild struggle to resist their ministrations. I had attended a lecture on Reye’s syndrome during medical school and knew the dreadful truth: the boy would soon be in a deep coma.
    In 1962, Doctor Douglas Reye, an attending at the Royal Alexandra Hospital for Children in New South Wales, Australia, described twenty-one cases of a mysterious disease. All occurred in children who suffered from what initially seemed like a routine viral illness, such as influenza or chicken pox. Over the course of a few hours or days, however, they became delirious, fell into a stupor, and developed liver failure and renal shutdown. Seventeen of the victims died. Many of those who survived had permanent afflictions, including cirrhosis, brain damage, and chronic renal failure. Doctor Reye, noting that all the autopsies showed profound swelling of the brain, liver, and kidneys, gave it the name “fatty degeneration of the viscera.”
    This paper was published ten years before Michael’s illness, and in the interim no cure had been found. Thus, when the boy entered our ICU, all we knew was that he would soon suffer total organ shutdown and his odds of survival were slim. The best we could offer him were educated guesses.
    An hour after his admission, I was startled to see a gray-haired man approach Michael’s bed. The man was a stranger to me and dressed in street clothes, but when he pulled a stethoscope out of his pocket, I realized he must be a doctor. This was Joseph Garvey, a senior attending on the pediatric service. I had never met him, but a few minutes later, in an office across the hall from the ICU, I stood by while he explained to my resident and me what we should do for Michael. To keep the patient’s kidneys working, he needed diuretics. To maintain hydration, he needed fluids. Most important of all, he needed cortisone to reduce the swelling in his brain.
    I could tell by their dour faces and subdued voices that neither Garvey nor my resident expected the boy to survive. Reye’s syndrome was a cruel, inscrutable beast that devoured organs one by one, transforming a healthy child into a bloated corpse. Depressed and exhausted, we went through the motions. I wrote out the orders and then, while the nurses infused the appropriate fluids and medicines into Michael’s veins, I explained our plans to the parents. Doctor Garvey had warned me not to give them false hope, but there was no danger of that. The heartbroken expression on their faces made it clear they expected their son to die.
    Perhaps fate was in a good mood that day. Perhaps Michael, unaware of the odds against him, decided not to die. Twelve hours after we began our treatment, he woke from his coma. His liver and kidneys began to function. A week later, when we sent him home, his mind was intact, his blue eyes bright and clear.
    His departure proved one of my most trying moments. The parents ambushed me. They bought a box of candy at the gift shop and had the page operator summon me to the discharge desk. I was tired from a night on call, wondering why the discharge clerk had paged me. The mother pounced first. She offered me the box of candy, then, before I could take it, she threw her arms around me. I struggled against her embrace, trying to explain it was all a mistake—I was just the gofer, a glorified errand boy—but she would have none of it. Yes, that grizzled Doctor Garvey may have been the brains behind it all, but I was the one who labored at their son’s bedside for hours every day. Before I could break from the mother’s grip, the father embraced both of us and pressed his cheek against mine. Tears flowed from their eyes, so many tears I got caught up in it all and wept myself. Michael sat nearby in a wheelchair. His face turned red, no doubt a blush of embarrassment, but he remained quiet until the blubbering died down. When everyone had blown their noses and dried their eyes, he stood up from the chair and shook my hand.
    “Thanks,” he said. “I was always glad to see you, doctor, especially at night. Don’t you guys ever get to sleep?”

During my thirty plus years as a professor, I have taught hundreds of residents and medical students, and at every opportunity I cite the following dictum: if your fairy godmother wakes you in the night to offer a choice between great skill and great luck, take the luck. In defense of this philosophy, I present the case of Michael B.
    The history of Reye’s syndrome shows just how great a role random chance plays in the practice of medicine. Over the decades after Doctor Reye published his famous paper, it was discovered that almost all the victims had been given aspirin early in the course of a viral illness. Though theories abound, to this day no one has discovered the mechanism by which aspirin interacts with a viral infection to destroy every vital organ in the human body. Yet pragmatism saved the day. An international campaign to avoid the use of aspirin for treating febrile illnesses in children has all but eliminated Reye’s syndrome.
    As for treatment, pragmatism again came to the rescue. There is still no specific cure, but now doctors know what to do: use common sense. The victims all suffer from dehydration, renal failure, and swelling of the brain, thus we should give them IV fluids, diuretics, and cortisone. Studies conducted since Michael’s illness show that these simple measures, if performed early in the course of the disease, dramatically improve the odds of survival and reduce the likelihood of permanent damage.
    So on that dark night when Doctor Garvey devised Michael’s treatment plan, guided by principles known even then to any third-year medical student, he came up with a regimen that remains the gold standard forty years later. Evidence has shown that if we can sustain the victim’s bodily functions, the mysterious disease will run its course without destroying the delicate intracellular structures that sustain life. And thus, despite our ignorance of the mechanisms involved, thousands of children have been spared the ravages of Reye’s syndrome. As with countless other maladies, when science fails, common sense and dumb luck can sometimes save the day.

John Gamel was born in Selma, Alabama, in 1944, earned a BA in mathematics from Harvard in 1966, and received his MD from Stanford Medical School in 1971. His scientific bibliography includes ninety-five book chapters and articles related to retinal diseases, ophthalmic pathology, ocular cancers, cancer-related survival analysis, and a variety of other topics. As his interest shifted from science and medicine to creative writing, he attended three sessions at the Bread Loaf Writers’ Conference, 1999-2002. His creative work has appeared in The Gettysburg Review, Abaton, the Antioch Review, Boulevard, Epoch, Shenandoah, and Southern Humanities Review.

“The Sleepers” appears in our Spring 2009 issue.