A History of Present Illness: A Novel

All this happened, more or less. I have seen a beating heart in a wide-open chest. This place has been a miracle land. No one even dies until we let them.

I have a picture from the first day, the white-coat day. We all lined up and had little lab coats placed on our shoulders, our arms, by practicing physicians in doctoral robes. I struggled, I remember, to bend my arms back right, though there must be loads of people who know how to get a coat put on them. This was a sweltering day in the far part of summer when the rich leave the city and the poor flee into the margins, line the city’s beaches in search of open air. At the service, the ceremony, faculty gave speeches, made cursory nods to the deeds we future doctors would perform for the good of society. But they were most clear and constant and explicit about our suddenly obvious worth. Over and over, each of them said: You must be smart, so smart, or else you wouldn’t be here. All of the other students had somehow known in advance to wear the school colors as a tie or a dress. So my clothes were all wrong, I can see looking back, as were my teeth, as was my hair. I look displaced and I am soaked in sweat. There is a sense, though, of light or life around the eyes—hope, almost? Now that I’m done, or close enough, I still have saved no lives myself, though I did check the pulse once of a woman who fainted on the subway. Let go of me is what she said.

We ended that first day by starting straight in with anatomy. They had us change into scrubs in a large conference room next to the cadaver lab divided by a rolling wall between the women and the men. I tried to keep my eyes on the floor. Four students were assigned to each table, each with a body facedown and draped in terry cloth soaked in phenol and glycerin. Ours was an elderly Black woman, almost gray, in size and shape so much like a West Indian neighbor I’d had before I came here who kept a barrel in the hall for all the goods she collected to send home monthly on a freighter. She lived with her brother, a gangly man who collected bottles and cans, who smoked in the stairwell and drummed on the walls to music playing only in his head.

The anatomy group was two women and two men. If you looked around the room you could see the groups were for the most part arranged this way, with some rare imbalance—the gender skew in medical school had recently turned slightly toward women. My group was an even split. One of the men was tall, white, with a tan, built but not quite well enough to counter his childlike face. For some reason he mentioned right away that he had a country house nearby to stay in on the weekends. The other man was from Texas. He said that whenever he said that, on interviews or wherever, they would next ask him where his parents were from, because of his name, apparently, or the color of his skin. He certainly did not have an accent. We all wore masks, which made faces hard to read, but made it, I found, easier to sustain eye contact. The other woman stood near the textbook, which was under a sheet of plastic to protect it from the fluids that quickly came to coat our gloved hands, and read out instructions to the rest of us.

Where did the bodies come from? I assumed they volunteered, though of course it would be difficult to recruit for such demand, to find enough people perimortem so committed to medical education. A fourth-year who used to write death notices for a national newspaper rounded up a group of us to write obituaries for some of the cadavers. After learning the basic technique, we would meet with the families or speak to them on the phone. I wanted to be assigned my own body’s family, but this was ruled out by the study’s design. Everything we did was studied, written up, and published in peer-reviewed journals. The whole school was rich with projects to prove that doctors could be made humane. So I was assigned some other group’s cadaver. His wife told me that she planned to become one too. For science, she said, and the savings they gave you on burial.

The country-house man took the first turn with the scalpel and drew a long line down our body’s back, and then we took turns pulling the skin away from the fat and fascia with knives and little scissors. She had wide shoulders and thin arms and was unnaturally flat from settling in the fixative. Her face and hands were wrapped in black plastic to keep them from drying out. It is normal from what I have read to have some feeling for your cadaver, though only the students who are women ever seemed to admit this. But the body was a problem right away for the country-house man. Once the spine was exposed, we had to crack each vertebra with a chisel and a hammer, slowly revealing the spinal cord. Fuck, this man said. Goddamn it, as the chisel slipped again. I had to imagine he was disappointed to be making such a bad job of her. Don’t swear, I said, and he did stop, though it was his high-stakes disposition that later passed us through every test. I was the weak link from the beginning. I have never had much skill at or interest in learning just the names for things. Once I came to the lab alone to attempt remediation, trying to learn the nerves of her neck. I even cut her ear off to clear the field, but it was useless. I was distracted, alone in the lab. Of thirty-one bodies, the only one who wasn’t dead.

But I was right about the volume. The lack of donor bodies was made up in unclaimed remains. The indigent or chronically isolated, so common in the city, even nursing-home residents, done now languishing in dementia, who had saved for a nice single grave in a field somewhere, but the money got lost or diverted somehow, so they ended up here on these tables with their pieces thrown out bit by bit along the way, whatever was left in the end burned and put unclaimed in a closet.

I never learned where our body came from or if we had her consent. After our first year, a state law was passed, placing stricter restriction on the bodies’ provenance and final place of rest. Some high-profile donor had, after dissection, been buried by accident in a potter’s field. He had signed up for a tidy cremation. There were, still are, mass graves on an island in the Sound, ten miles from the school, the largest mass graveyard in the country. Convicts in white jumpsuits bury bodies there for fifty cents an hour, stack pine boxes in neat rows three deep and five wide. The trenches for babies hold up to a thousand. After a century of epidemics and mundane city deaths, there are a million people buried there. You can’t visit without an escort from the Department of Corrections. A carved stone by the ferry launch reads BLESSED ARE THE POOR IN SPIRIT, FOR THEIRS IS THE KINGDOM OF HEAVEN.

We would go out sometimes, the group from anatomy, though the country-house man rarely made it. He didn’t drink. He may have been underage, in fact—of note, we never asked. So the Texan, and the other woman, whose name was June, and me. We were in one of those bars full of television screens, tuned to sports and nightly news broadcasts with subtitles—crowds cheering, scattered applause—unrelated background music loud and exhausting, when we heard on the news that a man with Ebola virus rode the subway from the hospital all the way out to an outer borough. He had done this to go to a bowling alley. The man from Texas had never heard anything so funny.

I was raised with a reverence for catastrophe. The thought of mass casualties—in the hospital, they call this Code D—has haunted me since I was a child. Back then I had a recurring dream that a trap I had crafted on the bottom bunk of my bed had filled up with the dead and dying bodies of my family, neighbors, and friends. Despite this, or perhaps because of it, I’ve always been a little nuts for plague literature and films, the desiccated bodies, heads hung back, mouths agape, leaning on each other in church pews, THE END IS NEAR graffitied on the walls, that sort of thing. The Texan, as much as I could hear, was describing the chaos that Ebola would bring to the city—people bleeding out on the subway, in the streets—with a speculative masculine glee.

I learned about Ebola in middle school from a video played on a rolled-in TV. Afterward I couldn’t close my eyes for weeks without seeing piles of bloody bodies with flies in their eyes, Croix-Rouge in white aprons over yellow Tyvek suits, graves marked with crossed plywood, the names written in marker. I had nightmares of pine coffins the size of children, wrapped in floral paper. The outbreaks in West Africa, the video said, were made worse by the local funeral customs: washing the bodies by hand, crying over them, cooking and sleeping beside them. The remedy arranged by well-meaning foreigners was mandatory cremation, so families kept bodies hidden in their homes, and whole households were lost this way, bleeding out from everywhere.

The city emergency departments stocked up on gloves and suits and made pop-up containment tents to prepare for an outbreak that never came. Later he gave a lecture on infectious disease, the man who rode the subway with Ebola. Of course he was a doctor. He had slides. I went to the lecture, I think, to make peace with or face up to something, or just to see the flies in the eyes again, the way you sometimes can’t help wanting to. But mostly he talked about medicine for HIV, cleaner water, mosquito nets. He really cared about West Africa. I still remember that night, the news, the Texan. I don’t know if he couldn’t tell or didn’t care how much he was upsetting me. Few things for some people are only in theory.

This fascination with disaster, both fear and fetish, I never quite outgrew. The truth is, you start to sort of wish for it. Like some Czech said: Vertigo is something other than the fear of falling. Half the rush is wanting it. Wanting to get it over with.

But you wouldn’t believe the parties they had, the students. The women in dresses with shoulders bare and necklines down to the navel, the men in well-cut suits. They would take the bags from inside boxes of boxed wine and drink directly from them, the bag held suspended over the drinker’s head. And there were ski trips, boat trips, field trips, orchard trips for apple-picking, all of this laid out and arranged for everyone who could afford it. The well-off came to be fast friends. They had a rock band, a theater troupe, and a midsize symphony orchestra.

The body, the West Indian lady. I had a habit of holding her hand at the wrist, even after her fingers were skinned. We would tug the bared tendons to marvel at her fingers’ bend, her thumb come to life like an empty crab claw after dinner at a seafood place. Those first months were a shakedown by worth, and some of us could quickly tell we were coming out toward the bottom. I, for instance, was not thriving; although for the most part I would present myself at lectures, I would return to my room at the end of the day and close the shades and stream syndicated crime dramas or simply stare at the walls. I tried not to let myself wonder too often just what I thought I was doing there. You might get the impression from this description that I easily settled into a featureless, mechanical existence—I did. It was hard to tell from the outset whether this was new or had always been latently within me. All my life, when left alone, I have often fallen listless and done literally nothing or boredly engaged in the kind of self-harm you see in captive animals. Maybe we were all like that.

There was a gym in the dorm’s basement and a pressure from the cohort to become or remain remarkably fit. In a country forty percent obese, we had two fat students in a class of more than a hundred. In the gym, you’d see every stair machine, elliptical, and treadmill in use, svelte students in headphones memorizing enzymes of metabolism or the nerves of the brachial plexus on tablets propped inches from their sweat-stitched brows. It is hard to imagine the stakes of the whole lives these people had come from. That first year you’d see students leave midweek with suitcases, dejected, headed home or to an inpatient unit to recuperate. And though I believe most of them came back, they usually stayed silent on the topic of what had come over them.

There were deaths, of course, and there were vanishings. In a city of tall buildings, it was the young doctors who tended to jump off. When a resident died, announcements were made, referring the other students to the proper places to go for emotional support, and the terraces were closed for the installation of protective fencing. The missing ones were often feared to have gone over the bridge, and often they had, and would be found later after the river had pulled them back and forth. The river—it was in fact a tidal estuary—was the backdrop of the dormitory and the view from half the rooms in the hospital. In the winter as the water froze you could watch the loose ice gather and clot where the land narrowed for the footing of the bridge, and the doctors liked to point to it, the dynamics, the reversal of flow at the bottleneck, a metaphor for junky carotids. It’s true you start to see the world like that. There was a long walk I’d often take from one train to another on a street with a slow traffic of people who were poor and poorly cared for, and I could count the feet sawed off from diabetes or catch the gait that meant the feet were on their way out.

The school held a memorial for the donor bodies when enough time had passed, when the students could face the families without a sense of blood on their hands. One son shared that his father was a priest of Santeria, and he placed black candles on the makeshift shrine of photographs and flowers. Which body was his, I wondered, and wondered only half as a joke which students he might have cursed for pulling him to pieces that semester. On the last day of anatomy, we changed our clothes together one last time, gathered our scrubs in trash bags, and threw away our shoes, two hundred shoes piled in a bin, like the aftermath of some atrocity.