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\nMissing

\nChapters outlined but not yet written will go here.\n

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\nFriday, April 18, 2008

\n\n

Eva Christine Kimball\n\nMs. Christina Askounis\n\nENGLISH 202S: Modern Biography\n\n18 April 2008\n\n\n\tTwo, One, Zero?: Biography of a Marriage\n\n\nPreface\n

\n\n\n\n

“My life began at 6:30 a.m. on my 24th birthday.” My dad used to love saying that. People would nod, then frown, then ask what he meant. He loved answering. The subject of my biography can trace its conception to that same moment, and died about 5 years ago . . . mostly.

\n\n

I chose for my subject not a person but rather a marriage—my parents’ marriage. Personification of a marriage seems especially apt in their (and my) religious subculture; one of our leaders said “A marriage, like a human life, is a precious, living thing” (Oaks 71).

\n\n

I consulted several primary sources, including my dad’s detailed journal, medical records, family letters and scrapbooks, and a remarkable set of handwritten notes (whose provenance I prefer not to identify) from the confidential church meeting that is recounted here in detail. Supplementing these sources are interviews with many of the people described (see bibliography). The key scenes are documented in surprising detail in these sources. Nevertheless, I have taken substantial liberties with the record for the sake of ease of reading.

\n\n

ECK\nDurham, NC\n

\n\n\n\n\n

\nThursday, March 20, 1986

\n\n

Frank gasped a few times in the cold, thin air, leaning over with his hands on his knees, and then straightened up to check his watch. 6:20. Good. He was right on time. Then he shook his head and grinned wryly. Duh! I need a watch to tell me the sun isn’t up.

\n\n

He pulled his blanket out of his knapsack, spread it on a reasonably flat boulder at the edge of the white scree, and sat down gratefully. I must be getting old. I’m still out of breath. He pulled his scriptures out of his knapsack and was starting to open them when the humor of that assessment hit him and he almost laughed out loud. Provo, Utah! The only place in the country where a 24-year-old who can run up a mountainside thinks he’s old. … Or worries about being single. He shook his head again and laid the book aside.

\n\n

Frank clasped his hands over his knees, bowed his head, wrinkled his forehead in earnest concentration, and started the conversation he’d come here for. Dear Father, what dost Thou want me to do with my life? And … well, can I please be happy? I don’t mean to be ungrateful. I’m alive and healthy and Thou hast blessed me with talents and opportunities. I know that. But, I’m checking everything off on the good-boy list, and, well, is this all there is? I’m not exactly depressed, but I’m not sure I’m really happy either. Is there something else I should be doing with my life? This would be a convenient time to find out about it considering I’ve already done my interviews for med school and I don’t even know if I really want to be a doctor, or if it’s just checking off one more thing on the list of What You Do. So, I’m not really asking for a sign, but I know Thou hast all power and can do whatever is needed to get me the message. Whatever it is, I’ll do it. I ask in Jesus’ name, amen.

\n\n

Frank opened his eyes and sat waiting for an answer. Nothing happened. He tried to keep his mind open to whatever God wanted to tell him, but thoughts skittered across his mind like the mountain chipmunk sneaking towards his blanket in brief dashes and terrified freezes. Wow, he breathes fast. I wonder if you could use that to figure out how much he eats in a day. One glucose for every six oxygens … pCO2 around 28 … maybe a cc per breath … Wait, come on, Frank, focus. A long pause. Still nothing. When did I get the idea to come up here for an answer? Kelly Canbridge’s face appeared in his mind, looking earnest and beautiful teaching Sunday school last month. Oh yeah, Exodus. Moses, Sinai, holy ground, “put off thy shoes from off thy feet”. … Where’s that verse about “draw near unto me and I will draw near unto thee”? D&C something, I think, or maybe it’s in the New Testament. He reached for his scriptures to look it up, stopped, and shook his head ruefully. I wouldn’t hear it if God was yelling at me. I can not shut up my mind.

\n\n

In the Sunday school class that day Frank had been sitting where he could see Y Mountain through the classroom window even when he was actually paying attention to Kelly’s lesson. He’d been watching the mountain when she’d said, “so, when we need divine guidance, we can do what Moses did—find holy ground.” She’d been talking about simple quiet and peace, the temple or any place with a closed door, but somehow, with his birthday coming up on the first day of spring this year, the idea of an early morning trek up the mountain for a prayer at daybreak had seemed obvious. Now, it mostly seems cold. And melodramatic. And maybe just dumb.

\n\n

The watch read 6:29. Frank bowed his head again. Lord, I know it’s probably silly to expect you to play by my timetable. But I am actually trying to listen, if you have something to tell me. He waited. He tried to clear his mind. Blank slate. Ready to listen. Still nothing. He opened his eyes. It looked brighter even though the valley was still in shadow. He checked his watch again. 6:30. Well, that’s it. Official dawn. Not that impressive. Right. Well, what did you expect to see at dawn on the west slope of a mountain? He pulled out his scriptures again. I guess if I’m up here I may as well do my morning scripture study anyway. I really don’t feel like walking back down yet. And who knows, maybe I’ll find an answer in here.

\n\n

The scriptures opened to his bookmark in 2nd Nephi. “As dead, having no life neither death … happiness nor misery.” Sounds like how I feel these days. Not even alive enough to be dead. Oh well. At least I suppose that’s an accomplishment. A sarcastic half-smile pulled at his lips as Frank looked out over the valley again.

\n\n

Just then, a bright flash across the valley made him blink. Something across the lake reflected the sun, and Frank realized that the west end of the valley was just now painted in sunshine. A light breeze began to brush his face. At the same moment, he startled to a woman’s voice behind him, singing. He jumped up, whirled around, and froze. Open-mouthed, he listened to the lines from the hymn: “The morning breaks, the shadows flee. …” If this isn’t an angel, forget the angels, I’ll take this! His mouth gradually closed into a smile. She was only 30 or 40 feet away, and she must have seen him, but she wasn’t paying any attention. The breeze now and again blew her dark hair back from her face and pressed her white dress against her breasts and thighs. Stop it, Frank, there must be some category of sin for thinking about an angel’s body that way. She looked rapturously happy. Her whole face was alive with every word of the music: “The dawning of a brighter day / Majestic rises on the world.”

\n\n

She finally looked at Frank and smiled, and he realized he was standing there staring with what must be an idiotic grin on his face. He walked over towards her, suddenly awkward with his feet and arms and generally feeling like a seventh-grader. He smiled what he hoped was a debonair smile and croaked, “Hi.” And winced at the inanity.

\n\n

She just smiled for an answer, but her eyes seemed to say she didn’t care if it was eloquent. Then she looked past Frank and pointed at the valley below them. “It’s amazing to me how the sun seems to paint everything. It’s not just brighter, it’s more colorful. The whole world seems to come alive.”

\n\n

Frank couldn’t help thinking something about differential sensitivity of rod and cone cells in the retina, but looking straight at her all he could think to say was, truthfully, “I was just noticing the same thing. The whole world looks brighter.”

\n\n

She smiled again, then reached out her hand to him. “My name’s Christine.”

\n\n

He shook her hand. “Frank Kimball. Your singing was beautiful. You’re beautiful.” He suddenly realized he’d spoken his thoughts. He felt his cheeks redden and decided to try to salvage a real conversation. “So, um, you come up here often?” Ouch! That sounds like the stupidest line ever.

\n\n

She just laughed, a laugh that somehow sounded like the only natural and obvious response to a world that was perfect in every way. “I’ve never been here before. I …” She looked like she was about to say something else, looked away briefly, and continued, “I heard it was something you should really do if you live in Provo.” She looked down across the mountain. “You know what’s interesting is that here we are as close as you can get to the Y, and you can’t really see it. I mean, you can see the white rocks and stuff but it doesn’t look much like a Y from up here. Life is like that, don’t you think? You have to get away from your day-to-day sometimes to get the right perspective.” She turned to look at Frank. “How about you? Are you up here every morning?”

\n\n

Frank smiled and shook his head. He was suddenly tempted to tell her he ran up the mountain every morning before class just as a warm-up, but somehow her eyes seemed to compel honesty. “I’ve been up here a couple of times, but, well, honestly, today I wanted to get up here by myself and try to find out what God wants me to do with my life.”\nShe opened her eyes wide, blinked once, then cocked her head and smiled quizzically. “But you were reading!”

\n\n

Frank answered defensively, “Well, I mean, studying the scriptures seems like a reasonable thing to do when you’re looking for answers.”

\n\n

Her forehead wrinkled a little. She looks so cute like that. “But seriously, why come all the way up a mountain to look for an answer in a book? Look at this!” She took his hand and swept her other arm across the valley. “Look! How can God hope to get you a message if you won’t look at what his hand has written on his biggest canvas?”

\n\n

Frank followed Christine’s eyes. Looking out over Utah Valley, Frank suddenly noticed it—really noticed the valley. For once, instead of the houses and streetlights and billboards and Cougar Stadium and I‑15, he saw the shape of the valley, the sunshine touching the opposite peak, the sheltering mountains and foothills, the river emptying into Utah Lake. All the scrabblings of mankind struck him as inconsequential shallow scratchings on the thinnest crust of the world, ephemeral graffiti on a beautiful ancient sculpture. He became aware that Christine was still holding his hand, and the warmth of her hand suddenly seemed the center of the universe. He looked at her and found her smiling at him, and suddenly, wordlessly, he discovered to his amazement that his constant mental background chatter had stopped dead, and he was perfectly at peace. A breath in, a breath out, and the perfection of the moment had passed, but he still felt ebullient, a vessel overflowing with joy.

\n\n

“You’re right. You’re so right! Thank you.” For once in my life a question has an unambiguous answer, and it’s a song without words. “I know part of the answer at least.” Frank looked Christine in the eyes. “The world is beautiful.” Especially here. He lifted her hand to his lips and kissed it lightly.

\n\n

For the first time she looked away, still smiling but a little embarrassed.

\n\n

“Hey, you look cold,” he said. “Are you ready to go? I’ve got a jacket in my backpack.”

\n\n

Frank helped her on with his jacket and, feeling gallant, gave her an arm. She laughed and took his hand again as they started down the trail.

\n\n

After the first few switchbacks, Christine asked, “you said you came up here to find out what to do with your life. So what do you want to do with your life?”

\n\n

“Well, I mean, I don’t know. That’s the whole point. I’ve got applications in to med schools and it seems like a good thing to do but I don’t know if it’s really the best option.”

\n\n

“No, I don’t mean what are you going to do, I mean what do you want to do?” She saw from Frank’s expression that he had no idea what she meant. “Look,” she went on, “what do you enjoy doing? What do you do for fun?”

\n\n

“I don’t know. Nothing exciting, I guess. I really haven’t thought about it that much. I mean, when people ask me what I like to do, my standard answer is ‘hiking and weightlifting and reading.’ But I guess if you judge by where I spend my time, I like learning stuff. I love reading almost anything, from science fiction to Shakespeare to biography. Even popular physics books, but I never admit that because most people just shake their heads and look at me funny when they try to think of physics being fun. I love my experimental psychology class, how the brain works—maybe the ultimate mystery in science. And I like people-watching.”

\n\n

“People-watching?”

\n\n

“You know, like if I’m in the cafeteria, or at the library and tired of studying, I love to sit there and watch people walk by or talk to their friends or whatever. What I really like is eavesdropping on arguments, to see what crazy stuff people are talking about. Have you ever noticed that most of what people say in an argument has nothing to do with what they think they’re talking about? And most of it is totally illogical. And I try to guess what people are thinking about. You have lots of clues, like what they’re carrying or how fast they’re walking or whether their shoulders are slumped or how much makeup they have on, and especially what they’re looking at. Kind of like Harriet the Spy, if you ever read that?” He stopped before going on and looked up at Christine apologetically. “Oh. Sorry, I’m not letting you get a word in edgewise. I kind of get going on something and don’t shut up.”

\n\n

Christine just smiled back. “My point is just that if you’re going to spend decades in a career, you should do something you like. It sounds like what you really like is learning new things and figuring out what makes people tick, so the question is whether medical school prepares you for a career as a perpetual student and people-watcher.”

\n\n

“Huh. You know, you’re amazing. That’s the first really new advice I’ve heard. I guess Dr. Becknard would be the one to talk to about that.” Frank started to plan that conversation mentally, then caught himself. “So, how about you? What are your life plans?”

\n\n

“Musical theater. Since I was a kid. I’ve always been the one dressing up, singing at the top of my lungs, dancing, whatever. I’ve seen Seven Brides for Seven Brothers I don’t know how many times.”

\n\n

“Um … I suppose that’s a musical?”

\n\n

Christine laughed. “You are hopeless! I can see I have a lot of work to do to get you to the point where you can carry on a conversation with any of my friends, or for that matter anyone whose nose isn’t stuck in a book. Look. This weekend I’m in The Pirates of Penzance. Why don’t you come see the show?”

\n\n

The conversation meandered pleasantly down the switchbacks. Halfway down from the Y, reaching for a water bottle, Frank noticed his wristwatch and burst out laughing.

\n\n

“What?” asked Christine.

\n\n

“Well, it’s just that I remembered being surprised that dawn hadn’t come when it was 6:30, when the paper said it would be dawn.”

\n\n

Christine turned an amused gaze on him. “You check the newspaper to see whether the sun is up?”

\n\n

“Come on, I looked yesterday to make sure I’d be up here early enough. Anyway, it was a few minutes later, when you started singing, when I saw the sun light up the valley, but I just now realized that really was 6:30 after all. I always set my watch 3 minutes ahead to make sure I’m not late.”

\n\n

She just laughed again. “You set your watch to the wrong time on purpose? Why would you want to know what time it isn’t? You’re a strange man, Frank Kimball.” But she squeezed his hand and smiled.\nThey walked along another minute or so, then Frank asked, “Christine, obviously you don’t have to tell me if you don’t want to, but when I asked you why you climbed Y Mountain today, I got the impression there was more to the story than you told me.”

\n\n

She didn’t answer for a minute, and Frank was about to reassure her she didn’t need to say anything when he noticed she was blushing. Finally she said, “Okay, the truth was I also came up here to ask God about something.” A pause. “I’ll probably regret telling you this, but you’ve been very open with me.” She sneaked a glance at him and then, deciding to go on, stopped walking and looked at him. “I came up here to pray for help finding a man who actually cared what God wanted him to do with his life.”

\n\n

For once in his life, Frank knew better than to say anything. He put his arms around her and kissed her softly on the lips.

\n\n

They walked very slowly the rest of the way down, and then on to campus … and Frank didn’t worry even once about being late to chemistry class.

\n\n\n

\nSunday, April 20, 1986

\n\n

“I’m what?”

\n\n

“You heard me. You’re a selfish tightwad.”

\n\n

Frank noticed a peculiar feeling in his stomach, as if a mule had just kicked him in the solar plexus. So this is what it must feel like to be a character in a Kafka novel. The last 45 seconds played over in his head like a 1940s black and white movie: happiest man in the world knocks on the door, comes in, says hi, reaches out to hug Christine; she frowns, takes a step backward, crosses her arms, and says the selfish tightwad line; he stands there, not breathing, with his mouth open and arms out.

\n\n

He remembered to breathe. He put his arms down and sat down slowly in her kitchen chair. “Christine, I’m sorry, but I don’t have the faintest idea what you’re talking about.”

\n\n

“Great! Make that insensitive selfish tightwad.” She sat down on the other side of the table, arms still crossed, foot bouncing, frown still fixed.

\n\n

“Look, honeycakes, whatever I …”

\n\n

“Aaaugh! Stop with the ‘honeycakes’! Where did you ever get that word, anyway?”

\n\n

By now Frank’s eyebrows were about halfway up his forehead. “I thought you liked …” He stopped suddenly as he noticed her glowering at him superciliously as if daring him to say she liked honey-anything. “Look, how about start from the beginning. What makes you think I’m selfish and”—he couldn’t bring himself to say “tightwad”—“stingy”?

\n\n

“Oh, I like that! You’ve changed the subject from your selfishness to my ‘thinking’! And I’ll bet you didn’t even notice.”

\n\n

The Kafkaesque feeling was not gone. It didn’t help that she was right about the not noticing; in fact, it took him a few seconds to figure out what that meant. “Look, my angel, whatever I did, I’m sorry. I love you. But I can’t fix it if I don’t know what you’re talking about.”

\n\n

She slammed a piece of paper down on the table loudly enough that he startled.

\n\n

“Yesterday,” she snapped, “I thought you were excited to be marrying me, but this—shut up, I’m not finished yet—and about 20 minutes ago I actually read this receipt from the printer for our wedding announcement. You are so damn … Oh, damn! You’re making me so mad I’m cussing! I haven’t done that in almost a year.” A sigh while she closed her eyes briefly to start over. “You are so darn excited to be married that you’re going to tell a whopping fifty people? And you’re so excited at the way I look that you don’t want to include an engagement picture?”

\n\n

“Oh.” A flicker of comprehension stirred in Frank’s befuddled mind. “You mean, all this”—‌he waved his hands vaguely in her direction—“is about saving money on the wedding announcements?”

\n\n

“No!” She slammed the table again with her palm. “This is not all about money! That is my point! It’s about my friends and my family and—oh, did you want to send any announcements to your friends and family? And it’s about me and you, about how much I’m worth to you.”

\n\n

“Honeyca… I mean, my darling Christine, you are worth more to me than everything in my whole life. If you really think $150 is all you’re worth to me, of course you should be upset, but if I’d spent 150 thousand dollars on those announcements it wouldn’t come close to how valuable you are to me.”

\n\n

Her tone this time was almost civil: “Well, at least you think fast on your feet. Figuratively, I mean.” She pointed to the seat of his chair.

\n\n

“I meant every word. You know how I feel about you. But look, I mean, we’re splitting the cost of the announcements with your dad anyway, and I thought, well, he’s on a tight budget, and …”

\n\n

“My dad would find the money.”

\n\n

Frank just closed his eyes for a second. He heard the unspoken “because my dad loves me” but couldn’t think how to answer it. “And besides, Christine, you know everything about my finances, or lack thereof. I admit it, I’m a student and living on my non-income. Mea maxima culpa.” He was getting a little angry himself.

\n\n

“There is nothing wrong with wanting a little touch of elegance for a wedding. You only get married once, after all. At least once was my plan.”

\n\n

Frank crossed his arms and started to answer defensively but thought better of it. A silence stretched on for interminable seconds of bilateral righteous indignation. Finally a playful smile started at Frank’s lips. “Hey,” he said, “you know what the good side is here?”

\n\n

“I am not noticing a good side.”

\n\n

“We’re finally angry! It gives us a chance to kiss and make up!” He couldn’t hold back his smile.

\n\n

Her reaction was ice. Make that dry ice. “Don’t you dare.”

\n\n

“But …” Frank wisely closed his mouth but now he was truly surprised. “Look, sweetheart, I’m sorry. I had no idea you would take it this way. I’m sure we can figure something out. I’ll get my budget out, and you can check with your dad if you want, and we can figure out what we can afford.”

\n\n

She actually screamed in frustration. “Aaugh! I am trying to tell you, it is not about the budget! It’s about you and me. I guess you just don’t care about the announcements.”

\n\n

“I’m just trying to live in the real world, Christine. I can’t just make money appear out of thin air.”

\n\n

“People borrow money.”

\n\n

Frank sighed. “I hate to start our marriage out in hock. But if it’s that important to you I suppose we can.”

\n\n

“You are really impossible. The question is not whether it’s important to me; it’s whether it’s important to you.”

\n\n

“You are important to me! It’s true, I really don’t care about the wedding announcements. For that matter, I don’t really care about anything about the wedding per se, the whole social angle of the wedding anyway. I just care about being married to you forever.” He noticed Christine’s head was bowed and her hand was shading her eyes. “Hey, what’s wrong? Are you crying?”

\n\n

“Frank, I don’t know what to say. Why don’t you go home?”

\n\n

“Are you kidding? You know I can’t stand being away from you.” She didn’t answer. An awful thought occurred to him. “Look, are you just having second thoughts? Are you thinking about canceling our engagement?” Now the crying intensified. Frank walked over to her and awkwardly reached out a hand to her shoulder. She shook it off.

\n\n

Frank stood there just as awkwardly, thinking I guess that’s one way to get into the Guinness Book of World Records. Shortest engagement ever registered by two sober people not living in Hollywood or Vegas: 32 hours.

\n\n

After a minute the sobbing quieted, and she got up and grabbed a kleenex. “I guess not. I mean, no. Let’s just talk when I’m feeling better.”

\n\n

“Feeling better? What’s wrong? Are you OK?”

\n\n

“Oh, I’m just tired. I woke up around 4 this morning and couldn’t get back to sleep, and I haven’t felt like getting off the couch to do anything until about an hour ago.”

\n\n

“Do you want me to fix you something to eat?”

\n\n

“With your cooking? No thanks.” But she smiled a little to take the sting away. “I’m really not hungry. Look, let’s just talk tomorrow after I hopefully get a good night’s sleep.”

\n\n

“All right. I’ll count the hours. How about a hug?”

\n\n

“Frank, please! Let’s just talk tomorrow.”

\n\n

He tried to summon a smile, though he imagined that it looked more like some kind of pathological facial spasm, and walked out. The walk home was much more lonely than usual.

\n\n

His apartment door was barely open when Alan hallooed at him from the kitchen. “Hey, Frank, I heard you’re engaged?” Frank nodded and grunted affirmatively while he tossed his backpack into his room. “Whoa, you’ve known her, what, a month now?”

\n\n

“Actually, a month today.”

\n\n

“You waited a whole month? What took you so long?”

\n\n

“I know, it sounds crazy to get engaged that fast, but I’m graduating this week after all, and I wasn’t about to let her get away.” Frank was close enough to see what was in the frying pan his roommate was tending. “Hey, what is that slop you’re cooking?”

\n\n

“Are you kidding me? This so-called slop is my new gift to the culinary world. I call it CSMP Sark B. That’s short for cheese soup / mashed potatoes / sausage and rice krispies burger.”

\n\n

“That’s disgusting.” Frank started rummaging through his cupboard looking for something relatively edible.

\n\n

“Your loss,” said Alan. Then, under his breath, he admitted, “I think. Haven’t tasted it yet.”

\n\n

A few minutes later, Alan sat down with his slop burger and an oversized bottle of ketchup, while Frank worked on ramen noodles and a frozen dinner.

\n\n

Around a mouthful of ketchup diluted with burger, Alan asked, “What’s her name again?”

\n\n

“Christine.”

\n\n

“She seemed nice enough when you introduced us. So, what’s she really like?”

\n\n

“Hm. Not a good day to ask.”

\n\n

“Oho, the great instant-engagement man is unlucky in love today?”

\n\n

“Ha ha. Look, I’ll tell you what she’s really like. Did I tell you about the impossibly amazing day I met her?”

\n\n

“Maybe three or four times … in the first ten minutes after you got home that night. Plus about a hundred times since.”

\n\n

“Anyway, she’s really like that! She sees wonders in the everyday, ordinary world. Around her the whole world is brighter and I feel like a new man. She joined the Church about a year ago and she has all these great perspectives on the scriptures, I mean, you know how everybody always quotes the same collection of verses on most topics? She has a fresh eye on them and she finds the most amazing things in the scriptures right under your nose. Plus, she’s smart, she really cares about other people, and as you saw, obviously she’s really sexy. We have this private joke: we’ve never argued about anything all month, well, we hadn’t until today, I guess I should say. We’ll be looking in each other’s eyes and thinking how lucky we are and one of us will say, ‘quick, make me angry!’”

\n\n

“Make me angry?” wondered Alan.

\n\n

“Yeah, because then we can kiss and make up, get it? And she really is a great kisser. Come to think of it, that’s probably just a natural part of her whole personality. She’s passionate about everything, singing and talking and kissing and … everything. So that was one thing that was weird today, because normally, maybe you won’t believe this, but normally it’s hard for her to keep her hands off me.” Alan made a “gag me” gesture. “Yeah, you’re just jealous. Actually I’m glad the temple had a date open at the end of June for our wedding. I don’t know how people wait more than a couple of months to get married. Well, I guess they don’t wait. Anyway, …”

\n\n

“OK, stop to breathe now, Frank; I swear, you talk like a fish drinks. I don’t need to hear about your passionate frustration. I get it, she puts the joie in the vivre, and you’re hopelessly besotted with her. But why isn’t today a good day to ask?”

\n\n

“Well, honestly I don’t know. Yesterday morning at dawn I popped the question, up on the mountain where we met, and all day everything was perfect. Well, perfect except for not studying for our last couple of exams. I’ll have to get up early tomorrow.” He frowned, and then seemed to remember he was in the middle of a conversation. “We called family, and called the temple to check on a June wedding date, which she’s always wanted, being the whole romantic actress type and all. Then we even got an engagement picture taken that same evening. \n“Then today after church,” continued Frank breathlessly, “‌I had some meetings I had to be at in my own ward today, and she wanted to show off her ring to all her friends at her ward, and the times don’t quite overlap so I couldn’t see her until—anyway, after church I practically ran over there and walked in and went to hug her and pow!”

\n\n

“She slugged you?”

\n\n

“No, I mean I walked in and instantly I was in the doghouse. She called me a … anyway, she was rude and didn’t want me anywhere near her, and I had no clue why. Then when I said I had no clue what was wrong, that was my fault too, apparently. Then she was crying, and for the first time we really were mad at each other but there was no ‘kiss and make up’ option, and I wasn’t even sure why she was crying. Finally it came out that she was upset because I didn’t order enough wedding announcements and they weren’t ‘elegant’ enough. I mean, honestly, she has a point, and we could’ve talked it out, but tonight was weird. We’ve disagreed about things over the past month, but we always settled them easily and there was never any name-calling or anything. What?” This last was because Alan was shaking his head and grinning.

\n\n

“Frank, Frank, Frank.”

\n\n

“What?”

\n\n

“Let’s summarize here. She’s emotional and unpredictable, you’re supposed to read her mind, and you’re to blame for everything. Hello? Have you forgotten her chromosomal anomaly?”

\n\n

“Chromosomal …?”

\n\n

“Two X’s, man! She’s a woman! All those features practically define women.”

\n\n

Frank burst out laughing but shook his head. “You’re positively atavistic, Alan. It’s a wonder your knuckles don’t drag on the ground when you walk.”

\n\n

“Yeah, I know, women equal men and all that, but which of us is understanding the situation? Huh? I tell you, it’s all in the X’s.”

\n\n

“I don’t know, Alan. I’m telling you this was different. This was not her today. She’s normally the easiest person to talk to I’ve ever met. She’s never been obnoxious or even ad hominem or for that matter anything at all but a poster child for the perfect woman.” He gave his dishes a quick wash and set them in the drying rack. “Actually, she’s still the most amazing woman I’ve ever met, and I still sometimes can’t believe she even speaks to me, much less wears my ring.”

\n\n

Alan shook his head smugly. “Like I said, besotted. Well, best of luck, buddy. Look, I never said she was worse than any other 46XX type. I’m just saying. …”

\n\n

“Yeah, I get it. Good night, Alan.”

\n\n

In his room, as Frank stretched before settling into his weight routine, the words “selfish tightwad” kept echoing in his mind. Tightwad: odd how word choice spins it. Couldn’t we say “frugal” or “careful with my money”? It really doesn’t grow on trees. The prophets have talked about it over and over: “avoid debt like the plague,” “interest never sleeps,” all that. But OK, even if I don’t think it’s wrong to be a tightwad, fine, probably guilty as charged. But “selfish”? Selfish? I’ve never thought of myself as selfish. No more than the next guy, anyway. I mean, how can you wash your girlfriend’s dishes just ’cause you love her and still qualify as selfish? Make that “fiancée’s dishes,” now, I guess. … I hope.

\n\n

Memories of the past month flooded into Frank’s mind as he did his first sets, bench press first as always. Christine’s nonchalant forgiveness when he showed up 10 minutes late to their first “real” date. Her finding an expensive ticket for him to her sold-out musical. Her listening raptly to his excited effusion about a chemistry class, and his only realizing on the way home that she hadn’t taken enough chemistry to understand his point, and hated chemistry anyway. Her spontaneous hugs and her spontaneous singing for joy.

\n\n

Suddenly Frank realized which two words were coalescing in his mind and he almost dropped the barbell on his chest before racking it. He stared towards the ceiling. Generous. Spontaneous. Who’da thunk it? The things I admire about her are generosity and spontaneity. Here what I worry about is being punctual and upright and thrifty, and I’ll bet she could care less. It occurred to him that if she cared so much about being generous, she probably judged him by whether he was generous too. So does she think I’m generous? Not today, that’s for sure.

\n\n

Frank mused on the unfairness of that judgment for about three more reps, but then a related thought struck him. If she was feeling that upset, all he was doing was carping about it to his roommate. Not much of a great start for a relationship of emotional intimacy and mutual trust.

\n\n

He picked up a dumbbell but stopped literally in the middle of an arm curl with a new realization. How could he live 24 years and never consider whether other people viewed his frugality as a virtue or as a lack of generosity? He resumed his curls as the answer was obvious. She was the difference in his life. A kind of awe filled him as he contemplated the changes in his life since they’d met. For the first time I can almost appreciate that annoying song, ‘You light up my life.’ She really does. The words he had read that delightful first morning on Y Mountain came back to him. The way he felt now, it was hard to believe that he had ever empathized with feeling “as dead, having neither death nor life.” It’s like the old cliché, at least when you hit your thumb with your hammer, you know you’re alive. Even today when I’m worried like crazy about my relationship with Christine, at least I know I’m alive. And after all, one bad day is just one bad day. Some guys I know have a whole bad marriage.

\n\n

Frank set down his weights and knelt at the side of his weight bench. Dear Father, I thank thee so much for answering my prayer that beautiful day last month. I thank thee for the privilege of meeting Christine, and I am so grateful that she said ‘yes.’ Please bless me with humility, that I can continue to see my faults and wherein I need to repent. I thank thee for Christine’s ability to bring me to see things about myself that I have never noticed before, and for her making me feel so happy and alive. Please help me to remember for the rest of my life how happy I have been this past month. In the name … Oh, and—here his heart swelled within him—I thank thee so much for answering my prayers this week to let me know for sure if she is the one I should marry. If on a day like this I am this happy and she is blessing my life so much, surely it can only get better and better from here on. In the name of Jesus Christ, amen.

\n\n

Frank walked over to the phone to call Christine, but by this time it was late, and besides, she’d pretty much told him to wait until tomorrow. He decided to go to her apartment first thing tomorrow, then realized he’d have to wait until after the biochemistry extra credit lecture. He spent the next half hour planning how to apologize and bracing himself to be warm and loving no matter what she said. A smile tweaked the corner of his mouth as he drifted off to sleep. He was sure he’d be ready no matter what she did or said tomorrow.

\n\n\n

\nMonday, April 21, 1986

\n\n

Frank paused anxiously outside Christine’s door, gripped the long-stemmed rose tightly, and took a deep breath before knocking. Whatever she says, I’m going to be patient. It’s my chance to be generous and charitable.

\n\n

Christine opened the door, wearing a bright yellow and white polo shirt and her favorite jeans. “Hi, lover boy! How are ya?” She threw her arms around him and kissed him passionately. After a second she came up for air. “You miss me?”

\n\n

Frank’s mouth literally fell open and once again he had the sense of being thrust into an alternative universe. Christine took advantage of his silence for another kiss. Finally Frank recovered enough to say something.

\n\n

“Angel, are you OK?”

\n\n

“Never better,” said Christine. “Why?”

\n\n

“I’m so glad to hear it. You didn’t feel yourself yesterday.”

\n\n

It turned out she had woken up hungry to the aroma of waffles fixed by her roommate, and ever since she’d felt great. Frank started to apologize for yesterday, but she told him not to worry about it. Christine had already decided she could live with a compromise between what he’d ordered and what she’d thought they needed, and she had already called the printer to change the order. Frank almost asked what it would cost, but thought better of it in time for her to tell him the difference in price and how she’d figured where they could save money to make it fit the budget. He finally started to relax, and she asked him about his morning.

\n\n

“Christine, you would not believe it. This was the best lecture ever. This M.D./Ph.D. biochemistry-genetics guy from California was here for some conference and knew somebody at BYU so he agreed to give a lecture.” The visitor had talked about a fascinating and horrible condition called Lesch-Nyhan syndrome.

\n\n

“I’ll skip all the biochemistry stuff; it wouldn’t really interest you anyway, but the fascinating part is that the patients have these compulsive urges to hurt themselves. He showed slides of these poor kids who basically had chewed their fingers off, or had chewed up their lips. A lot of them know they will do it if they are left to themselves so they will actually ask for their parents to tie their hands to their wheelchair or put in a mouth guard or something. Is that crazy? They don’t want to do it but they can’t help it. The hopeful thing is that this is a condition where they actually know what causes it. It all comes from one little base pair being mutated in one of the metabolic genes we all have. One base pair out of all the millions of base pairs in their DNA. That keeps the gene from doing its job, but since we know what it does, it’s possible that they’ll be able to come up with a cure.

\n\n

“I asked this doctor whether he thought the kids had any ability to stop their self-mutilation, any free will in the matter. I mean, obviously it’s an inherited condition that was determined when they were conceived, and it’s not their fault, but do they have any free agency? I think that’s a fascinating question, whether you can do something about abnormal behavior that is clearly not your fault. He really got into that question. He said in his opinion they had just a small amount of choice, that many of the patients described a brief moment during which they felt they could either ask for help or not ask for help, but once that moment had passed, their control was gone. Anyway, this was one of those moments where I was really excited about being a doctor, and learning about these diseases and even hoping to actually cure people because of knowing what causes them.”

\n\n

“It sounds like he’s a people watcher and perpetual student too?” asked Christine, happily amused by Frank’s enthusiasm.

\n\n

“Yeah, it gives me hope. I mean, you know how Dr. Becknard suggested psychiatry might fit my interests but then when I hated that psychiatry lecture, I was worried about whether going to med school would be a waste of time. But this guy isn’t a psychiatrist and he watches people every day he’s in clinic. I think I could love this as a career.”

\n\n

They talked about waffles and psychiatry and various safe topics until eventually Frank got up the courage to ask about yesterday.

\n\n

“Oh,” Christine answered, “I was just tired. Everybody has a bad day every month or so, right? Plus I guess it was that stupid movie I watched yesterday morning.”

\n\n

“What movie?”

\n\n

“I don’t know the name, it was just some dumb movie where a woman dies in a car accident. Reminded me of my mom. I guess I never told you. She died in a car accident too.”

\n\n

“What happened? Was there a drunk driver?”

\n\n

“No,” said Christine, frowning slightly at him. “Her car just ran off the road at a bad spot.”

\n\n

“Were her brakes bad?”

\n\n

“I don’t think so.”

\n\n

“Was it snowing or something?”

\n\n

“Frank!” Christine snapped. “Why do you want to know all the morbid details? She’s been gone for years.”

\n\n

“I’m sorry, honey, I guess it’s just my curiosity. Actually I suppose that bodes well for medical school, if I like to figure things out and diagnose them.” He was about to ask if her mom had been sleep-deprived when the fatal accident had happened, but fortunately thought better of it.

\n\n

“Oh, don’t worry about it.” She huffed silently for a few moments, staring down at the floor. Frank started to try to pick up the conversation, but Christine interrupted him. “Hey, we’ve been talking long enough, honeycakes,” she smiled. “Time to shut up and kiss me.” He was happy to oblige.

\n\n\n

\nMissing

\n\n

\nChapters outlined but not yet written will go here.\n

\n\n\n

\nMonday, September 5, 1988

\n\n

The night shift nurse stopped Frank as he walked by the nursing station. “Hey, you’re the student working with Mr. Castela, aren’t you?”

\n\n

“Yes.”

\n\n

“He’s sundowning. Acting totally crazy. I put soft wrist restraints on him so he wouldn’t pull out his i.v. lines. I’ll need an order.”

\n\n

Frank was almost done with his internal medicine rotation, and almost feeling like his inexperience wasn’t a danger to every patient. It had been a rough start, and he had questioned more than once whether he had what it took to be “a real doctor.” At least most of his patients asked him when he introduced himself if he was a real doctor or “just a student.”

\n\n

Frank wrote the order, paged the intern to co-sign it when she could, and went in to see Mr. Castela. It was a slow call night, and Frank hadn’t seen sundowning. The hapless patient turned his eyes toward the knock at the door, and when Frank appeared, started yelling: “Get it out! Get it out!”

\n\n

Frank took a half step backward, then caught himself. The desiccated septuagenarian lay tense, muscles quivering, hyperalert, sweating. He was trying repeatedly but fruitlessly to reach his right wrist with his left hand. His hospital gown was all askew and Frank, embarrassed, pulled one flap over to cover the man’s exposed groin.

\n\n

“Get it out!” the old man yelled again.

\n\n

“Get what out?” Frank asked.

\n\n

“The snake! It’s eating into my hand. Get it out!”

\n\n

Mr. Castela was pointing desperately at his right arm. Make that “right upper extremity,” Frank reminded himself. The arm proper is only from the elbow to the shoulder. It looked normal enough. An i.v. line entered just above the right wrist. He picked up the line. “Um … this is all I see, Mr. Cas—“

\n\n

“You’ve got it! Get it out! Get it out!” The patient’s eyes were now even wider, and he was panting.

\n\n

“I’m sorry, sir,” said Frank in his most professionally polite voice, “but this is just your i.v. line, and you really do need it for the antibiotics.”

\n\n

“You’re with Them!” the patient screamed. “You’re in with whoever’s torturing me! You ugly sunnuva …”

\n\n

The nurse skidded into the room and interrupted at this fortuitous moment with “Hi, Mr. Castela. Maybe I can help.” She shot an annoyed look at Frank and continued sotto voce. “I’d just calmed him down. Let’s see if we can repair the damage without snowing him.” While keeping up a soothing patter, she tucked the i.v. line into a makeshift pocket of sheet at the side of the bed and covered Mr. Castela’s right forearm with the sheet. The offensive clear plastic snake had disappeared and when the patient looked down it was no longer there.

\n\n

“Thank you, honey,” he said. His breathing slowed. The nurse established that the patient thought he was in a warehouse and thought it was July, 1977.

\n\n

After a minute or two, he closed his eyes.

\n\n

“Wow. That was pretty amazing,” Frank told the nurse. “You’re good at this.”

\n\n

She just grunted while arranging the sheets on the other side of the bed, but she looked marginally less grumpy.

\n\n

“Just like a baby,” mused Frank. “Out of sight, out of mind. You hid the i.v. line and as far as he was concerned, the ‘snake’ magically disappeared.”

\n\n

Unfortunately the patient heard the offending word and instantly resumed his hyperalert paranoia. “It’s you again!” he yelled, staring accusingly at Frank. “What are you doing here again! You’re the one with the snake!”

\n\n

The nurse groaned audibly and started to shoo Frank out, but the door opened again and Frank’s intern appeared. Dr. Mary Pettit walked in briskly, with the “I’m-here-now-I’m-in-charge-of-the-situation” attitude that Frank had already begun to imitate. “What’s going on?”

\n\n

Dr. Pettit had seemed more or less perfect to Frank for his first 6 weeks on the rotation. Not only did she have an M.D./Ph.D. behind her name, from Hopkins no less, not only did she seem entirely capable and unflappable, not only was she distractingly cute even in intern whites, but she somehow managed to show up every morning at 7a.m. with matching earrings and necklace and carefully applied makeup. She had earned grudging respect from the “real” internists after her first few months on service, even though she was a psychiatry resident just rotating through medicine. Frank had tried hard to impress her only to be caught out on numerous occasions in some rookie error or other. A couple of weeks ago he’d realized she was human too, when he found her in the report room crying after they lost their first patient together.

\n\n

The nurse answered over the patient’s intermittent yells. “Your student here”—the omission of his name was one more proof that nurses, the hospital’s only permanent inhabitants, viewed the transient medical students as entirely fungible—“your student seems to have a positive gift for upsetting this patient.”

\n\n

Dr. Pettit turned a cool gaze on Frank and asked for the patient’s vitals. Not thinking fast enough to ask the nurse for them, Frank admitted he had no idea.

\n\n

“Do you know why they’re called vital signs, Dr. Kimball?” The nurse rolled her eyes at the honorific.

\n\n

Frank desperately fished for some recollection from a second-year lecture on the physical exam, and came up empty-handed. He punted. “Well, vital comes from the Latin root for life.”

\n\n

“Whatever. They call them vital because they’re actually important. For every patient.” She turned to the patient and felt his pulse.

\n\n

Great, thought Frank. Three other people in the room and depending on which one you ask, I’m either evil, immature, or inept. He moved to stand behind the nurse to take advantage of the out-of-sight-out-of-mind phenomenon, and Mr. Castela quieted somewhat, calling “get it out” at intervals but somewhat half-heartedly now that the snake was no longer visible.

\n\n

The nurse pulled out her rounds clipboard and read out his last set of vitals. “128, 160/100, 12, and thirty-seven three.”

\n\n

Dr. Pettit never believed the respiratory rate. “The whole ward could die and the charts would show them all breathing in perfect unison at 12 per minute,” she’d said once. “Frank, count his respirations.”

\n\n

He pulled out his watch and counted breaths for 20 seconds. A pen and a watch, the only two reasons that anyone ever wants a medical student, he reflected. “Twenty-seven,” he announced, after a quick 9 times 3 in his head.

\n\n

“What’s a normal respiratory rate, Dr. Kimball?” asked the intern while auscultating the patient’s back, without looking up at Frank.

\n\n

“Twelve to 20,” he reported, confident for once of the right answer.

\n\n

“Close enough,” she said. “So what does that tell you here?”

\n\n

The patient still looked terribly frightened, but was now quietly monitoring the conversation, looking confused like a head-injured spectator at a tennis match. The nurse gave up and left the room and to keep out of his line of sight, Frank retreated further, behind the corner that hid the bathroom door.

\n\n

“Well, he’s breathing too fast. But he’s really anxious, after all. Paranoid, actually. Wouldn’t that explain the tachypnea?”

\n\n

“Maybe, but this patient is here why?” asked Dr. Pettit.

\n\n

“Community-acquired pneumonia.”

\n\n

“Meaning he has a couple of other reasons to breathe fast,” she answered.

\n\n

“Do you want me to get an ABG?” Frank volunteered.

\n\n

“Frank. First tell me what else you observe about the patient without a needle or a lab.” Mary Pettit was a big Arthur Conan Doyle fan. “Take your time. Well, take 15 seconds, anyway.”

\n\n

Frank commented out loud as he looked the patient over for a second time: 73-year-old man in a hospital bed, looking even older, general appearance frail, tachypneic, diaphoretic (like all med students, Frank had soaked up the fancy words that made you sound smart, like “diaphoretic” for “sweaty”), i.v. line in the right forearm, no redness above the i.v. insertion point, and so on. When he started to repeat the vitals they’d just discussed, she interrupted.

\n\n

“Look here.”

\n\n

“Oh. And a nasal cannula in place running”—he walked over to the wall—“2 liters of oxygen.” The patient started yelling at him again and Frank retreated once again around the corner.

\n\n

Dr. Pettit shook her head slightly, took the two soft plastic nasal prongs from the man’s cheek and placed them in the man’s nostrils where they were supposed to be. “Now watch,” she said.

\n\n

Frank watched from his post behind the corner. Mary waited one minute on her watch, then talked to the patient. “Can you tell me your name, please?”

\n\n

“George Castela,” he said quietly.

\n\n

Dr. Pettit beckoned for Frank to come out from behind the corner and he cautiously did so.

\n\n

“Hi,” said the patient, and turned back to the intern. She continued.

\n\n

“What’s today’s date?”

\n\n

“I don’t know, honey. I think it’s early September.”

\n\n

“And the year?”

\n\n

“1988, of course.”

\n\n

“Remind me what’s the name of this place?”

\n\n

“Duke Hospital.”

\n\n

“And do you happen to know your room number?”

\n\n

“I think it’s 2315.”

\n\n

“That’s right. Has anything been bothering you?”

\n\n

“Well, I think I was having a nightmare where I was in a pit with snakes crawling all over me.” He looked over at Frank. “In the dream I was cussing you out. I hope I didn’t actually say anything out loud.”

\n\n

By this time Frank’s eyebrows were riding high, but he managed to say, “Mr. Castela, please don’t worry about it. You’re here in the hospital and you’ve been pretty sick. When I’ve talked to you before, you’ve always been beyond kind.”

\n\n

After they exited the room, Frank couldn’t suppress his wonder. “I can’t believe that, Mary. Are you telling me all that paranoia and the snake hallucinations and yelling at me were all cured by just putting his oxygen back on straight?”

\n\n

“Yup. Look, it’s a slow call night. Ouch. Shouldn’t have said that.” Frank never tired of watching how incredibly superstitious residents and students were on call nights. The general theory was that if you talked about good luck it was sure to end. “Why don’t you go over to the library and do some reading on this.” She wrote out three phrases on a piece of medical record paper and handed them over. “Basically when somebody starts acting crazy for the first time when they’re in the hospital at age 70-something, it’s either drugs you’re giving them, drugs you’re not giving them—mostly alcohol and sleepers—or they’re just really physically ill. I read an article in med school that called it ‘acute brain failure.’ That made sense to me and it reminds you how seriously you have to take it. By tomorrow I want you to have a differential diagnosis and a prioritized list of diagnostic steps you’d want to take if his sensorium hadn’t cleared up after I moved his nasal cannula. Oh, and also look up the distinction between hallucinations and illusions.” She strode off to intern-land and Frank only with some effort stopped watching her walk. For some reason the children’s book, Where Do Butterflies Go when it Rains?, came to his mind.

\n\n

He sighed, thought about calling home to Christine, looked at the note, and headed over to the library to look up “delirium,” “mental status changes,” and “acute encephalopathy.”

\n\n\n

\nThursday, May 11, 1989

\n\n

Frank paused outside the door to the locked unit and rummaged for his keys. He reflected on how tightly he had held his keys during the first few days on the psychiatry rotation. Perhaps it was not surprising after all: John Umstead Hospital was a strange place, with strange denizens, in a strange small town. Then too, perhaps subconsciously he had worried at first that the keys were the only feature that would distinguish him from the patients and save him from being locked in by accident. Not that he was really worried that he was crazy, of course.

\n\n

Since then he had gotten to know the patients of Three East, and was much less concerned. These were seriously ill folks. True, there were a few sociopaths and the occasional malingerer, and even a very few indigent patients with good old major depression. But very few North Carolinians visited Butner, N.C., for a holiday, or for that matter for any reason at all. The town was even far enough from I‑85, and close enough to Durham and Raleigh, that almost no one came into town even to fill up a tank. Most out-of-town visitors came in heralded by flashing lights, in an ambulance or a sheriff’s van. Mary Pettit had been in the ER here for his first call night at Butner. The familiar face had been reassuring for his first call on psychiatry, though he’d failed to break his tradition of feeling mentally slow in her presence.

\n\n

She’d patiently heard his evaluation of an ER patient, and his diagnosis of “major depression, recurrent, moderate severity,” and had shaken her head when he’d had no answer to her follow-up question, “what else does he have?” Then she’d shared this clinical “pearl” which, like most things she taught him, he’d written down in his lab coat pocket book of Stuff to Memorize: “Frank, no one is here at Umstead for just one problem. People are depressed and alcoholic, or schizophrenic and antisocial, or manic and unemployed. Otherwise they’d be at their local community hospital, or Duke or Chapel Hill.”

\n\n

Myrna Jones might be the exception, though, thought Frank as he walked through Three East toward the nurses’ station. What a fascinating patient. And he might actually make a difference in helping her. Last night he’d called home for the first time this academic year to tell Christine he’d like to stay over on a partial call night rather than leaving for home around midnight. Many students stayed over anyway in Umstead’s rudimentary student call room, either to try to impress a resident with their devotion above and beyond, or because no one really enjoyed the longish, lonely drive back to Durham. But Frank was a fish out of water without Christine, and usually one night away from home was one too many.

\n\n

Last night he’d been in the hospital library reading up on the new admission when he realized with a shock that it was almost midnight and he had been having a great time reading. That was a first; there had been fun moments studying earlier in 3rd year, but they had been rare and brief. Sitting there still half-disbelieving the time on his watch, an echo of a fondly remembered conversation had tickled his memory: If you’re going to spend decades in a career, you should do something you like. It sounds like what you really like is learning new things and figuring out what makes people tick, so the question is whether medical school prepares you for a career as a perpetual student and people-watcher.

\n\n

He had sat bolt upright. You’re kidding. Psychiatry? I must be sleep-deprived. But today the thought refused to die, popping up in his mind a few times already.

\n\n

As he sat down at the nurses’ station and pulled out Mrs. Jones’s chart, Susie Applegate walked by in a flowered sundress, waved and smiled at him. Frank waved back, trying carefully for a neutral, professional gaze, and turned back to the chart. Ms. Applegate was the first patient he’d admitted at JUH, a 38-year-old woman who had been picked up by the highway patrol for walking naked along I‑85. Frank vividly recalled the team conference the next morning when, after reviewing the available history, they had invited her in. She was wearing short shorts and a halter top, with lipstick and eye shadow applied overenthusiastically. She smiled at Frank more than was quite comfortable. He could replay the conversation in his mind like a favorite videotape. Why was she here? The cops had brought her in. Why? There was a simple misunderstanding. They didn’t know she was a priestess and that’s how priestesses dressed. When did she become a priestess? She had been one for months, but she had just realized it that afternoon. How had she been sleeping? Fine. How many hours did she sleep at night over the past week? One and a half. Wow, that’s not much sleep—was she tired? No, she was full of energy. What was her job? She had quit her secretarial position a week and a half ago. How was she going to support herself? She had recently come into some money. Then the most fascinating part: How much money? She asked for a piece of paper and a pen, leaned over the table and carefully wrote: $1,305,723,987.18. (The ridiculous precision amused him, then mystified him as he tried to think like a psychiatrist—did the 18 cents mean something?) Frank had been fascinated to see a textbook description reified. Mania was standing right there in front of him.

\n\n

The really amazing thing, though, had been her dramatic improvement over the next couple of weeks on lithium. She didn’t like to talk about the I‑85 episode and sounded embarrassed about it. She was sleeping 6 hours a night and had called her boss to apologize for walking out and to ask for medical leave. There was no more talk of being a billionaire. And yet there were moments when Frank wasn’t sure how complete her recovery really was. She said she wasn’t a priestess, but she didn’t actually deny she had been one. Her makeup was no longer smeared but was still prominent. And she still sometimes flirted with Frank. His attending, Dr. Gamble, was trying to finesse Ms. Applegate’s increasingly frequent queries about when she could leave. “Gamble’s rule,” he called it: when you think a manic patient is back to baseline and ready to discharge, wait 5 more days. “The first thing that disappears in early mania is insight,” he reasoned, “and it’s the last thing to come back. If you send bipoles home too soon, they quit taking their meds every time and they’re back a week later.”

\n\n

Focusing on the chart in front of him, Frank tried to focus again on Mrs. Jones. She was a rare patient brought in directly to Umstead by her family, who lived in Creedmoor, about 5 miles away. She’d been there once before with the same symptoms, and the first time had been a painful 30-hour ordeal for the family that involved two general hospitals, a long overnight in the ER, and a lot of needles and X‑rays. In the end she’d landed in the Umstead ER anyway. This time they figured they’d skip the ordeal in favor of the 10-minute drive.

\n\n

Mrs. Jones had come in from the hospital entrance on a gurney, face up, eyes open, mouth ajar, unblinking, pointing upwards at a fixed 30-degree angle with her right arm and index finger. She had remained in that posture, mute and unresponsive, until she’d fallen asleep half an hour after 5mg of Haldol i.m. According to the nurses’ notes, she’d only slept 4 hours; the next time the nurse had come by for rounds she was in the same position she’d been in when she’d rolled into the ER, and had lain motionless ever since.

\n\n

That reminded Frank of his reading the night before, and he flipped to the orders page and wrote for an i.v. with a slow saline drip, subcutaneous heparin every 12 hours, and an order to turn the patient every 2 hours. Before signing off on the orders he checked the vitals section, found the usual blank page, hunted down the rounds clipboard, and found that morning vitals were unremarkable except for a heart rate of 100 beats per minute since admission.

\n\n

A quick physical showed some of the signs Frank had read about, but no complications. He made a few notes and made it back to the nurse’s station a few minutes before rounds.

\n\n

Dr. Gamble came into the report room joking with the ward social worker. He sat down at the head of the table, smoothed his coat briefly, and caressed his goatee. “OK, one admission last night? Which resident was on?”

\n\n

Before his resident could answer, Frank raised his hand and said, “Dr. Petropoulos and I were on last night. I’d be glad to present the case if you like.” Susan Weight, the other student on service at JUH, raised her eyebrows at Frank, who had a reputation among his classmates of never volunteering for clinical work.

\n\n

Dr. Gamble smiled avuncularly, glanced at the resident for confirmation, and told Frank to go ahead, but warned, “you have 8 minutes.”

\n\n

For perhaps the first time all year, Frank felt truly ready. He glanced at his written admission note to make sure he got the first few sentences perfect. “Mrs. Jones is a 66-year-old woman who is admitted involuntarily on an urgent basis due to catatonia that developed gradually over the past two weeks. Information comes from the patient’s husband and daughter-in-law, who seem reliable, and from hospital records. Her psychiatric symptoms first began when she was 25. I’ll come back to her recent symptoms in a minute.” He looked up at Dr. Gamble to make sure he was OK with including the past psychiatric history with the HPI (history of present illness). Some psychiatry attendings liked it that way and others didn’t, but Dr. Gamble just nodded absently. “She was hospitalized on her 5th wedding anniversary, two weeks after her father’s funeral, after a psychologically serious suicide attempt. In the hospital she lay in bed for two weeks, nearly mute, refusing all food. She needed an i.v. for hydration. She cried silently at times. Once, the psychiatrist asked her a few questions but after she remained mute, he finally gave up and turned away, only to have her then finally answer the first question correctly. To make a long story short, she had a typical but severe melancholic major depressive episode that lasted for 3 weeks and then resolved after the 4th of 7 bilateral ECT treatments. She then recovered completely.”

\n\n

Dr. Gamble interrupted. “You mean she was normal for her—normal enough that the family didn’t worry about it—or she was absolutely normal?”

\n\n

Frank was expecting that question. “She was completely fine. She raised 4 children, volunteered at her church, enjoyed playing bridge with her friends and several other hobbies, and displayed normal affect. Then three decades later, at age 56, she developed a second depressive episode, this time accompanied by delusions of guilt and auditory hallucinations of the devil telling her she would soon die and be under his control because of her terrible sins. Her pastor visited several times and never could figure out what sins she was talking about.

\n\n

“Again she recovered completely, this time without treatment. Finally, last year at age 65 her family brought her here after she “froze” in an awkward position with her head turned to one side and her neck flexed, with her lower extremities rigid but not twisted. The ER doc here sent her to Duke via Durham County General, where her physical exam, drug screen, head CT, thyroid function tests and routine labs were all normal. She lay in that position for over a week until she again underwent ECT, this time 6 unilateral treatments, followed again by full remission.

\n\n

“She’s been fine for the past year, until 2 weeks ago. She started repeating her own spoken phrases and crying, supposedly ‘for no reason.’ She started ‘freezing’ for 2 to 15 seconds, with her hands in whatever awkward position they had been in when the freezing spell began. When asked after the fact, she remembered what happened around her during the freezing spells. She stopped baking oatmeal raisin cookies every Saturday for the grandkids, who usually visited on Sundays. One of the older grandchildren stayed overnight two weeks ago, and said she heard grandma up half the night pacing the floor. Yesterday when they came to visit, she handed her son a manila folder with information about a reserved burial plot, but about 75% of the time she was holding an uncomfortable position, like this,” (Frank demonstrated). “She didn’t speak the whole visit except once, when they asked her what she was pointing at, she said, ‘the devil,’ but didn’t answer further questions. Finally they carried her to the car and drove her here. She has never had a manic episode nor had psychotic symptoms when she wasn’t depressed.”

\n\n

Frank continued with her past medical and surgical history, which was minimal except for a blood clot in her leg that had gone to her lung during her previous psychiatric hospitalization, her medications (warfarin, to prevent future blood clots), and her family history and social history. “On exam last night, vital signs were normal except for a pulse of 104; blood pressure was 95/50 and we did not attempt orthostatic vitals. Neurological exam was limited by cooperation but showed no focal signs. She was lying on her hospital bed with her eyes closed but holding the pointing-finger posture. Her lips looked dry. She was mute throughout the exam, so much of the typical mental status exam was not possible. However, when I told her I wanted to look in her eyes, she squeezed her eyelids shut more tightly. Her eyes were closed tightly with a prominent frown on her face. When I moved her arm to a resting position, it gradually drifted back up. The nurses report that overnight she appeared to sleep for 1 or 2 hours only, and she has not spoken nor eaten or drunk anything since her arrival last night. Serum chemistries, CBC and urine were all normal, except for an elevated BUN. PT and PTT were elevated, consistent with her warfarin history.

\n\n

“So, to summarize, this is a 66-year-old woman who most of her life has been in good physical and mental health but who has had 3 major depressive episodes, two of them complicated by catatonia and the other by mood-congruent psychotic symptoms. Now she has catatonia, manifesting catalepsy and negativism on exam, in the setting of 2 weeks of crying, apathy or decreased enjoyment, thoughts of death, severe insomnia, psychomotor agitation at home, decreased p.o. intake, and an apparent recurrence of hallucinations and delusions about the devil.”

\n\n

Dr. Gamble interrupted, “hallucinations?”

\n\n

“She said she was pointing at the devil, so most likely that was a visual hallucination,” clarified Frank.

\n\n

“And why did you say psychomotor agitation at home? Usually that’s a sign, not a symptom.”

\n\n

“The granddaughter said she was pacing most of the night.”

\n\n

Dr. Gamble nodded. “So, what’s your diagnosis?”

\n\n

“Well, catatonia can come from numerous neurological or systemic illnesses, but in this case by far the most likely diagnosis is recurrent major depression with psychotic features.”

\n\n

“OK, let’s say that’s her primary diagnosis. What should we do for treatment?”

\n\n

“Catatonia generally needs supportive as well as specific treatment. Supportive measures include hydration, prevention of DVT and pulmonary embolism, and feeding if needed. In her case I believe the best direct treatment is ECT—it’s a first-line treatment for catatonia and for psychotic depression, and she responded well to it in the past. She’s not eating, so there’s some measure of urgency, too, and medications don’t work as quickly. Besides, it’s what her family is expecting.”

\n\n

“Hm.” Dr. Gamble thought for a minute. “So, you’ve covered the most likely diagnosis. What about possible diagnoses that are easily treatable, or that we would hate to miss because they could make her worse if not treated?”

\n\n

Frank replied, “in her case, given the neuro exam and labs, the most obvious would be severe hypothyroidism. But it doesn’t explain the relapsing-remitting history very well, and last year during a similar episode her thyroid function was normal.”

\n\n

“Good work! Anyone else have something to add?” Dr. Gamble looked around the room. When no one answered, he asked, “What else might kill her, if complications of not eating don’t do her in?” After another silence, he added, “come on, what is our most common lethal concern for depression?”

\n\n

“Oh. Suicide,” answered Frank along with a couple of others.

\n\n

“Right. She’s probably already on suicide precautions, but we’ll want to watch her as she starts to get better. OK, one more for Mr. Kimball. Suppose she gets better with ECT. Do you want to send her out with any other treatment?”

\n\n

“She’s had more than two episodes of depression,” answered Frank, “and they have all been pretty severe, so she should be on an antidepressant to reduce the risk of another episode. Given her age, I’d like to avoid a tricyclic, so I’d vote for fluoxetine. But we’d have to monitor her labs carefully, since it can interact with warfarin.”

\n\n

“Alright, we have a plan, but there’s a problem. I’m guessing she’s not able to provide informed consent for ECT. How do you want to address that?”

\n\n

Frank replied, “Well, in a lot of states, a court can approve ECT, and the family says she was glad it was there for her last time she was sick. But there’s another option that Steve—Dr. Petropoulos—and I were considering. There are a handful of reports using lorazepam i.v. for catatonia. In about half of the cases, there was dramatic improvement, though it didn’t always last. We wanted to propose giving that a try, and if she improves enough, that would allow her to consent to ECT herself.”

\n\n

“Huh. Well, sounds like it’s worth a shot. Steve, if you do go i.v., I’m sure you’ll be careful with the dosing and monitoring. I’d like to see the papers you looked at. Alright, folks, let’s go take care of sick people.”

\n\n

A couple of hours later, Frank and the resident were seated by Mrs. Jones watching her closely. “OK, Frank, how long since we finished the first half milligram?”

\n\n

“Eight minutes.”

\n\n

“Feels like an hour. Check her respirations for me, OK? I’ll answer this page and be right back.” Frank counted it out. Sixteen per minute, maybe a touch slower, but her finger was still pointing at the top of the wall past her feet, her face still looked anguished, and she had yet to speak. Frank mused on how, even though he was still wanted for his watch and pen, he had begun to feel like a real part of the team. He could appreciate the change in his skills and confidence since his medicine rotation at the beginning of third year.

\n\n

Frank heard a quiet noise and looked over at Mrs. Jones. She swallowed again and he realized that her hand had drifted downward almost to her lap. She blinked a couple of times. Frank wrote down the time and watched her carefully. Dr. Petropoulos walked back into the room and the patient turned her head slightly and looked to see who had come in. “Oh!” Steve said, eyes wide, and glanced at Frank. Frank leaned forward and asked, “Mrs. Jones?” She blinked twice, swallowed again, and looked like she was about to say something. They waited for another minute, and Frank was about to call her name again when she said roughly, “I’m thirsty.” Then she started crying. Frank ran for a cup of water while Steve patted her shoulder and asked what was on her mind.

\n\n

“It’s all my fault,” Mrs. Jones said after another pause of at least a minute. Her body had now relaxed into a normal posture, and she had finished her glass of water. Eventually she was able to tell them that her whole family was dead due to her negligence. Frank tried to reassure her that no, her husband and children had been in touch within the past few hours, but she was sure they were just trying to placate her with polite lies.

\n\n

“Mrs. Jones,” Steve said, “it looks like we don’t agree on your family’s health, but I think we can agree that you have been feeling horrible lately.” He waited, and five or ten seconds later she nodded through her tears. “You have all the features of a severe depression, and our team believes that the best treatment for you is ECT, the same treatment that helped you so much last year. Will you agree to have ECT again?” After another ten-second eternity, she nodded again. “Frank,” Steve said sotto voce, “get me the consent form, now.” As Frank started for the nurses’ station, he heard Steve reminding her about the procedure and its likely good and bad effects.

\n\n

Half an hour later, back in the resident work room, Frank was still flabbergasted. “That was amazing! I mean, she was 90% better in just a few minutes. The closest thing I’ve seen all year was when a guy on medicine basically passed out in the middle of a sentence and his blood glucose was 25, and he woke up and started talking while the i.v. glucose was still going in. I guess those are the miraculous moments you dream about in medicine.”

\n\n

“Just remember this moment,” Steve said, “the next time some internist tells you ‘at least we can cure people in medicine.’ And then,” Steve grinned, “you say ‘yeah, like you always fix heart failure.’”

\n\n

“Actually,” said Frank, “I was just reading how the treatment response rate was slightly higher for the top ten diagnoses in psychiatry than in the top ten diagnoses in general medicine. Not significantly higher, but still. I think people just get some prejudice against psychiatry stuck in their head and it sticks there like bubble gum to the underside of a chair.”

\n\n

The conversation lost steam as they continued with notes and orders for the patients on their team.

\n\n

The next morning on rounds, Mrs. Jones, still looking fatigued after pacing the halls most of the night, asked when “they” were going to kill her. She refused consolation for her conviction that she had led to her family’s death. After her husband and daughter visited later that day, Frank sought out Mrs. Jones to see if their visit had cheered her up. Crying, she said, “it isn’t going to work, trying to make me feel better by bringing in those actors.”

\n\n

“Actors?”

\n\n

“Those people you brought in made up like my family, trying to make me feel better.”

\n\n

“What? We would never try to deceive you like that. And anyway, we don’t have a budget to hire actors! This place doesn’t even have the budget to replace these windows with”—he paused before saying “shatterproof glass,” worrying that might give her ideas—“with newer windows,” Frank finished lamely.

\n\n

She looked over Frank’s shoulders at this point, eyes widening, and her hand drifted up pointing past him. He looked over his shoulder but saw no one there. “He’s coming for me!” she said breathlessly, still pointing.

\n\n

“Who?” Oh. “The devil?” She did not answer this time, just nodded her head fractionally, still pointing.

\n\n

Frank spent the next fifteen minutes helping Mrs. Jones sit down, and calling Steve to get her another dose of lorazepam. Frank was thinking it would be hard to wait for ECT to get started. She was already on the schedule for tomorrow morning, but 20 hours seemed like forever given how pitiful Mrs. Jones was feeling.

\n\n

The next morning, Frank was in the ECT suite, eager to see firsthand this treatment with a reputation somewhere between magic potion and evil tool of the oppressor. The chief resident was there, looking busy, and asked Frank if he’d gotten lost. “No, I’m the med student taking care of Myrna Jones, and I wanted to see her treatment.”

\n\n

“Yeah. OK, stay out of the way.” But over the next 5 minutes, the chief mellowed enough to quiz Frank a couple of times—why is the blood pressure cuff on her calf? why will people have jaw pain in spite of the neuromuscular blocker?—and seemed at least somewhat less unimpressed with Frank when he actually knew the answers. Mrs. Jones hadn’t yet reverted this morning to keeping her arm in the air, but she seemed awfully tense. It was almost a relief to see her relax when the methohexital went in and her eyes closed. The succinylcholine was next, and anesthesia breathed for her with an Ambu bag a few times. The paddles were placed, there was a buzz for a few seconds, the toe that had had the cuff inflated pointed down vigorously for a few seconds, then twitched up and down for another 20 seconds or so, then relaxed.

\n\n

“Wait, that was it?” Frank almost asked? After standing in cardiac surgery watching them stop a heart, stitch in the opened chest, and restart the heart, this 30 seconds of almost nothing was completely anticlimactic. Mrs. Jones was already breathing on her own again, though still unconscious. He followed her into the recovery room, and over the next half hour she woke up, asked for a drink of water, and gradually moved from muzzy-headed to fully alert. She actually smiled at him when he brought her the cup of water, and he stopped briefly in surprise at seeing a completely new expression on her face. She tended to be more distractible for a few hours after each ECT session, but memory function was normal by the next day. Over the next week, she passed milepost after milepost: stopped pointing at the devil, stopped believing her family was dead, cried less, started sleeping 5-6 hours every night, started eating at every meal, and eventually joining in occupational therapy activities on the ward.

\n\n

Over the course of that week, Frank read about involutional melancholia, mood-congruent delusions, psychosis with temporal lobe lesions, and Capgras syndrome—and loved it all. Christine loved it less when he went on and on about these topics with guests over dinner. “But at least,” she relented later that evening, “it’s better than having you ruin our appetites at the dinner table about pathologists and food.” A couple of months ago, Frank had been expounding his theory that pathologists must be hungry because they named everything after food. The conversation had gone downhill after he started listing off examples, like apple green sputum and nutmeg liver.

\n\n

Now he was telling everyone about Cerletti and Bini, who found out that an abattoir in town was knocking out pigs with electricity before killing them. “They figured, hey, we’ve got distraught people that could use calming down, let’s try it on people. Obviously this was 100 years ago, in the days before human research ethics boards. So they just picked a guy, zapped him with some electricity, . . . but nothing happened. In fact the guy says, ‘not another one, you’ll kill me!’ So of course they tried again with higher charge, and then the guy has a seizure and started to improve.”

\n\n

Christine responded, “sounds like this was also in the days before decency and common sense.”

\n\n

Frank strolled along with Dr. Gamble towards the parking lot, the two of them walking alone at this time of the evening. “Well, Frank,” the older physician said, turning briefly to look at him, “you did good work there with Mrs. Jones.”

\n\n

“Thank you, sir.” Frank had lived in North Carolina long enough to know that “sir” was not a title of nobility but rather a polite necessity.

\n\n

“I think you have that something special it takes to be a good psychiatrist. You have some feeling for what makes people tick—some psychological-mindedness—to go along with a good foundation in neurobiology and pharmacology. If you decide you’re interested, feel free to call me up for advice, or if you need a reference letter.”

\n\n

“Thank you! That’s very thoughtful of you. Honestly a few months ago I wasn’t thinking of psychiatry at all, but I’ve really enjoyed this rotation. Thanks for being a good mentor.” After a moment, Frank continued: “I just remembered, I do have one question from rounds today. That guy who had a delusion of being a psychiatrist . . . you said, ‘he must be a frequent flyer.’ You were right, he’s been admitted about 20 times. But how did you get that before you’d heard anything but the warning that he thought he was a psychiatrist?”

\n\n

Dr. Gamble laughed. “Son, this guy has a delusion of grandeur. He could have believed he was president, tycoon, even God, omnipotent and omniscient. You know how people generally see us head shrinkers—we psychiatrists have the lousiest PR of any profession. Except maybe politicians. Anyway, who else but a long-time psych hospital patient would even entertain the belief that psychiatrists have great power or know everything?” He chuckled and got in his car, leaving Frank to ponder on the intersection of power, prejudice and humor.

\n\n\n

\nSaturday, May 23, 2015

\n\n

\nAre you enjoying this book?

\n\n

OK, the secret is, I’ve written a detailed outline and 5 or 6 chapters but I haven’t finished the book yet. But if you are enjoying it so far, here’s how you can help motivate me to finish it. On the main web page for this book, do any or all of the following:

\n\n

Scroll down to the Feedback section to start a public discussion, or to email me feedback privately.
Click on the “Notify Me When This Is Published” button.
On the right side of the page, there’s a form for giving me an idea of what you might pay for this book when it’s a finished product. (No obligation, I’m just trying to figure out what people think is fair.)

\n\n

Thank you!

\n\n

Kevin Black

\n\n

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\nMissing

\nChapters outlined but not yet written will go here.\n

Table of Contents

\nFriday, April 18, 2008

\nThursday, March 20, 1986

\nSunday, April 20, 1986

\nMonday, April 21, 1986

\nMissing

\nChapters outlined but not yet written will go here.\n

\nMonday, September 5, 1988

\nThursday, May 11, 1989

\nSaturday, May 23, 2015

\nAre you enjoying this book?