Book Review

The Blood of Strangers: Stories from emergency medicine

N Engl J Med 2000; 342:826-827March 16, 2000

Article

The Blood of Strangers: Stories from emergency medicine
By Frank Huyler. 163 pp. Berkeley, University of California Press, 1999. $19.95. ISBN: 0-520-21863-9

In Huyler's story “The Virgin,” 15-year-old Anna has a problem “down there.” “She was so beautiful she caught me. I entered the room looking down at her chart, so that when I raised my eyes I had no warning, no time to prepare myself. She was fifteen and I was exactly twice her age. But I couldn't help it. She was oracular, the kind that leaps from the crowd.” As he examines her, Huyler is breezy and conversational, but “[t]here's no avoiding the power of that moment, what floats out of you like a secret. You just don't acknowledge it. You banish it with an act of will . . . you feel dark, ashamed.” When Anna leaves with her scowling, proprietary gangster boyfriend, she is smiling, overjoyed that she is not pregnant and filled with gratitude; Huyler watches as they go and thinks of what he saw under the microscope: privileged sperm twirling between delicate tendrils of yeast.

I cannot locate the quote, but I believe it was Gerald Weissman who pointed out how courses in the medical humanities manage to capture the worst of both disciplines. My own suspicion is that this improbable outcome is the result of the underlying wishful notion that inspired the creation of such courses in the first place: exposure to literature will make modern doctors more feeling and compassionate. This assumption, I think, is mistaken on two counts. First, literature answers to an altogether different, non-Hippocratic authority, and second, human emotions are far too unreliable to serve as a foundation for medical care. Perhaps it should not be cause for hand wringing at all, then, that becoming a doctor and practicing medicine are often accompanied by a dampening of the emotional register, particularly during residency. Feelings are banished by an act of will. Medicine is an ambivalent privilege; its ample emotional rewards exact a price.

Huyler's perfectly titled collection of ultra-brief stories, The Blood of Strangers, has the force of literature because he does not ignore either medicine's rewards or its price. Without sentimentality or melodrama, Huyler, an emergency department physician and poet, spares us the moralistic exhortation to “treat the person behind the patient” (Who is this person, and what is he or she doing there behind the patient anyway?), the frantic heroics, and the gratuitous exclamation marks. These spare stories transmit emotions as if from a distance, but with a tender fidelity. With Huyler's light touch, the muting of a doctor's feelings and the coarsening of his spirit — which might have been rendered as callousness or indifference by a heavier hand — come off more gently, as a form of modesty, as a kind of phlegmatic wisdom, as an acceptance of limits.

Huyler sets this theme in “Prelude,” which describes his experience as a medical student in the anatomy laboratory:

Our cadaver was sixty-two years old, and after a while, when we had gotten used to it, we cut around his tattoos and saved them, like a little pile of photographs which we left by his intact head. Mother. A red rose, and a woman's silhouette. The United States Navy . . . even as we reduced him to pieces I knew he was real, that he had stories to tell, that he looked out at the sea from the decks of ships. I could feel it when I chose to. Mostly I chose not to. Mostly it was anatomy.

This anatomy lesson proves to be valuable. Choosing when and when not to feel, Huyler negotiates his way through a jungle of entanglements in the hospital, blithely and professionally, dispensing boilerplate to bereaved families: “It's serious. I think you should be prepared for the worst,” or, “He didn't suffer at all. It was very peaceful.” These practiced responses to emotional situations allow him to continue his work.

Compassion, on the other hand, is fickle. It springs up seemingly at random. Huyler dotes tenderly on a murderer — adjusting his pillow and bringing him water — yet wishes another patient, who deprives him of sleep, dead. When the wife of a patient who just received a liver transplant approaches Huyler to thank him, all he can think of is her husband's alcoholism. “ `I want to thank you all.' She said for perhaps the twentieth time. . . . Her hand on my arm was fierce, and she tried to pour herself into me with her gaze. . . . I found myself easing away from her.”

In these stories, compassion for oneself emerges as the first casualty of training, willingly exchanged for the possibility of becoming a bloodless machine — a machine perfectly competent and wholly without needs. But Huyler offers a glimpse of the Mr. Hyde behind the white-coated Dr. Jekyll. Rosa, the chief surgical resident, advertises her loneliness obliquely with vulgar jokes and awkward, poorly calibrated flirtations. Blake, the chief trauma surgeon, abuses levothyroxine to maintain his edge; he copulates “like a thresher” with young nurses in his office and, unexpectedly, commits suicide. The most singular example, though, is Ruth. She is a neurosurgeon, a clinical virtuoso — distant, controlled, and British. Ruth's secret life as a “rave-queen,” a nymphomaniac, and a drug addict is gradually revealed. Every morning, we find out, she takes two lines of cocaine with her black coffee. After bad days, she performs a ritual involving a live chicken and a straight razor; she beats Esmeralda, her big, black lover.

In between the stories, you can see the cult of competence and power; medical training breeds contempt for weakness. “You know,” Rosa says at one point, “It does change us. There's no doubt about it. We'll never be the same.” And you understand that saving lives, the swashbuckling, is, for all of them — Rosa, Ruth, Blake, and Huyler — a narcotic.

At times, Huyler's writing is so crisp and beautiful it startles. Although less impressionistic, it nevertheless reminded me of the fiction of the great stylist James Salter, a retired Air Force fighter pilot; it is as though their professions share some essence that makes their prose reticent and exacting. But Huyler also inherits a tradition from other physician-writers. His even-handed distribution of empathy brings to mind Chekhov and William Carlos Williams. Huyler's story “Power” is a remake of Williams's “Use of Force.” In it, a terrified, 50-year-old victim of multiple trauma, scarred by childhood rape, resists and cries out for his wife as Huyler forcibly performs a digital rectal examination. The massive internal hemorrhage found on peritoneal lavage, Huyler suggests, justifies his brute insensitivity.

A curious paradox is this: although literature may not make good doctors, the evidence seems to indicate that doctors often make good literature. What accounts for this? Huyler's collection suggests that physicians can make no special claim to compassion and sensitivity. But what lies at the root of good writing may not be compassion, but an ability — at times mistaken for compassion — to contemplate the beautiful and the grotesque without losing one's bearings. The Victorian writer John Ruskin advised: “Does a man [die] at your feet, [a writer's] business is not to help him but to note the color of his lips.” A doctor's business is, of course, both to observe and to help. And, at least in the first task, Huyler succeeds brilliantly.

David Kent, M.D.
New England Medical Center, Boston, MA 02111

Citing Articles (1)

Citing Articles

1. 1

   Seth Collings Hawkins. (2004) Emergency Medicine Narratives: A Systematic Discussion of Definition and Utility. Academic Emergency Medicine 11:7, 761-765
   CrossRef