The Fifth Horseman

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It’s not an exact Science

The morning ward rounds had particularly been a task that Dr Satya constantly made the attempt of avoiding, not because he didn’t like doing it but rather he had done it so many times he found the dance all too prosaic, so he would usually usher his younger more junior Medical Officers ahead of him and do the rounds vicariously through them, and all they had to do was keep him in the loop. Dr Satya found that things increasingly bored him, and he was starting to get worried that it was becoming detrimental to his own psyche, whether or not his judgment was taking a toll, specifically on the case of the recent death Dr Sheila Thomas.

The psychiatrist understood that his department’s forte was primarily the clinic and the outpatient setting. Some days it could get hectic, and some days not so much, but that was where they made their biggest difference. Some mornings, they would get a barrage of drug abusers, manic- depressives, schizophrenics and some days it would be just your run-in-the-mill dysthymia.

Today, Dr Satya got an interesting phone call from a particular house officer. It was not out of the ordinary that a house officer calls in for a consult, usually for stress management and some advice. However, after receiving the aforementioned phone call, he told his staff that he would be busy the entire morning attending to this one case. It was all in secret, as he wouldn’t reveal to anyone who this person was, but he insisted on seeing him that very day.

As Tzen nervously approached his office, he was welcomed in almost instantaneously. They sat across each other separated by Dr Satya’s office table.

‘You care for some water from the cooler, Tzen?’

‘No thank you, Doctor,’ he replied in humility.

There was no doubt in Dr Satya’s mind that person needed his help. Just the very demeanour, hunched posture and attitude alone gave it away. Tzen’s hair had not been trimmed in months, his facial hair unruly, his breath could use some freshening, and his white coat could hardly be considered ‘white’ anymore.

‘So you called me. How’s work?’

Tzen smiled. ‘Why is that always the question?’

‘Excuse me?’

‘Work. It’s always about work,’

‘You have been asked this many times I see,’

‘Yes,’

‘Friends? Family? Or your bosses?’

‘All of them,’

‘Then would you rather me ask you something else? Or how about you just tell me,’

‘It’s not really the work, more like how work has become,’

‘Meaning?’

‘I used to enjoy it,’

Dr Satya patiently gave him his time. Tzen looked around noticing things around the room. It wasn’t cluttered with anything he could really fix his attention to. Little did he know it was done so on purpose. Dr Satya had made it a rule to keep his office clutter free, so much so nothing really distracts his patients from their own minds.

‘I…,’ Tzen paused to collect his thoughts. ‘I hate it.’

Dr Satya was tempted to ask ‘why?’ but instead, he approached the table and gave an inquisitive look.

‘I feel like… I don’t know,’

The psychiatrist felt he was already losing the boy before they even started. Much a time, at such crossroads, some guidance is necessary. So he intervened, ‘Well, tell me one thing about it you hate,’

‘The yelling,’

‘Of whom?’

‘Everyone,’

‘Specifically?’

‘Well, you know, people are always yelling. The patients yell, the nurses yell, Medical Officers yell, and specialists yell. Hell, even we yell,’

‘Yelling does happen, yes,’ Dr Satya went along with it. At this moment he started to clasp his hands together and twirl his thumbs around each other. He waited for Tzen to focus on them. Most people would see that as a little quirk, but as innocent as that notion was, it was key to the hypnosis. Dr Satya knew that for Tzen to really open up, he needed to focus, and watching those dark brown fingers with contrasting pink nails just swirl around each other clockwise at a constant pace. Tzen would soon let his guard down. It wasn’t an exact science, but it did the trick when he needed it to.

‘So much yelling,’

‘Did something happen Tzen? Did someone yell at you? Or did you…’ he started to turn the thumbs counter-clockwise. He continued, ‘…yell at someone?’

Tzen looked up away from the Dr Satya’s fingers to his face. ‘I do take part in it sometimes. I hate myself for it.’

Dr Satya rested his back against the chair. ‘Who did you yell at?’

‘A nurse. She’s young and she just started 6 months ago. She put on the ECG leads wrong. I needed the reading fast and she was so patient she did it two more times. It was still wrong. I had so much work, so much more to do. But the guy was in pain, I had given more than the usual dose of sublingual glyceryl trinitrate. I needed to know if he would need aspirin or worse, but I needed the ECG for that. What if he needed thrombolysis you know?’

‘This was a heart patient?’

‘YES, and she screwed up. So I yelled. And I did the ECG myself eventually. She looked so disappointed. It was a simple error of improper placement. I mean we have all been there but this whole thing… it’s just so…’

‘Just so what Tzen? You can tell me,’

‘Toxic. I hate to use that word. It’s an overused word. It plays like a cliché that it’s lost all meaning. Everything has no meaning.’

That last line was Dr Satya’s first mental note. ‘Everything has no meaning,’

‘So did you apologize?’

‘I didn’t. I walked it off. Because nobody apologizes. Why should I right?’

‘But still, you felt that you should,’

‘I know I should. Mistake or not, I didn’t have to yell,’

‘You know some people take a very different lesson from this,’

‘What do you mean Doctor?’

Dr Satya further elaborated. ‘They would say, “Well, it’s going to make her tougher. She’ll learn what not to do next time”. I personally am not a fan of the whole “what doesn’t kill you makes you stronger” philosophy.’

Tzen chuckled a little. ‘She should be fine,’

‘If it bothers you Tzen, just take my advice. Apologize. Only we who see it for its toxicity can start the cleaning up. Otherwise, nobody is going to do it.’

‘I should. Thanks, Doctor,’

‘Well, anything else?’

Dr Satya noticed the boy was anxious as if there was more to say but he rather didn’t.

‘Would that solve it?’

‘Sorry,’ Tzen wasn’t concentrating. His thoughts were fleeting about in anxious thought.

Dr Satya immediately went back to twirling his thumbs and refocused the boy.

‘I asked if that would solve your problem. You know with all the yelling among other things,’

‘I think it would. But not everything of course,’

‘Bingo! We’re back in,’ Dr Satya smiled to himself. ‘Everything?’

‘Yeah, like…’ Tzen kept watching the thumbs circle around, slowly, then slightly faster as if to rush him to speak. ‘Yeah, like going home on time.’

‘You don’t usually go home on time?’

‘No, I had to cancel a few movie dates for that.’

‘Any specific movie comes to mind?’

‘That new superhero movie, I wanted to watch the premier so badly.’

‘Marvel or DC?’ Dr Satya joked.

‘Marvel of course. I heard it was a good one too. But, ‘NO’. I had to finish up reports, discharge summaries and Dr Gladis had me run to opposite wing of the hospital to rush radiology for a CT scan, and at 4.45pm at that. I mean who does that?’

‘I can’t speak for her. Sometimes people do that. I know the feeling. Even I do that. Sometimes it’s for our patients.’ Dr Satya didn’t want to seem too pandering, because at this moment there was no good cop or bad cop; it was just him trying not to tilt the balance. ‘But then again, sometimes…’

‘I don’t know. I don’t like bad-mouthing people. I mean…’ Tzen paused to take a breath. ‘Can I have that water now?’

‘Yes, of course.’

Dr Satya filled a cup full from the cooler and handed it to him across the table. He waited for the boy to finish. Then, he noticed the house officer relax, and sit back on the chair. Now he was ready to speak.

‘I hate it when people bad-mouth each other. I mean sometimes work is just work you know? But then there are these people, who make it their whole lives. I mean “just relax” right? Why care if someone else gets to go home on time? Why talk about how much easier their workload was compared to themselves? Why talk about who’s taking longer breaks or smoking in between breaks or even talk about them at all? Right?’

Dr Satya nodded, his brows furrowed.

‘I mean I am just saying. TOXIC doesn’t begin to explain it,’

‘The question I believe Tzen, is what can you do to make sure that toxicity doesn’t reach you,’

‘But it has!’ he exclaimed. ‘It has changed me. I was a very passive person. I was an introvert even. And now, I am yelling at people, bursting out in an unhealthy way. I am badmouthing them. I am becoming another person that I myself would hate to meet.’

‘You are having an existential crisis,’

‘Yeah, I think so. I mean, it’s been weird really I asked myself that question too. Who am I now?’

‘Tell me then. Who are you?’

‘I am Tzen. I am a house officer. I am a Doctor. I help people.’

‘Is that all that defines you?’

Tzen stopped to think.

Dr Satya reached for his drawer under his desk. He then drew out one sheet of blank A4 size white paper and a box of crayons. ‘I have something for you,’ he said.

‘What is this?’

‘Choose from a variety of crayons from the 16 colour box set, and start drawing. I want you to draw a person.’

‘Who?’ Tzen asked inquisitively.

‘Anybody you want. I would give you all the time you need.’ Dr Satya excused himself to the toilet, so as to allow Tzen his own mental and physical space without feeling awkward about doing such a pedantic exercise.

As soon as Dr Satya returned, Tzen had finished his drawing.

‘It was a man, much like a cartoon caricature of himself, in sunglasses, wearing a Hawaiian Shirt and shorts, smiling, his arms to back.’

‘Why did you ask me to do this?’ Tzen queried.

‘There’s always a reason. I needed to know what kind of person you are. And it’s not an exact science but I can’t see your hands in this one.’

‘Yeah!’ Tzen chuckled, ‘ fingers are tough. I’m not really an artist,’

‘So, it’s a picture of you, on holiday I’m guessing, and you’re hiding something. Not something people do on holidays,’

‘Wow, all that from a drawing?’

‘There’s more. If you’re interested, do consider a residency once you are done with your rotations. I could use a few more Medical Officers, especially for rounds,’ Dr Satya chuckled.

‘I’m not. Psychiatry is tough. You need a lot of patience to deal with people the way you do. Patience I don’t have. I mean my mother herself. Wow?’

Dr Satya made his second mental note, ‘Your mother?’

‘Yes,’ Tzen breathed aloud, ‘she’s a manic depressive. She’s under a follow-up, but I know how it is to take care of her. I know how it is when she doesn’t take her meds. I see the patients here do the same thing sometimes. Just excuses on top of excuses.’

‘But in the end, we want the same thing, don’t we? Meds or not,’

‘To get better?’

‘And feel better. Most disciplines don’t really care about that part, which is why their patients end up coming to us.’

‘I agree. It’s just a hormonal construct,’

‘Is that something you go around telling?’

‘NO! That would make me sound like a sociopath,’

‘I see,’ Dr Satya moved his hands to rub his chin. ‘I’m not saying you are, maybe you’re just cynical.’

‘I know, that’s what I have been telling myself. That’s what all my friends say as well. Jenny has been saying it a lot.

‘Dr Jenny Tan, you mean?’

‘Yes, before her, well… Sheila. She used to say it too. She actually made me stop and think about it. That perhaps all the negativity isn’t good for me.’

Dr Satya noted Tzen’s face straying away from him. The boy started to stammer and his shoulders were now tense again as he moved forward from leaning.

‘Smart girl she was,’ the observant psychiatrist replied.

‘Very,’

Dr Satya knew he was on thin ice. The slightest error in the questioning regarding Sheila would end this prematurely and he couldn’t have that.

‘Was she right about other things too? Like the toxicity?’ Dr Satya calmly waited for his response, hoping that he would comply and answer him directly.

‘She was,’ he replied. The psychiatrist contained his relief. He hadn’t lost the boy yet.

‘She always said they yelled at her more, that it was harder because she was already a moving target. I didn’t think it was true at first, but the more I saw it, it just made sense.’

‘That she was given unfair treatment?’

‘No, more like she was becoming paranoid, and that made her more of a target, like a vicious cycle, further confirming her bias. In the end, it was like she was a social pariah. I should have been there for her.’

Dr Satya was indeed impressed at Tzen’s outlook. ‘You must really miss her.’

Tzen looked up. His face was pale, and his forehead sweaty. Dr Satya offered another glass of water. Tzen immediately gulped it down, his hands shaking.

‘I don’t miss her. I want to. I really want to,’

‘So, you’re feeling apathy, and you’re worried you’re not being a good friend by showing any sign of grief?’

Tzen shook his head, violently.

‘I don’t miss her because… because…’ he swallowed a gulp of saliva.

‘Because?’ Dr Satya lowered the baritone of his voice.

‘Because she’s right there.’ He pointed next to him.

‘Tzen?’

‘Yes, she is. She’s wearing the same black. She’s smiling. And I need your help to make her go away.’ Tzen was shivering as he said that, frightful that the apparition would hurt him.

Dr Satya added his final mental note. He sat back and took a deep breath. One look at the horrid expression the boy had and he knew he wasn’t faking this.

‘I admire your courage to tell me that. I really do,’

Tzen started crying.

‘Does she speak to you?’

Tzen nodded, silently.

‘Does she command you do to things?’

Tzen shook. ‘She…she pushes me, manipulates me, like the way only she could. The real her, I mean.’

‘The first step is acknowledging that she isn’t real. I’m glad you did that, albeit all on your own.’

‘I had help.’ Tzen wiped his tears. ‘Jenny knows. She was the one who told me to meet you. Has she come here by any chance?’

‘No, she has not. If you feel she should then you should ask her,’

‘I did. She’s going through some stuff too,’

‘Well, she has to come here on her own volition for it to work. Otherwise, it’ll only seem like a lecture.’

‘Well, she’s a huge nerd, so she probably enjoys lectures,’ Tzen started chuckling.

‘NO! Stop laughing,’ Tzen suddenly burst out. ‘Look! She’s laughing as well. You’re not real!!!!’ he yelled at the wall next to Dr Satya. The psychiatrist felt his neck hairs rise for a split second.

‘Please make her go away. Please, I beg you, Doctor.’

Dr Satya got up from his seat and came close to the boy. ‘It’s alright.’ He stretched his arms out for an embrace. The house officer hugged him while crying. Dr Satya held Tzen by the shoulders and looked him directly in the eye. He felt the tension slowly ease off as the boy was beginning to trust him.

‘We are going to start you on some meds, and we are going to have a lot more of this.’

‘I know. My career is going to start to take a very different path,’

‘No it’s not. What do you want to be? Have you ever thought of that?’

‘A cardiologist,’ Tzen blushed.

‘Yes, I guessed as much. Nobody gets that worked up for ECG leads,’ Dr Satya joked. Tzen started chuckling exaggeratedly.

‘Well I’m going to make sure you finish the year you have left, so you can start preparing for just that,’ the psychiatrist continued, ‘and whatever you and I say to each other in this room stays in this room. You understand that?’

Tzen nodded.

‘Good,’

‘Now, take the rest of the day off if you can. Your only task tonight is to meet some friends or even just one friend. I don’t care who it is, it just has to be someone. You think you can do that for me?’

Tzen nodded. ‘I’ll try,’

‘Do or do not, there is no try.’

Tzen chuckled at the Star Wars reference. ‘You like movies too Doctor.’

‘Yes, of course.’

‘So does she,’ Tzen looked to his right.

‘You mean so DID she,’

Tzen glanced back at him. ‘Yeah! So DID she.’

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