Toby Fleishman awoke one morning inside a city he had lived in most of his adult life but no longer recognized — a desiccated husk of a city, a city that was quiet and scary with bare streets and closed bodegas and a wartime dread. Ten million people confined to where they lived, minus a few: the crazies (including the conspiracy theorists and DON’T TREAD ON ME–flag types); the grocery-store workers (and delivery people and commuting kitchen staffs and the like), the sick en route to the hospital (some of whom were those very crazies who had not taken precautions), and, of course, the medical staff, of which Toby was a member.
It was April 7, which they’d know only later was the virus’s peak in New York and in its hospitals — the day of the most deaths, the day when it felt like the extinction event people had jokingly been tweeting about had arrived. But Toby wasn’t at the hospital, or not at his usual one, St. Thaddeus, anyway. He was reminded of this particularly now, as a pretty young nurse wheeled a chronically ill man in kidney failure down the hall, telling him, “This dialysis will take ten years off your kidneys.” The previous day, he’d heard a similarly pretty nurse, but one with lip injections, tell a patient, “We’re going to freshen that liver right up.”
As the pandemic hit, Toby Fleishman, a hepatologist, had been tasked with making sure that non-urgent liver patients got at-home protocols and that their appointments were rescheduled into the late summer. Slowly, his hospital had begun to clear out of patients with mild to moderate liver illnesses, and in their place swept in a terrifying tsunami of gasping, high-fevered terror. First you’d hear that the ER was filled with COVID patients and therefore closed off to any patients for whom COVID wasn’t suspected. Then you’d hear that half of the cardiology floor was overcome by it. Then, within what seemed like a few minutes, the entire cardiology floor was now a COVID floor. He stood on 8, in gastro, wondering exactly when it would come for him. It was just three hours after having that thought when the pulmonology staff started rolling ECMO machines onto 8 and he was told that hepatology was to head up to 9.
Before they could make it up to 10 (which had been orthopedics), he was cleared out of St. Thaddeus completely, into one of the cohort systems that the hospitals had created for urgent cases that weren’t COVID-related. Doctors from different hospitals with the same specialty gathered in various smaller hospitals and surgical centers to treat the patients that couldn’t wait. The cardiologists were sent to a hospital that mostly did joint replacements. The urologists went to a hospital that mostly trafficked in minor ear, nose, and throat procedures. And the hepatologists and nephrologists and their staffs — Toby’s people — were sent to a surgical center on Fifth Avenue that was mostly a place where the women and men of that specifically Upper East Side region of Manhattan got face lifts and nose jobs and liposuction. He’d been there once before, the previous summer, when he had lost a battle and his 14-year old daughter had gotten a nose job. The small comma-shaped nose that she’d inherited from her father was flattened out into an em-dash for the sake of traditionalism: She came from a long line of people who had straightened out that very nose, so that the nose wasn’t as much the tradition as the surgery was. Anyway.
The plastic surgeons had abandoned the surgical center, absconding to East Hampton to ride this out while their colleagues put patients on lung bypass machines. They left gauze and extenders and lipo hoses behind like they’d been Raptured — like they’d been liposuctioned. The surgical center was now a field hospital, the plastic-surgery nurses and orderlies and techs and all the other support staff remaining behind as the only witnesses to a world in which there had once been medical care that was elective. The place had rolling Barcaloungers instead of wheelchairs, and when the nurses — uniformly, absolutely thinner, prettier, and better maintained than any other nurses he’d ever seen, both the men and the women — came to get a patient for a procedure, they would use euphemisms instead of actual terminology. After Toby heard that nurse talking about “freshening that liver right up,” the same nurse had told a woman who had just been taken off of a ventilator from her surgery that she looked beautiful. “I can already see the difference,” another nurse said to a man who was waking up from a hemorrhagic stroke.
Meanwhile, Toby didn’t know if he himself was a miracle or if he was on borrowed time. He had no symptoms, even after working in a hospital at the hot-zone height of this thing. He was fine. He took care of his kids most nights. He had bought a Peloton (though he didn’t dare tell anyone that) so that he could keep his immune system up and his body-fat percentage down. There was new protective wear and there were new protocols for interaction with patients, but once he left the hospital, it appeared that he might make it through this. No one could come in or out of the building without being tested, but day after day, Toby awoke, no signs of this new plague anywhere on his body. And so his brain, anxious from the way the numbers were rising, was left with was an imagination full of fear and nowhere to point it. He could imagine that he felt a person’s breath when that person spoke. He had had to get home one night fast when his daughter called to say that his son had a persistent cough. (This was before they knew that kids didn’t really get it so much except for the ones who did, who got it extra-bad.) He remembered the stories about AIDS from his teachers when he was in medical school, and he had thought how terrifying it sounded to have a new disease confront you in real time. For Toby, before the obvious terror of how to cure it came the primary terror, which was: What would he, as a doctor, have dismissed or rounded up or down to other viruses or cancers or syndromes before having the imagination to remember that a new thing could come along? What if he was dumb? What if he was arrogant? There were new advances in liver medicine all the time, but very few new diseases. A new disease would warrant a full issue of a journal; Toby could not picture himself as the doctor on the discovery team for a disease that concerned an entire issue of a journal. So was his self-esteem as a doctor, though he tried to comfort himself by repeating the thing that his teachers had said when he expressed these concerns, which was that it was the people who worried about their stupidity and arrogance who tended not to make mistakes. He had believed that was true until fairly recently. A divorce is very instructive in that way.
A patient of his named Ira had come into the hospital for sudden and severe jaundice without accompaniment — normal for these times — but even as he was admitted for his jaundice, Toby noticed that Ira’s wife, Rhona, never called to check in on him. Toby asked if everything was okay at home. Ira was sitting up in his hospital bed, looking at the mirror at the end of the hospital tray, a feature extremely specific to this kind of place. “She found out I was cheating on her,” he said to himself to Toby.
Toby didn’t know what to say to this, so he said, “How did she find out? Was it a phone call? A secret phone call?” Toby pictured Ira in the bathroom, the water running, Rhona banging on the door.
“Kind of,” Ira said. Ira and Rhoda had three children at home in New Jersey, where they lived. When the schools were shut down, all the iPads in the house had been commandeered for the daylong instruction and enrichment that the private schools kept up in order to make sure that parents felt they were still getting their tuition’s worth. Ira was in his late 50s, which was exactly how old you’d have to be to not understand that when a kid signed into an iPad using your Apple ID to download the distance-learning apps, she also signed into everything else — text messages and email accounts. It was literally four hours into lockdown before the woman he’d been fucking on the side texted him:
FOND MEMORIES OF BEING BENT OVER YOUR DESK AND FUCKED LIKE U R A MACHINE
His daughter saw this and began to cry. She was 11; she didn’t know what she was looking at, but she knew to cry. Rhona, trying to figure out how to set up a conference meeting for their 9-year old, came over to see what the ruckus was. Now, two weeks later, Ira was praising God for this bout of jaundice, because it got him out of the house from a wife who had not experienced the catharsis of filing for divorce only because the courts were not yet online and was therefore letting him have it on the hour.
“This quarantine is going to shine a light, my friend,” Ira said. “It’s going to show everyone exactly who they are and where they stand. And then you know what’s going to happen?” He shook his head at himself in the mirror. “When it’s all over, we’re going to forget how to live in the dark again.”
“Maybe that’s good,” Toby said, as he made notes on Ira’s chart, because that felt like a thing you should say to that.
Ira made a disgusted noise that involved a rush of air being extinguished from his nose. He never stopped looking in the mirror. “You have no idea how important the dark is, my friend.”
The virus had decimated many things, and one of them was Toby’s love life. He had been dating a lawyer, but she’d gone back to her ex-husband after he’d tested positive for COVID, which she felt was a sign that they had been frivolous with their marriage and should give it another try.
Casual sex was gone too now, maybe forever. Just a few days before all this, there had been a nephrologist named Nancy who, one night, lured him with winks and lip twitches into the hospital chief’s own bathroom under the guise of looking at a sonogram reading and had pushed him up against the wall and proceeded to give him a handie. He and Nancy had gone to medical school together; she, too, was recently divorced. It had been so long since he’d had this kind of contact. Okay, it had been two weeks. But two weeks, after an adulthood of not that much action, followed by two years of a lot of action; Toby had lost time to make up for. He’d been blind but now he could see, etc., etc. What he felt, what was most alarming about this time, was the eerie dryness in his life, like a literal one. A lack of moisture — in the air, on his body. He was wearing a face mask all the time now, his breath bouncing back at him, chapping his lips, his entire body separated from the rest of the world, separated from a bottle of water that he could never locate once he’d opened it.
It was not to be with him and Nancy that day. She had used gloves as a precaution and it was too weird. He couldn’t even settle into the recurring fantasy he had (the one he summoned when he was near latex) in which he was getting examined by an amorous doctor who, driven crazy with lust, couldn’t control herself anymore, because Nancy was one of those who liked direct eye contact the entire time. “Open them,” Nancy kept saying. “Open them.” What was he going to do? Tell her he was trying to picture someone else? No way. Meanwhile, she’d gotten some lube from a sonogram machine, a blue jelly that made a farting noise when she squeezed it from the bottle. It was all so clinical, he couldn’t bear it. He took her wrist and said, “I’m not sure this is working.” They were the kind of horny that was born of sadness and fear — the worst kind of horny, so much so that they couldn’t even get it right. Nancy had nodded despairingly — how fast people can go from being dirty to being despondent — and he’d worried that he’d broken some kind of unspoken code about the secret hospital hookup. That you’re never supposed to acknowledge it or speak of it, and for the love of god, you don’t stop it midway. It was important to keep this up because nearly 80 percent of sexual encounters among doctors at a hospital are about the immediate need for an expression of vibrant health and vigor in the face of disease, the only defiance a person could cling to after seeing some of the things they saw. He should have just pretended to come. She might not have noticed with the gloves, or maybe he could say he was doing that Sting orgasm thing where he just holds it in forever so that his jizz could recirculate through his scrotum in an neverending whirl of unexpressed desire or some shit.
This was a fate worse than being alone: To be so scared that you couldn’t imagine sex anymore. Was sex over, too? For good? All of it? It was hard to look at anything and want to touch it. Every surface seemed tainted with an invisible muck, a dry poison, a killer. And people — they were the carriers. How could you ever be safe around a person again? And yet Toby’s body was desperate for anything — new lips against his, bare breasts against his bare chest, a tongue on his perineum, even a wiggly finger up the asshole, which he didn’t normally love, but it might be just the thing right now. His children were stuck at home for days on end. They no longer had bedtimes. It was chaos. Meaning he couldn’t find a place even to jerk off in peace.
So he did his job. He evaluated his patients who were concerned that something was wrong; he ordered bloodwork for the ones whose symptoms seemed emergent or alarming. He did triage not just on who deserved a liver but who needed that surgery right away. Just the week before, Toby had participated in the first liver conference of the day, where he was presenting for his patient, Felix Jimenez, a 66-year old MTA retiree. Felix had cirrhosis, his alcoholism only discovered eight months before, when he’d been found passed out on the train tracks he’d been inspecting and his daughter, Barbara, had been called to the hospital and alerted to a high blood-alcohol level.
“He never had a drinking problem before,” Barbara had told Toby. He’d waited with his hands folded, looking at Felix, who finally spoke up. It turned out that every morning, he’d been spilling out half the coffee in his thermos on the way to the train each morning and refilling it with vodka that he’d hidden in the shed in their backyard.
“Drunks aren’t supposed to be functional,” he told Toby that first time they met. He had never been much of a drinker, but his wife had died ten years back, and he had started to seek comfort where he could. “But I can’t function without it.”
Toby had suggested a rehab center, a bare-bones facility in Staten Island that was the only place where Felix’s insurance would pay up. He’d followed up with him every week he was there. Felix was a big man, and during the worst of his withdrawal, the first two days or so, they’d had to restrain him. Toby had told Barbara not to visit, that it would confuse Felix, but really, it was because Felix was delirious — later on, he didn’t remember that Toby had visited him that first week — and he didn’t want Barbara to have those memories. She’d been through enough.
But the rehab had worked, and Felix had retired from his job and was now in his fourth month of regular AA meetings. But his liver wasn’t getting any better, and then it was getting much worse, and it became clear to Toby that Felix Jimenez wouldn’t be able to ride out the virus and wait for a regular hospital stay, so Toby put his case up for conference — the panel that decides if a patient is a worthy candidate for a donor liver.
Toby entered the abandoned office he was squatting in, which had a bulletin board of before and after photos of rich women along with the kinds of thank you notes that you find in a pediatrician’s office after a successful delivery. There was a large screen that was sponsored by Juvederm that was, contractually, always on (but why? What did the doctor get out of it if it was just a loop of Juvederm commercials?). He pulled up the digital conference Zoom room, which was attended by a social worker, a psychologist, a surgeon and a hospital administrator, greeted them, and gave his testament to the group, telling them that he’d seen up close Mr. Jimenez’s hard work and initiative in getting sober; he’d been impressed with the fact that here were no stops and starts, which is rare.
“Four months without drinking is a real inflection point,” the psychiatrist said. “Let’s not do any victory marches yet. I’ve spoken with Mr. Jimenez twice, and he doesn’t sound very positive about a life without alcohol.”
“How so?” Toby asked. Or at least he tried to say that. The psychiatrist had tried to continue, but when she saw that Toby was trying to speak, she said, “Oh, I’m sorry. No you. No you. No you.” So Toby kept saying, “How so?” until it registered.
“I asked about his hopes of staying sober with his new liver and all the stress a surgery can bring and he said,” she checked her notes “‘I hope I can do it.’ Not great.”
“Sounds honest to me,” Toby said. “Would we believe anyone who absolutely knew they could do it? Is the whole 12-step infrastructure not built on some kind of humility?”
“Patient is widowed and lives alone,” the social worker said. His face stopped in a lurid open-mouthed pose but Toby could still hear the words. “Not much post-surgical support.”
“His daughter lives next door and has dedicated her entire life to taking care of him,” Toby said. He heard the whininess in his voice and adjusted; he knew the room yielded to stone-cold stone. He straightened himself out. Maybe his mouth was open, too. “I have full confidence.”
“Well, I think he’s an excellent candidate,” the surgeon said. “I wouldn’t mind him losing some weight, but, well. What can you do? Not like the gyms are open.”
“He doesn’t have time for that,” Toby said. “He’s in failure.”
“Calm down, Toby,” the surgeon said, speaking for the first time.
“I’m plenty calm, Marco,” Toby said. He hated this fucking guy.
The medical administrator took her notes and then looked up. Toby had never met her before; she was from a hospital downtown. “This is a safe space to disagree,” she said to everyone. “There are a lot of worthy people and very few livers. We have to have absolute integrity when we recommend to the registry. The gift of life via organ donation is precious and each case deserves our rigor.” Then, to Toby, “We absolutely appreciate the passion.”
Did they think he was an idiot? He nodded and his face shield almost fell off. They were all wearing plastic shields on their heads now, and protective gowns. They were spacemen now, alone in tiny space pods.
“Thank you, Dr. Fleishman,” the admin said. But right as Toby reached to end the meeting, the admin said, “Dr. Fleishman? I’m so sorry. But do you mind sticking around for the next one?” Apparently, the hepatologist for the next patient — from a hospital on the East Side — had had symptoms that morning and hadn’t come in, and his internet connection was bad. Toby had talked to that guy yesterday, and so he began to squirm as he felt the coronavirus, spindly and spiky and venomous, creeping up through his skin, up into his veins, right into his lungs.
“… Sure,” Toby said, and sat down again, though he badly wanted to leave and wash his hands.
Marco made a move to leave, too, but the administrator asked him to stay as well, because the attending surgeon had been called into an emergency consult. Marco agreed, annoyed because of how important surgeons are and how much more valuable their time is than anyone else’s.
That next case was a 60-year-old man named Christian Hughes, a hedge-fund guy who also had cirrhosis. He had been a binge drinker since college but had quit three months before, his third time doing so. He’d never made it past three months — “but he’d also never been diagnosed with cirrhosis before,” said the social worker, the only new person on the conference call.
Mr. Hughes was not asking to be put on the registry. Rather, he was going to be the recipient of a living-liver-tissue donation by a young woman who had heard of Christian’s predicament and, for the sake of altruism, volunteered a slice of organ to him.
“She heard about his predicament?” Toby asked.
The admin checked the papers. “Yes. They know each other for many years, apparently.”
Toby laughed. “And this is fine? We apply not even a teaspoon of skepticism to this?”
“We allow living-tissue owners by acquaintances,” the social worker said. “We do it all the time. There are still good Samaritans out there, you know.” She laughed a little.
“What is the relationship between them, Mr. Hughes and the donor?” Toby asked.
The social worker and the psychologist looked their papers, but it was the admin that answered, through a stiff jaw and tired eyes. “Donor is the daughter of a friend of the family.”
“A friend of the family.”
The social worker read from the form. “An employee who had been with the family for years.”
“So a housekeeper. Or a driver.”
“Not clear,” the admin said. “But yes, in his employ.”
“And that’s okay with us?” Toby asked. Nobody said anything. “That’s illegal! This whole conference exists to catch these guys buying organs.”
The psych got huffy. “I interviewed her myself. She said that she was not coerced. People become very close over the years. Our nanny is an honored guest of ours at Thanksgiving, and she doesn’t even work for us anymore.”
“How old is the donor?” Toby asked.
“And what does she do for a living?” Toby asked.
“… she also works in the house,” the psychologist said.
“This is illegal,” Toby said again.
The admin threw up her hands. “Donald Bartuck called to say that we should take good care of Mr. Hughes.”
Toby knew where this was going. When Bartuck wanted special care for a patient, it was hard to argue. “Shouldn’t we take good care of all our patients?” he tried.
“I think that’s Dr. Bartuck’s point,” the admin said.
“Not really,” Toby said. “This makes the young woman our patient, too, right? We have to take care of her, too.” Then, to Marco, he said, “You really going to do this, Marco?”
“Nope,” Marco said, because he didn’t give a shit. “Not my patient.”
Toby’s objections were noted for the record and now, a week later, Toby had received a call that there was a liver ready for Mr. Jimenez. A nurse gave Felix a COVID test — negative — and then wheeled him through the halls in an easy chair, saying, “Welcome to the last few minutes of your Before!” Felix didn’t understand, but that was okay; he was already sedated. He was prepped for surgery by a group of nurses in scrubs that weren’t like the scrubs at Toby’s hospital — instead they had cinched waists and ruffles along the hems. The staff had seen a lot that was gross but very little that was tragic.
Toby went to see Felix and walk alongside his gurney to the tunnel that connected the plastic-surgery center to the main hospital below ground. “I’ll keep Barbara updated for you,” Toby said. Felix nodded, unsure of anything anymore, but the mention of his daughter’s name immediately messed his face with tears and mucus. Marco joined them and asked Felix if he had any questions, but Felix was asleep, which wasn’t supposed to happen before the patient spoke with the surgeon. Chaos.
Toby went back to the plastic-surgery facility and did his rounds. He didn’t hear anything until four hours later, when he went to check on the operation only to find it hadn’t happened. Felix had been taken back to his room, the sedation had worn off, and he was awake.
“Nobody will tell me what happened,” he told Toby. “Do I have a new liver? That was it?” Actually, a nurse had informed him that he’d been in the operating room for ten minutes before the surgery was delayed, but had spoken so totally in euphemism that when she left, Felix was less sure than ever about what was going on.
Toby told him that no, he hadn’t had the surgery. He told him that sometimes the liver proves to be faulty, though that wasn’t true in this case, at least not as far as he knew. He wandered around the building looking for an office of authority. He had Marco paged but was told Marco was in surgery. Finally, he found the admin in a hallway.
“Hey, my patient was supposed to get a liver today,” Toby said.
The admin took a minute to remember who Toby was and then looked at her clipboard.
Toby was impatient. “What happened?”
She made a them’s-the-breaks face. “Dr. Feldman’s wife has COVID. He didn’t want to risk it.”
“Does she now,” Toby said. Feldman knew the policy that sick spouses meant you couldn’t come to work. Feldman had also been complaining that their summer rental in Berkshires was sitting unused while he dealt with this shit.
“Yes, they went to their place in Massachusetts to ride it out.”
“I bet they did.”
She kept her face professional, refusing to engage. “Dr. Bartuck asked Marco Lintz to cover. He did the surgery on Mr. Hughes. He couldn’t be in two places at once, and Mr. Hughes had already been scheduled for today.”
“But Hughes wasn’t his patient! And we had a liver from a dead donor. It had already been harvested.”
The admin just nodded, which made Toby insane.
“Hughes could have waited till the next day. His donor was alive.”
She aimed eyebrows at him. “Mr. Hughes didn’t want to risk COVID exposure by waiting an extra day in the hospital.” Off his disbelief, she said, weakly, “Dr. Bartuck had asked that we take special care.”
So Felix Jimenez was being sent home. In his room, Toby couldn’t bring himself to tell him why; he couldn’t figure out how to overcome the shame of telling a person they were not considered as real or urgent as another person. So he just said there was an emergency, that this kind of thing happens all the time, and had a nurse call up Barbara. The liver had been thrown in the garbage.
He passed by Christian Hughes’s room on his way to Felix. He heard a nurse tell him how much better he looked now than before. “So well-rested,” she said. “Like you took a Caribbean vacation.”
He wheeled Felix out himself. He had wanted to hug him then, but hugging was extinct. Handshakes were over. We were now fully separate from one another, scared of closeness. The normal ways Toby had of dismantling the alpha-beta structure of a doctor-patient intimidation cycle — a high-five, a hand on the shoulder — those things were over. Everyone was alone.
On Toby’s way out that night, an anesthesiologist from Lenox Hill gave him one of those smiles that had a little more sexual missile lock than is collegial. Two years after his divorce, he knew the signs; he knew how to identify a person giving him the eye. Let’s do this, he thought. He had to try. In the name of keeping society intact, he had to fuck this doctor.
Her name was Stacy. She was young, but he didn’t mind. So he joined her in the locker room and they didn’t do anything except immediately strip down to nothing but surgical masks and their shoes. He had taken the plastic screen off his face, but left the mouth covering. He couldn’t help it; he wanted so badly to feel her moisture on his face, somebody else’s wetness.
But then they were standing there naked and they didn’t know how to approach each other. They took a step in but couldn’t make it work. Another step, and they didn’t even have enough good humor in them to laugh off how awkward it all was. He looked at her — this beautiful, available young woman — and realized he wouldn’t be able to do more than jerk off at home alone, if the kids would ever go the fuck to bed. He realized standing there that, actually, he would not have been able to withstand the moisture on his penis, the wetness of a mouth, intentional closeness just then. He suddenly understood that he couldn’t bear closeness. God, would he ever enjoy a blow job again? Would he ever delight in the mess, the smells, the gross chemical intermingling again? Or would they forever be changed? Did the separateness now make it so that none of this made sense anymore, or was intimacy like a word you use often until one day you just stop using it, and you stare at it and it’s now just a jumble of letters that feel like nonsense? All the noise that these encounters generated for him (the emotional noise, the actual noise) — that was over now, and the questions that hung over him made a quick fuck in the hospital unbearable. What do you do when your body cannot comfort you anymore? What was the comfort, after all, when it was only of the body in the first place?
That’s what the virus seemed to do: it showed you what your motivations are, who you valued, how you’d been spending your time and to what end. Ira was right. It was all laid bare now. They had always been there, these things we held most important and the people we held most dear and the way we could barely tolerate being alone, but now they were triaged and made clearer than ever. Toby wondered if society would ever recover from these things coming to the fore — wondering if he would, either. He also wondered how many blow jobs and hand jobs you can turn down before they stop getting offered to you.
Toby left the hospital and walked home through the streets. He had only seen the city like this in movies. Particularly he was thinking of a dream sequence from a Tom Cruise movie in which he runs with horror through an entirely trafficless, personless Times Square. How terrifying it was to see the streets like that in that movie — how the entire point of seeing those streets that way was to terrify. The emptiness showed things as they were, too: That the city was small and dumb, that there were too many pharmacies and not enough of everything else. Suddenly, he heard a loud noise, and he jumped. It was the sound of wooden spoons hitting pots and pans. It was 7 p.m. The city was cheering for him.
Fleishman is in Trouble, Taffy Brodesser-Akner’s debut novel, is now out in paperback.