On the Interstitium

For years I worked as a pediatric emergency physician staffing the only Level One pediatric trauma center in what was (and is) one of the poorest states in the union.

Tragedy is a regular visitor in these kinds of places. Among the usual hordes of kids with sore throats, and bronchitis, and assorted rashes there were the true horror stories:  the children who arrived silent with fear after car crashes that battered their families, and the kids found face down in pools.


At times like that our team would pull together, working quietly and with great purpose: around the bed would gather the nurses who had been at this for decades, the respiratory technicians, the wide-eyed residents, sometimes frightened parents who often looked as though they’d been torn apart atom by atom.

At those times, while we worked on tiny children, I often had the sense that we had somehow entered a different place defined by its amorphous nature, without walls or structure. Time was marked by the completion of tasks: the placing of a line, the passing of a tube, the addition of a medicine or the change to a ventilator setting.

The sick kids were undeniable evidence that the world can easily crumble.  When really bad cases arrived we all felt that were wading through soup, where there was nothing to hold onto and where terrible things were not just possible, but viscerally real.  It was a space that I would come to call the “interstitium.”

Classically, interstitium is defined as the in-between space separating structures or systems.  In medical circles, interstitial spaces are the voids between organs and cells. As a doctor, I soon found that when structure and order fall away, you’re left in the interstitium.  Developing into a seasoned emergency physician meant learning to becoming facile with stepping in and out of the between spaces, as disorienting as that was.

It’s been a Spring marked by escalating tensions, fearfulness, the rapid rise of nationalistic fervor and a disintegrating social order.

I’m uncomfortably aware that each regression of social norms and civilized behavior brings us closer to the interstium.  When the things that we believed to be true are no longer so, and when social institutions are discredited, we are in danger of finding ourselves in a world without handholds.

Here is what I know to be true: my father, who escaped Hungary in 1945, regularly described his near-death at the hands of the Nazis.  He and other members of the family were passengers on the historic Kasztner Train which safety transported 1,670 Jews to Switzerland in exchange for cash and gold.

What is most striking about his stories, to me at least, is how he remembers Budapest as relatively “normal” during his final days there, even as he was making his escape.   Author Anna Porter wrote a book about Kazstner’s Train, and describes my father Peter’s experience of boarding the train and leaving his mother in Budapest (because she was divorced, and because there was no more money for additional seats beyond the ones his father had secured):

[At the loading area] Two uniformed ss men read the would-be passengers’ names in guttural German.  As each person stepped forward from the crowd, the guards ticked off the name, checked the travel documents and allowed the individual to enter the camp. The family reassembled on the other side of the gate.

Before leaving the… compound to board the train on June 30, Peter called the commandant of the Csepel detention center, to which his mother had been transferred.  Strangely, he was allowed to talk to her one last time, and the commandant reassured him that she would be fine.  She sounded cheerful, unconcerned and said that the commandant had been most polite, the food was good, and her maid had come from home with freshly washed and ironed clothes.

A few days later, Katharina Munk boarded a transport train of boxcars bound for Auschwitz.

I say, with no uncertainty and from personal experience, that the border between order and the interstitium is a fragile one.  It can so easily fall apart with the slightest provocation. I’ve seen it.

Leaders: let’s regularly be reminded of the fragility of things– of social structures, empathy, decency and cosmic fairness– and recognize that order and normalcy are often thin veneers overlaying an endless interstitium.



Photo: mitchelhawkins Flikr, cc license