By Joshua Gilder

Simon & Schuster. 350 pp. $23. As a speechwriter in Ronald Reagan's White House, Joshua Gilder was credited with Reagan's never-to-be-forgotten "Go ahead, make my day." For his first novel, however, he has put politics behind him and written a superior medical thriller about a troubled young plastic surgeon in San Francisco.

Good popular novelists often devise dynamite opening scenes that hook readers before they have time to become restless. In Gilder's opening, his narrator, surgeon Jackson Maebry, is performing a routine face-lift. We learn that he is smart, skilled at his work and given to wry commentary about his colleagues. ("Like all first-year residents, he'd developed the ability to catch up on his sleep while standing over an operating table.") He's also wildly in love with a young woman called Allie and can't wait to get off work and be with her.

Instead, Maebry is called to the emergency room to assist with a woman who has been so horribly beaten and burned that only the Herme{grv}s scarf she is wearing prompts him finally to realize she is his lover. When her heart stops, and the doctor in charge is ready to move on, Maebry won't give up. He cuts her chest open and "I squeezed Allie's heart between my fingers. One. Two. Three. I counted and squeezed again, forcing the blood to circulate. I can do this forever if I have to, I thought. She's not going to die."

If that's not a grabber, I don't know what is. Does Allie live? Does their love survive this catastrophe? Who did this to her? In time, as these questions are answered, Maebry will learn that it is easier to massage a heart back to life than to understand why our hearts so often lead us to disaster.

Allie survives but says she cannot remember who beat her almost to death. Maebry sets out to investigate, and we discover his dark side. He fears he may have inherited his mother's schizophrenia. He sometimes drinks excessively, blacks out and reveals a nasty temper. We start to wonder if he could have attacked Allie and simply not remembered it.

Still, there is no shortage of other suspects: an older plastic surgeon, who loved Allie; his wife, who hated her; one of Maebry's ex-girlfriends, who was jealous of her; plus a woman who had once been Allie's lover. As a lawyer says to Maebry: "This is, after all, San Francisco. Passion takes on -- how shall I say it? -- an almost infinite variety of forms in this city."

Gilder keeps the suspense rising -- two murders follow the attack on Allie -- and he does other things nicely, too. His dialogue rings true, as does his portrayal of hospital life. He deftly captures the ego of a world-famous plastic surgeon, who grandly declares: "In plastics you're dealing with the whole person, with his image of himself. His desires. His dreams. You have to be more than a doctor. You have to be an artist." And a long scene in which Maebry and the older doctor reconstruct Allie's face may tell you all you want to know about the plastic surgeon's art. For example: "I lifted the skin from her forehead and laid it inside out over her chin, the interior of her eyelids about mouth level. A faceless head with opaque eyes stared up from the operating table."

Gilder keeps us guessing about the killer until his novel's final page, and even then his ending is ambiguous. Justice is elusive, he warns, and truth even more so. Maebry, who has suffered much by then, leaves us with this:

"Everything I've written is true, but I also know that what we call truth, like justice, is only a faint echo of a summons we heard long ago, and our human approximations, as necessary as they are, are just that, approximations. Like the beauty of music or children's voices. Like our human passions. They are only approximations. They can never fill the longing we feel. They are the longing."

A man who can write that paragraph deserves to be known for more than having once lifted a line from Clint Eastwood. "Ghost Image" is an unusually intelligent and skillful first novel. Gilder now lives in Bethesda and is a partner in a business consulting firm. I hope he's also at work on another novel. This one made my day.