Oxygen

by Carol Wiley Cassella

  I throw a lever and begin to ventilate Jolene by hand using a breathing bag—but there is too much resistance. She might be reacting to the surgery, coughing against the ventilator. Another monitor alarms—her blood pressure has dropped by twenty points and her heart rate is going down.

  Mindy looks up and sees the flashing red lights on the screen. “Everything OK, Marie?” She is used to the minor problems that happen during many surgeries and waits to hear the alarm go silent, to know all is under control.

  “It will be. Could you mix up some epinephrine for me?”

  The reassuringly high pitch of her oxygen monitor is starting to drop, and there is more resistance against the breathing bag. I squeeze it with both hands. I trace the tubing—it’s clear; the blockage must be inside Jolene’s airway passages. I put my stethoscope over her back on the right, on the left, and can hear only faint breath sounds, a high-pitched wheeze when she exhales.

  “Mindy, get a suction catheter out of the bottom drawer and hook it up to the vacuum.”

  My voice is steady and calm, but I know she hears a new urgency. I slip the catheter down Jolene’s breathing tube to check for plugs. The tube is open.

  The numbers on the oxygen monitor begin to spiral down. Any reserve is going fast. Jolene is in bronchospasm. Her smaller airways are swelling and tightening, strangling her from the inside. It must be anaphylaxis—a profound allergic reaction, or undiagnosed asthma. But her heart rate should have increased, at least initially.

  My mind separates itself from my body. I enter some hyperfunctioning realm where I race forward in emergency protocols, calling for backup help, telling Stevenson we have to stop the surgery, turn her over.

  He stares at me as if I’ve lost my mind. “She has an open wound on her back. We can’t turn her over.” I hear someone command him to put sterile towels over her back and turn her over now. Now! It is my voice.

  Her heart rate keeps falling, the pitch on the oxygen saturation monitor is in a steep decline. Nurses and technicians pour into the room, but no other anesthesiologists are available. I rip sterile drapes from the operating field, shove my hands under her shoulders and head, tell Stevenson to grab her feet, Mindy to push the epinephrine, give her albuterol, atropine, antihistamine. We logroll her onto the gurney as her monitors plunge in pitch, plunge in heart rate.

  Her skin is white, her lips are dusky. I call out emergency drug doses, order another IV, a defibrillator and arterial line. I place my hands over her sternum for chest compressions—her heart is failing and can’t circulate the drugs that might save her life. I tell Stevenson to squeeze the breathing bag. The pressure monitor bounces off the scale with each breath like a bicycle pump on a tire with a blocked valve. Jolene’s chest compresses easily beneath the heels of my hands, her pulse shows I’m circulating blood. But blood without oxygen is worthless. Her face is gray now, her lips dark blue.

  She is dying. My God, this child is dying. I can feel blood rush into my face, the team watches me, waits for me to pull off a miracle, all of us teeter on the brink of realizing that Jolene has already been starved of oxygen for so long nothing of her former self will survive. A sound buzzes inside my head, and the garish operating lights make my hands glow as they pump up and down on Jolene’s sternum. I don’t know how much time has passed. Ten minutes? An hour? The noise level has dropped from a cacophony of commands to a heavy, weighted silence.

  I feel Stevenson’s hand on my shoulder, a gentle, focused pressure. “Call it, Marie. Call the code off. It’s over.”

  4

  There is a roaring in the background, maybe inside my head, as if some cavernous space has cracked open. Everyone in the room—Mindy, Alicia, Bethany, Don—stares in never-intersecting lines of sight. If we look at one another, or speak, or break open the tight circle we stand in, this disaster will become real. It will become irreversible.

  Someone squeezes my hand. Don has grasped it, urging me back into the role I must play, the professional face I need to apply. I look up and clear my throat, try to make my eyes focus. “Thank you. Everyone. I appreciate your help. I know you all did the best you could.” No one wants to meet my eyes. Several people touch my shoulder or brush my arm as they leave, some attempt at support that might leave me intact.

  I have to look over at her, this child, still plugged with IVs and monitors, the breathing tube still taped so securely to her lips, arms stretched out with her palms up so we could access her veins, lying there in the shape of a supplicant. I have witnessed the deaths of any number of people since I began medical school, almost all appropriately at the end of full lives of mating and parenting, loving and arguing, worshipping God and wondering whether God recognizes them. I have stood at bedsides while life support was discontinued, and held warm and supple hands as they entered death, wondering if I discerned that imprecise moment when a soul and body separate. But I have never seen a dead child. It feels wrenchingly incongruous to see her pallid, inanimate death mask without wrinkles or gray hair.

  Don must have led me to a stool, because I’m sitting down and he’s kneeling in front of me holding my clasped hands inside his own.

  “We’ll need to tell her soon, Marie. She’ll be asking why it’s been so long.”

  “Right.” I barely hear my own words over my breath. I have to think of what to say. I have to think of how to tell her. I don’t know how to do this. I can’t tell her she’s lost her little girl. I rock back and forth on the small stool, grip Don’s hands as if they could anchor me to this spot in time.

  He stands and guides me up to him, holds me wrapped in his arms and whispers, “Don’t think. Don’t be Marie yet. Be her doctor. Be the highly competent and skilled physician you are, helping a woman understand the most probable medical causes of this death. Just one more hour, then you can let go.”

  He leads me to the door and opens it. Jolene is behind me. It is such an adamant, ingrained principle of anesthesia never to leave a patient alone in the operating room, even for a moment, that I hesitate before walking out, still unable to comprehend there isn’t something more I can do to help her. I must leave Jolene to care for her mother in a crisis of my own creation.

  The surgery waiting room is lodged in an afterthought of space created over the parking garage, down two linoleum-tiled hallways. They retain the sterile, tunnel-like quality of institutional America, the floors and walls marred with pocked tiles and black streaks left by gurneys and wheelchairs. Our paired footsteps are magnified in the awkward silence. I will be the one who tells her—the death is clearly not a surgical complication, even if I cannot yet answer the blaring question of why Jolene died.

  Bobbie Jansen is sitting in the back corner of the room, flipping through the pages of a magazine. When she looks up at the clock she sees us, and I watch the knowledge overtake her. I watch her search my face for the composed and reassuring anesthesiologist who interviewed her three hours ago. I see her realize that I am no longer the same woman, and that because of what I will say to her, she also will never be the same.

  I kneel beside her chair so my face is level with her eyes. It feels like the whole world has dissolved into those two black holes. My words come out in a raspy whisper. “Ms. Jansen, Dr. Stevenson and I would like to talk with you in a more private place. Could you follow us, please?” She allows us each to take an elbow, one on either side, and walk through the waiting room filled with expectant, cautious faces. All watch as we turn down a short walkway into a small, dimly lit room with a couch and two straight-backed chairs. All recognize that this one woman will hear the words they have imagined but suppressed. Just below their tension I sense the guilty relief believing that surely two tragedies would never happen together, and this woman must have absorbed the horror that otherwise could have struck them.

  Don and I lower Bobbie to the sofa and we take the chairs facing her. A box of Kleenex sits on the side table. She sits stiffly, her arms straight, supporting herself on the edge of the seat as if poised to r
un. The door clicks open and shut behind me, and I turn to see Bethany standing in the corner with her hands clasped in front of her and her head bowed, trying to remain an invisible witness. Of course. She will have to notify the medical examiner’s office and enforce whatever regulations First Lutheran has in place for an intraoperative death. Does she have a page inside her book of protocols that dictates how I should tell Bobbie that something I did killed her child? A spasm grips my throat and for a second I’m terrified I will start to cry. Then I divide myself, split the doctor from the woman, and start to talk.

  “Ms. Jansen, there has been a complication during your daughter’s surgery, a complication from her anesthetic.” I study her face, try to gauge how much to tell her at once, how much she already knows. Her fingers are white, clutching the edge of the flower-patterned sofa, and I feel an overwhelming urge to take her hand in mine, some need to connect with her physically as I talk, but I can’t. “Jolene suffered what I believe was a respiratory arrest. A breathing problem during surgery. Her airways, the passages that take air into her lungs, closed up, and we weren’t able to give her the oxygen she needed. We couldn’t open them up.”

  She stares at the floor, nodding to herself, as if she’s acknowledging an internal voice. I see her torso sway and I reach for her, but then her body goes rigid, like a warning to keep away. “I…We tried everything. All the drugs that might have helped. We all did everything we could to…”

  She clears her throat and breaks in, speaking in a flat monotone. “Tell me what you need to tell me. Tell me whether she’s still here. Whether she’s still alive. Tell me now.”

  My ears are ringing so, it’s hard to hear my own voice. I keep scrambling for the right words, magic words that could make a brutal truth bearable. “Jolene died, Ms. Jansen. We tried everything we could to reverse it, to save her, and we couldn’t. I couldn’t. She may have had an allergy we didn’t know about, a drug reaction, or asthma. It may be difficult to ever know for sure.”

  In slowed time Bobbie curls in on herself, clenches her arms across her stomach. She lets out a keening moan, an animal howl, both desperate and hopeless, as if she’s trying to block out the sight and sound of us.

  Don glances at me. He looks ashen, almost disoriented. He coughs and says, just loud enough to be heard above Bobbie’s cry, “Mrs. Jansen, when things like this happen, when a death is this unexpected, we suggest—the coroner will suggest—that we examine the body…the person, in more detail afterward. Particularly for other family members who might need surgery in the future, finding the cause of death can give everyone more peace in the end. Sometimes…”

  Bethany steps up behind Don and puts a hand on his shoulder. I look at him in stunned abashment, wondering if he has leapt to the only bit of science he could resurrect from this emotional maelstrom.

  Bobbie lifts her head and stares, her mouth ajar, and his speech stutters to a halt. “You want to cut her open, is that what you’re asking me? You come in here and tell me she’s gone, and in the next breath you ask me to let you cut her apart?” Her mouth gapes, and every line on her face is creviced deep, and abruptly old, wrung out, as if all the pain she’s tolerated in her life is crashing her open.

  “I think Dr. Stevenson meant…” I start, unable to stop myself from reaching for her hands.

  “Actually, the medical examiner will need to decide that,” Bethany says, sounding so sane and calm the contrast is harsh.

  Bobbie shoves my hands away from her and shouts, “Get your hands off me! What are you saying? There aren’t any other family members to put at peace! There’s nobody but the two of us. Jolene and me. Now. You take me to her. You take me to my baby!” She gasps in irregular, audible gulps of air, as if she were forcing herself to breathe. Then the breaths coagulate into a sob and she drops onto the floor clutching her head in her hands.

  Don stands up and nods toward the door, signaling me to follow him out. I feel like I’m rooted in the chair, waiting for some conclusion. “Ms. Jansen,” I say in a hoarse whisper, “I…I can’t tell you…” Someone puts a hand on my back. The hospital chaplain has come in, recognizing that I have reached the end of what I can bear to say, the end of what Bobbie can bear to hear. He will sit with her until she seems ready, and then escort her into the curtained cubicle where they have taken Jolene, IVs and wires and endotracheal tube carefully left in place for the medical examiner, a white sheet pulled up over the discolored area on her chest where I did CPR.

  I walk back to the operating rooms and begin the documentation that follows any medical complication: the detailed chronological description of each event that took place from the moment I met Jolene. Every sentence I write unravels a train of automatic responses I apply to an emergency, a train that has to move forward without hesitation during a crisis.

  But now the damage is known. Now I stand back as the critical observer of my fallibility, rewinding the action from an omniscient standpoint, knowing the outcome and therefore knowing that every decision I made, every confident, assertive action I took, every command I gave, ultimately has proven wrong. The only salvation I can find in the act of writing my own perfunctory defense is that it keeps me from having to drive home from the hospital and be alone.

  5

  I barely remember going out to my car or coming up in the elevator. Bethany shifted the rest of my cases to other rooms. I’m sure it made other people’s schedules awful, but I couldn’t have introduced myself to another patient. I don’t think I could have given a safe anesthetic.

  I should eat something. It’s after eight o’clock and I haven’t had any food since Brad got me out for lunch. I open my refrigerator and a wave of nausea sweeps through me. My living room is chilly. I stand by the windows pressing my forehead against the cold glass—pressing hard until my skin feels bruised. Like pulsing physical pain, I pass through seconds of forgetting into exploding images: Jolene’s dark purple lips, Bobbie’s mouth gaping in a ragged hole, the sound of her moan that felt like something sucked out of my own lungs.

  My answering machine is packed. Three of my partners have left messages offering to give up their vacation days if I need some time off. Don Stevenson has called to tell me he knows I did everything possible and I have his full support. Joe has called, too, at first pretending to be insouciant and upbeat; then, dropping his voice, he reminds me it’s part of the risk we all take being doctors, no one could have done a better job. The hospital chaplain has left his home telephone number, encouraging me to call at any hour if I need to talk. He had caught up with me just as I was leaving the hospital, still too stunned to cry. “You’ll need to grieve almost as much as her family,” he told me. “Grieve. And then forgive yourself.” The minute he said it I knew the question that would become my cross: Did I miss a diagnosis in her? Could I have prevented Jolene’s death?

  I wonder who’s calling Bobbie Jansen, offering to sit up through the night with her, make food or help with funeral arrangements. Who’s letting her rage about the guilt and anger she must feel having entrusted her daughter to doctors, to strangers—to me?

  The day after Jolene’s death, I park in the same spot, take the same elevators to the same locker, hang the same stethoscope around my neck and dive back into my work. But there are oil splotches on the parking garage wall I’ve never seen before, deep chips gouged out of the cement pillars I’m sure weren’t there yesterday. The carpeting in the elevator must have been replaced overnight. It’s the color of blood—an odd choice for a hospital—stained with car grease and frayed to bare jute strands near the doorway. The locker room is bigger today, and there is a brown water stain across the acoustic ceiling tiles in the shape of a human heart. I eat breakfast because it is time to eat. I nod at the laundry woman because I can’t fabricate a smile. And I gradually begin to understand that nothing in my life will feel or look or behave the same again. Even when this is years behind me, and I’ve successfully anesthetized and reawakened a thousand patients, there will always be
the before and the after Jolene Jansen.

  Phil Scoble has left a note in my mailbox asking me to drop by his office. On my way up I run into Will. His smile is too bright. “Hey. Marie. How’re you doing?” Then he drops the facade and hooks his thumbs under the string of his waistband. “I heard about your case yesterday. I’m sorry.”

  “Thanks.” Despite myself my mouth starts to tremble. Will pinkens with embarrassment. He shrugs his arms forward, as if he’d like to give me a hug but has discovered his hands permanently affixed to his waist. They flap awkwardly once and sag, a bird arrested at take-off, and he looks down at his feet.

  “I’m on my way up to see Phil,” I say, rescuing him. Then I put my hand on his arm and attempt a smile. “It’ll be fine, Will. Thank you for being brave enough to bring it up.”

  I step into the closing elevator and Will wedges his foot against the door. “Marie, it happened to me once. Years ago. Lawsuit…the whole thing. It can get pretty lonely.” The elevator door starts to buzz and he releases it. “Call me, if you want.” I hear his disembodied voice as the doors seal shut.

  Pamela, Phil’s secretary, stands up as soon as I walk into his waiting area. “Hi, Dr. Heaton. He’s expecting you. Need any coffee?” I would love to believe she hasn’t already heard, but she’s never stood up for me before. She hands me a Styrofoam cup and blushes the instant our eyes meet. She turns and begins stacking papers on her already tidy desk. “Go on in. Let me know if you want a refill.”

  Phil immediately walks over and hugs me. I’ve known him for eight years, had dinner at his home multiple times, even joked with him about crossing over to the “dark side” when he joined the hospital governing board, but he’s never touched me in any way other than the most cordial handshake. He clears his throat and pulls a chair up to his desk for me. “Did you get any sleep last night?”