Oxygen

by Carol Wiley Cassella

  The purchases almost seemed part of the rite of passage of becoming a full-fledged physician, like framing my medical degree, licenses and board certifications—documents I was expected to display, status symbols I was expected to crave. I think I mainly desired the proof that I could provide for myself. I put so much on hold.

  I ended up never hanging the certificates on any wall. Instead I filled the blank spaces with family photographs—my nieces and nephew at christenings and birthdays; my sister and me at the beach, at a rodeo, doubled up bareback on the sagging spine of her pinto mare; my mother in her rose garden, still as slender and fresh as one of the unopened buds gathered in her gloved hand, an age before my clear memories of her. And one formal portrait of my father taken for his retirement announcement, propped up in the center of a bookcase from which he can judge the wealth and security I’ve accumulated without his help.

  I arrange the wilting iris and daisies in an orange juice glass and set them on my bedside table, scribble a note to Gary apologizing that I have to attend a conference the week he’s planned to visit, begging him to reschedule. Then I call Lori.

  “It wasn’t broken—only a sprain. Her doctor loved the magazine idea. We went with Rolling Stone in the end. How was your day?”

  “Not so great,” I answer. Then I take a deep breath and add, “I went to a funeral.”

  “Marie, I’m sorry. Who was it?”

  I sit down on the bed and knot the phone cord in my hands. The iris hangs limply over the rim of the glass—I turn out the light so I can’t look at it anymore. “It was a patient. Someone I took care of.”

  Lori is soothing and sympathetic. She’s heard me talk about the lingering, often painful deaths of cancer patients who may undergo multiple surgeries before letting go. “Ah. That was kind of you to be there. Had you gotten close to the family?”

  “No.” I stop. A soft cry escapes me; I can almost feel Lori’s tension at the other end. “It was a little girl. Eight years old. She died on my operating room table.”

  Lori lets out a low groan. “Oh God. What was wrong with her? What kind of operation?”

  “Nothing. She was a healthy patient having a completely routine surgery.” My breath reverberates against the mouthpiece; otherwise there is complete silence. I curl down onto my pillow with the phone snuggled under my cheek. “We were in the middle of her operation and suddenly I couldn’t ventilate her. Her airways closed.”

  “There wasn’t any reason? I mean, nothing you could predict?” She sounds almost panicked, and I know she’s talking to me as a mother right now, not a sister. How can she help that? I hear another, smaller voice murmur in the background; Lori whispers, “Shhh, shhh, everything’s OK, baby,” and there is a rustling of fabric. Then she speaks into the phone again. “Lia’s in my bed. She had a nightmare.”

  “I’m sorry. I should let you go.”

  “No, it’s OK. She’s back to sleep. I can’t believe you’re up there going through this all alone. Do you want to talk about it?”

  The tug of loneliness stretches the continent between us. “They’ve told me I’m not supposed to talk about it. That’s almost the worst part right now.”

  “But you know it wasn’t your fault, right? I mean, do things just go wrong sometimes?”

  “In sick people. Old people. Not in eight-year-olds. At least not very often. I think she had an anaphylactic reaction to one of the drugs. Maybe latex. And I treated her for that, but…it all happened so fast.”

  “Is that like an allergy?”

  “The worst kind. The kind that kills people.”

  “But you couldn’t have predicted that, right? I mean, that isn’t your fault.”

  I don’t answer her. How can I explain that blame is only one part of guilt when something goes wrong in a doctor’s work?

  “Do you want me to fly up? I could ask Olivia to help Gordon with the kids. I could be there tomorrow.”

  “Uh-uh. Don’t even think of it.” I try to force my voice to relax. It sounds hollow in the cove between my face and my pillow. “I’ll be OK. I guess at some point I was bound to have a bad outcome, just based on statistics.”

  “Oh, Marie. I know you took wonderful—perfect—care of her.”

  I roll onto my back, brushing damp hair from my temples onto the pillow. “If I’d taken perfect care of her, she wouldn’t have died. She was an only child, Lori. Her mother’s only child.”

  Lori and I lost our mother twelve years ago this month, when I was twenty-five. I was in my third year of medical school. After twenty-four months bent over microscopes and cadavers and textbooks that broke the spine of my bookcase, my classmates and I all felt ready to apply our memorized Latin terms and lists of symptoms to flesh-and-blood patients. Finally we graduated to the hospital, and began to wear the emblematic white coat of a physician—pockets crammed with rubber stethoscopes, reflex hammers, tourniquets and antibiotic tables. We were the lowest tier of patient caretakers at that stage—even nurses’ aides smirked at our flailing efforts to mesh aced exams with the practical realities of illness. No textbook can teach you how to insert an IV catheter into a vein or a nasogastric tube into the stomach, or to suture a kicking child. Egos collapsed under the weight of bedpans and Band-Aids taped over our botched efforts. Still, for most of us, that white coat implied some mastery not only of medical knowledge, but of medical morals—the ethics of life and death. At some point, though, we all had to face humanizing reality. I had to face it inside my own family’s private crisis.

  My mother had rheumatic fever as a young child, which damaged her heart valves. Over the five and a half decades of her life, her heart strained to push blood through a shrinking portal, building up its thick, muscular wall like the oil-slicked biceps of a weight lifter. Her heart strained and thickened while she ran with girlhood friends in her rural Texas school yard, fell in love with the older graduate student who lived in her mother’s boardinghouse, worked as a waitress to buy her husband’s books, tried for years to conceive a child and then bore my sister and me within fourteen months of one another. Her heart struggled and strained during all of this, quietly compensating for the misshapen valves so that all along she believed herself healthy, believed she would live to see her daughters marry, hold her grandchildren, help her husband into the infirmity of old age.

  Her heart granted her this grace period of apparent health until it turned some physiological corner of irreversible damage and she became aware of a breathlessness when she mopped her floors, a pain in her chest while weeding her rose garden. By the time Lori and I were in high school she’d marshaled a standard list of excuses for missing picnics or walks or trips to the lake. Even then her quiet pride, her maternal endurance, kept her symptoms a private matter, each year without medical intervention diminishing any chance to reverse her decline. She kept her symptoms hidden until I began to notice how she paused in the middle of our staircase every time she carried up the socks, books, sweaters or shoes that we, her family, ungraciously dropped in the middle of our kitchen.

  But it wasn’t until I was in medical school that I understood it well enough to insist—in a newly respected voice, propped up by my fresh white coat—that she see a cardiologist and take advantage of what modern medicine could offer her. By then her only choice was open-heart surgery.

  Her cardiologist explained that she would likely do well after the surgery. Yes, her risks were higher than they would have been in the early stages, but without the surgery her risks were higher still. My family turned to me to translate this foreign dialect of choice and consequence. And I could—even in that infancy of my medical life—explain ventricular hypertrophy, valvular areas and gradients, cardiac output, cardiopulmonary bypass. Those words I could look up in my Stedman’s Medical Dictionary, dissect down to their Latinate origins and offer their meanings up to my parents like gifts, proof that my education had worth. What I could not give them, and what they needed most, was the perspective of experience, the critical f
ilter of judgment that might have made their choice clear: without heart surgery she would almost certainly die within two years.

  Somehow the choice seemed to paralyze them, having grown up in a world where illness rarely offered options. We talked in circles. I tried to persuade her, using simplified words and penned sketches of her circulatory system. She turned to my father, as always, for his opinion. He asked me to explain it all again, as if a more thorough description might guarantee her life would be saved. My mother sank into a depression that stalled her ability to see a future either way.

  Then one morning she rose from her favorite chair and collapsed to the floor with a crushing weight in her chest. The pain so ripped the breath from her that she couldn’t cry out. My father heard the shattering teacup and ran to the living room. She was still talking when we reached the hospital. But much of her heart was dying. The stiffening muscular wall that had granted her one last decade of life had grown so thick it squeezed shut its own blood vessels—retribution for its malfunctioning valves.

  She was rushed into intensive care, the very unit where I was assigned to learn the intricate balancing of medication drips and electrical wires and breathing machines that can save a life or merely painfully prolong it. There was a chance still, said her cardiac surgeon. If the stress on her heart could be lightened enough to allow some healing, some trickle of oxygen-rich blood to its inner core, she might survive the surgery.

  They slipped a small pump through the flesh of her groin into her femoral artery and up into her aorta to lodge just beyond her flailing valve. The pump was timed to the electrical rhythms of my mother’s heart, inflating and deflating to siphon the blood forward, out to her body and her brain.

  I sat in the half-light and listened to the rhythmic thudding of the mechanical pump, muffled through the layers of her living flesh. I envisioned the submarine-shaped pump expanding and contracting in the bright blood of her aorta, its cord snaking down the pulsing vessel to erupt from her groin and connect her to the machinery. The sound lulled me into a realm where memories of my life with her and hope for my future could weave together, connect as a continuous line, without the scar of grief I knew her death would leave inside me.

  My father circled the floor like a confined animal, repeating the same questions over and over. I kept trying new words, new metaphors that might make the mystery of her failing body comprehensible to him. But as days went by and her kidneys stopped cleansing her bloodstream, her liver quit manufacturing enzymes and proteins, her bone marrow stopped creating new blood cells, waiting for surgery became moot. Now we were waiting for death.

  A meeting was gathered of her medical team, my sister, my father and myself. This time her cardiologist’s words were chosen haltingly, chosen to be soothing but without hope. He gently guided my father to the understanding that he must end this artificial extension of his wife’s life.

  I’m sure my mother never suspected she was raising a doctor. Female doctors were rare in her world. She taught me the things she believed I would need in my life: how to sew a bias-cut tie as a gift for my father one Christmas—a wide garishly flowered thing he wore once out of courtesy; how to separate the white from the yolk when making meringues, slithering the contents of the raw egg from half shell to half shell until the golden center swam naked in its clear membrane; how to pluck my eyebrows, put on a bra and pull sheer stockings up my legs without snagging the interlaced filaments.

  She taught me all the things my sister has put to excellent use in her life, all the complexities of stabilizing a home and joining two people and the generation they create together into a new and whole family—critical facts that make families work, passed from woman to woman, never tested or graded or ranked, but invaluable nonetheless. I stored them up to share with my own daughter someday, after the temporarily consuming labor of medical training was finished. Once I regained some control over my life, after my residency, I always knew, I would rejoin the intended stream of marriage and motherhood. I never meant to dam myself off from those. I just knew they would require careful scheduling.

  7

  After the first week people stop telling me how sorry they are or asking me if I’m holding up all right. Instead of being a disaster shared with everyone who works in the operating rooms at First Lutheran, it gradually becomes the silently screaming secret that sends an awkward hush over groups of surgical techs and nurses chatting at the coffee bar the minute I show up. I ask a question about the schedule, offer an opinion on the new epidural kits, give the most intentionally bland comment on the weather, and the responses return stained with pity.

  The other anesthesiologists at the hospital are bolder: “It happens to a lot of good doctors; I might have made all the same decisions”; “I know how you must feel. But for the grace of God I could have been assigned to that room”; “You have to get up and go on, Marie.” Only the vaguest shadow of judgment in their eyes, only the slightest drop in their voices dangles the question of doubt.

  Within a few days after Jolene’s funeral it becomes obvious that my closer friends are working harder so I can get out of the hospital earlier. Joe, Will, even Sandy McLaughlin, who is usually so private and self-contained, all seem to be coincidentally discovering my late case has been transferred into one of their rooms. They wind up unexpectedly free right around noon with nothing better to do than send me out to pick up Thai food for everyone. It’s hard not to care that I’m never assigned any pediatric cases.

  One morning the garage elevator opens and Brad gets in. As soon as he sees me I can tell he wishes he’d taken the stairs. It’s the first moment I admit to myself that I’ve been avoiding him in the cafeteria and conference room. He nods at me and pushes the button for the next floor up, even though we both have to get to the fourth floor operating rooms. When the doors open, though, I get out with him in the deserted vestibule of basement offices.

  “Brad.” I hesitate, stretching for safe words. “Look. I never got a chance to tell you how sad I am that you’re caught up in this. It was just…bad timing. Bad luck.” I intend to stop with that, I know I should stop, but there isn’t a soul around to hear us. “I don’t think anything could have made a difference, on either of our parts, but if you noticed something, even some change that didn’t seem important at the time…”

  He is beet red, shaking his head. “I can’t. I’m sorry, Marie. My lawyer says I can’t say anything to anyone except a shrink or a priest.” He reaches past my head to push the elevator button, and I feel my own face grow hot.

  “Your lawyer? Why did you talk to a lawyer?”

  He shrugs and pushes the button again. “I just needed to know where I stand. When…if a suit’s filed.” He steps inside the elevator and looks directly at me for the first time. His eyes seem sad, or disappointed, or maybe just afraid. “Marie, I’m the new guy here. I don’t have any record to stand on. Who are they gonna try to hang?” The doors close between us and the cables hum as he is hoisted away.

  A week to the day after Jolene’s death I need to leave early to meet with my malpractice case representative and Joe comes in to take over my thyroidectomy.

  “Got your speech ready?”

  “I guess. Do I look nervous?”

  He puts an arm around my shoulder, his mouth at my ear. “Just remember. You’re paying her.”

  “Yeah. It’s easy to forget that right now. Sort of feels like she’s the whole jury.”

  I tell him my patient’s medical history and allergies and my anesthetic plan for her. I’m about to leave when I remember her primary request of me. “She really wants her dentures back in as soon as she’s awake,” and I point out the clear container holding a perfect plastic grin.

  Caroline Meyers-Yeager, my malpractice claims manager, is a petite woman, somewhat older than myself, wearing a crisply fitted ivory silk suit that matches her equally crisp blond hair. Her clipped New York accent cuts to the bone of historical payouts for pediatric deaths and the statistical odds
against prevailing in front of a jury if this comes to trial. I’m sitting opposite her desk, unable to swallow the tea her assistant brought, uncomfortably aware that I haven’t combed my hair in hours.

  She listens to my well-rehearsed synopsis of Jolene’s anesthetic and code—the version my own bathroom mirror confirmed I’d performed flawlessly. “I’ve gone over my notes repeatedly,” I tell her in my most objective and collected voice. “The most likely explanation is anaphylaxis.”

  She jots a note or two on a long yellow legal pad. “But she had no history of allergies.”

  “Not in her record. Her mother didn’t know of any.”

  She frowns and skims her notes. “You’ve done a good job with your charting. Very detailed—Donnelly will like that. But if you had to question your own diagnoses”—now she flashes a more conspiratorial smile—“if you were your own cross-examining prosecutor, is there anything that doesn’t fit?”

  I start to answer her, consciously composed, but she catches the flicker of doubt. “It’s OK,” she says. “Nothing we say here is discoverable.”

  “Her heart rate.” I pause and bite my lip. “It should have gone up at first. Before her oxygen level dropped. That’s the one thing that doesn’t make sense.”

  “How significant do you think that is?”