Oxygen

by Carol Wiley Cassella

  “I’m sorry about that. We shouldn’t have talked to them about the suit. I can’t excuse myself for it.” She twists the end of the dish towel deep into the funnel of the fragile crystal to polish the inside back to clarity.

  “Well, I might as well get used to explaining this—it’ll be on my permanent record.” I keep my voice light, but she stays self-consciously silent for a minute. We both know that from now on, every year when I renew my medical license or my hospital privileges, I will have to write a detailed description of the malpractice claim.

  “Marie,” she says, pointlessly buffing the gleaming steel faucets. “What do you think really happened? What caused it?”

  She can’t help asking. She is searching for the consoling nugget that will guarantee her own child is not vulnerable, that her own child can proceed to the tonsillectomy, the appendectomy, the ear tube placement, and come back home alive.

  I’m on the verge of telling her what I suspect. I’m on the verge of asking her opinion about which heart defect Jolene must have had, what twisted unfurling of the chambers and vessels must have occurred when one flawed scrap of DNA misfired and finally, fatally, declared itself on my operating room bed. We could discuss it as equally educated physicians, as uncompetitive friends, talk through the physiology to find an answer. She would never tell. Surely she’ll never be deposed against me—she wasn’t even in the hospital that day. But what look will cross her face when she realizes I might have missed a diagnosis that could have saved a life? What will be her own verdict?

  I carefully refold the damp dish towel and place it on the counter before I turn to face her. “I don’t know, Karen. I may never know for sure.”

  Karen ducks out to collect dishes and I slip into a spare bedroom to call a taxi. Sitting on the bed by the phone, damp coats piled beside me, I wait on hold and study the room, paintings of hunting dogs above the bed, Ralph Lauren plaid comforter and drapes. Family photographs are arranged on the bedside table and dresser: Karen and Ricky and their twin sons in front of a fireplace draped with Christmas stockings; Matt at his first T-ball game, his baseball cap so big on him his ears are folded in half and stick out like tiny pink wings; Karen in the delivery room just at the moment of birth. I’ve always sworn I would never display pictures of my own babies’ births throughout the house like some public anatomy lesson.

  Once the taxi honks, no one can protest enough to drive me home. The usual misting rain has progressed to a steady fall of tear-shaped drops and the taxi’s headlights glint off puddles in the intersections.

  The driver lets me off at the corner of First Avenue, just beyond the arching Gothic-carved stone doorway of the converted red brick factory where my top-floor loft collects Seattle’s northern and western horizons and cityscapes through windows as tall as trees. It went to a bidding war, this loft, when it first went on the market. I paid 30 percent more than the asking price—already at the peak of Seattle’s housing boom. I fell in love with its wood-burning fireplace, its exposed brick library walls and honey-colored cherry cabinets. It felt like a complete home to me, even if I didn’t share it with anyone yet. Eight years later I’m still the only one with a key.

  I let myself in and put hot water on for tea, watch the blue flame wrap the bottom of the kettle in a fiery flower. Then I pull the Seattle white pages off the shelf beside the kitchen phone and look for Barbara Jansen’s address.

  10

  Bobbie Jansen lives in Rainier Valley. Her address is not far from mine when measured in blocks or neighborhoods or even miles. But it falls across an invisible line that separates lives with leeway for art collections and exercise clubs and dinners out from lives of juggled utility bills and generic food staples and unsympathetic landlords.

  She lives so close, in fact, that from my balcony I can stretch around the scarred redbrick corners of my building and look down the canyon of high-rises to the point where the rooflines drop to one or two stories, just beyond the dim globe of downtown lights. It makes me feel like I live in one of those glass spheres, and the hand of God might shake up a sparkly snowstorm while Bobbie’s house sits darkly fixed.

  My head throbs. I walk into my bathroom and twist my hair up, run hot, hot water over a washcloth until it stings my hands, drape it across my face and exhale a steamy plume. Water. Touch. Temperature. Contact with something soft and warm and moist, like skin, like breath.

  I strip off my dress and it puddles to the floor, a sylph’s scarf. It was a foolish choice for the evening, too early in the year. I was shivering half the night. My bathrobe hangs on the door hook, next to my jeans. I reach quite specifically for the robe, not surprised at all when I put on the blue jeans and an old sweater. There are some things you know you are going to do despite the voice screaming at you to stop.

  I drop my car keys into my pocket without even bothering to pick up my purse. Does some part of me think I’m more anonymous without my wallet? The only pen on the kitchen counter skitters dry in the middle of her street number, so I rip the “Jan” page out of the phone book and fold it twice, three times over. I’m in my car and leaving the garage before I start talking out loud to myself. Who will even notice me—one car circling the block, one woman out for a midnight drive on a Friday night? What are the odds that Bobbie will be awake and outside on her porch (if, indeed, she has a porch), or watching from her upstairs bedroom (if her house has stairs), or sitting by the living room windows (if they face the street)? What harm could I cause by trying to attach some concrete image to the ones I can’t quit imagining? Halfway there I cut closer to the bone. What is my goal here? To see if her house has a For Rent sign? To see if she has wiped out any clue that a child ever lived there? To see if, maybe, there is some chance, some small chance, that she isn’t in that house alone night after night?

  I’m at a stoplight three blocks away when a siren screams through the intersection, and my heart races until it hurts. I feel illicit, thieving, deceitful, desperate. And still I don’t stop. I make it all the way to the corner of her block. I am turning, I can almost see her house.

  And then…What? God! What am I about to let myself do? Walk up to her door? Ring her bell? Wake her up? Ask her to forgive me? I press one foot on the brake and one on the accelerator, squeeze the steering wheel until my knuckles are white and the two halves of my mind slam together, fuse in shame, and I force myself to turn my car around.

  11

  I’m on call. A Sunday. A quiet day. The techs have a Mariners game on in the lounge and the ER staff invites me down to a potluck. I pull a chair into the corner, behind the lunch tables, and call my father.

  “Hey, Dad. It’s me.”

  “Lori?”

  “Marie.”

  A pause. “What’s all the noise?”

  “A baseball game on TV. I’m at the hospital today—in the lounge. How are you?”

  “All right. Same as always.”

  My legs are tucked into a knot beneath me; my foot tingles and starts to cramp. I get up and walk around, trailing the phone cord. “You said you had a doctor’s appointment this week—any news?”

  “Good news is no news. I try not to listen to him. How’s your job?”

  In the background a line drive sends up a swell of rowdy yelps that sound more like I’m in a bar than a hospital. “Great, Dad,” I lie with an audible smile. “Challenging.” Closer to the truth, at least. “Your birthday’s coming up soon. What’s on your wish list?”

  He pauses again, so long that I think I’ve lost the connection. “Get me a new pair of eyes. Maybe there’re some spare ones rolling around in those operating rooms.”

  I order a HoneyBaked ham, a basket of flowers and season tickets to the Houston Symphony, and try not to wonder who he could share them with.

  By midnight I have only two labor epidurals running. The corridors are silent except for the hum of cleaning crews and the occasional sleepless patient pushing a rattling IV pole on his way to the vending machines; I could actually sleep f
or a while.

  Instead I find the isolated elevator to the subbasement. The elevator is scuffed and dented from the wheeled metal carts used to shuffle volumes of data from storage to clinics to hospital wards to operating rooms and back to storage, thicker each trip with coded diseases. The sheer weight of paper becomes a quantifier of suffering. The secretaries’ desks are deserted, dried coffee grounds ring Styrofoam cups, incomplete charts are piled in metal trays and stacked in leaning towers on shelves and folding chairs and sagging laminated tables.

  Jolene Jansen’s medical chart is alphabetically filed among the thousands—tens of thousands of charts packing miles of metal racks in First Lutheran’s basement records department. It is a part of the hospital I’ve never visited before—a part usually reserved for transcriptionists and the tapering levels of administrators who convert illness and disability into thick paper files of diagnostic codes and insurance billing numbers. Ten letters down the alphabet, dozens of rows into the racked aisles, I almost miss it because it’s so thin, a half-inch pile of paper describing the medical facts of Jolene’s short life. The majority of pages deal with the day of her death.

  I’ve turned on only one light; it barely penetrates this deep into the room. I walk to the end of the rack, under a single overhead spot, and crouch with the folder across my knees.

  The elevator shudders inside the wall and startles me. I clatter against an empty metal shelf to catch my balance and hold my breath until the elevator stops somewhere above. If discovered here in the desertion of midnight, I could say I’m looking for my own uncompleted charts, lacking the signatures that might stall insurance reimbursements or incite punitive fines from hospital inspectors. I could say that I have to review a chart for an upcoming surgical patient, or the past anesthetic records of all craniotomies. But I came here to see if any doctor before me wondered why Jolene couldn’t run as well as other children, whether her impaired mind and small stature cloaked an impaired heart. And I came here to learn more about Jolene Jansen’s mother.

  Bobbie and Jolene had been connected with First Lutheran’s medical social workers, as commonly happens with Medicaid patients or handicapped children. The overwhelming job of finagling governmental regulations and pharmacy coupons and mental health evaluations and home care plans would have swallowed the allotted time and patience of Jolene’s doctors. So she was passed to the idealistic and bureaucratically talented assistants capable of unscrambling the loopholes of subsidized medical care. Their notes are filed at the end of the chart under a tab labeled Miscellaneous. The room is silent as a vault now. I relax my crouch enough to sit cross-legged on the thin carpet and read.

  The one-page summary of Barbara Helen Jansen’s life tells me she moved to Fairbanks, Alaska, from Florida at the age of nineteen. She supported herself as a cook for the North Slope oil field workers. After four years of cooking and cleaning, Bobbie earned enough to move to Yakima, buy a house and begin taking occasional classes at the community college. Jolene’s father, a supervisor of migrant field workers for one of the large apple orchards in eastern Washington, walked into Bobbie’s life relatively late. Shortly after Jolene’s conception her father was reported missing. Bobbie was thirty-one years old at the time. His disappearance fell on the heels of a major labor dispute with the orchard’s owners, and the social worker writes that Bobbie Jansen believes her husband was a victim of the violence and corruption scorching the farm labor community at the time. The police recorded his disappearance as abandonment.

  Jolene’s mental retardation was diagnosed when she was three, when she had still not begun to talk. Over the next several years Bobbie’s money was consumed by doctors, psychologists, speech and occupational therapists, and specialized teaching programs until she had no more to spend, no more to sell and trickled out of mainstream health care to join the voiceless swell of public health patients. Jolene’s infected cyst had reconnected her to the medical and social services available to her tier.

  I rifle through scrawled Urgent Care Clinic notes and a few faxed pages from the public health clinic. There is no mention, in this abbreviated, summarized medical review, of any confirmed heart defect. But there is also no hint that any doctor ever listened carefully enough to consider the possibility.

  12

  I know Bobbie Jansen’s neighborhood. Ten years ago, after my internship, I worked in her public health clinic for six months.

  My original plan had been to go to Africa and work with AIDS patients for a few years between internship and the three-year residency required for anesthesia. My father was stone-faced when I told him—not that I’d expected him to like my decision, but as a history professor he would at least appreciate, I’d hoped, my desire to see the world from another culture’s point of view. If my mother had been alive, I know she would have been distraught and anxious and even skeptical, all the while helping me pack my bags with unconditional support.

  But I had only my father and Lori. And below his impassive disapproval I sensed, or wanted to sense, a need to keep me at least somewhat closer to home. After four years of college, four years of medical school and the near poverty-level wages of internship, I was too far in debt to even buy the plane ticket. So I compromised. I answered a small ad in the back of a public health journal and moved to Seattle to work in an understaffed and poorly supplied clinic with some of the most irreverent, dedicated doctors and nurses I’ve ever met. I found the third world in the middle of urban America.

  The clinic was part of a loose network offering medical care to the increasing numbers of uninsured people in the region. I had to postpone my anesthesia residency to work there, a decision my program director and certainly my father considered pointless. What use would primary-care medical experience be to an anesthesiologist? Pap smears and family planning were skills I would never need in my future. But the work quieted some loss I felt about specializing in anesthesia, a more anonymous field—most of my future patients would sleep away the time I spent with them. I would never get the Christmas cards and homemade brownies that real doctors might receive from the families they cared for.

  Anesthesia was the antithesis of the complete, personally involved physician I had idealized to myself and my parents for all the years I studied chemistry and physics and biology alongside music and literature. It came as an unexpected, almost uncomfortable surprise to me when I discovered the immediate gratification of my specialty—injecting a local anesthetic at the precise nerve plexus to relieve the unrelenting pain of strained backs or injured limbs; calming a terrified obstetrical patient rushed into an emergency cesarean section, keeping her pain-free and hopeful, so her infant could make the miraculous transition from fetus to newborn uninjured; pulling the sleeping heart bypass patient back to consciousness and the inexpressible relief that they are still among the living. All of this, I discovered, was in contrast to general medicine, which could often do little more than shift the incessant, declining slope of mortality that begins the day we are born.

  The patients I treated at the Rainier County Clinic, Bobbie’s neighbors, were a mixed group—some unemployed and uninsured, some who’d tumbled down the social ladder to a bewildered state of neediness they’d never anticipated or saved for and many who were employed in low-wage jobs that gave them no health insurance and no sufficient means to pay for their own care. A lot of them came to us long after their early symptoms had ballooned into unchecked diabetes or hypertension or heart failure or metastatic cancers, because the balance of debt versus illness had to tip before they could risk visiting a doctor.

  This same mix of crises meant social and psychological care became as fundamental to their cure as medication or surgery. I loved that part of it—opening a window into the back rooms of other lives, lives I walked past every day at bus stops and McDonald’s and Wal-Marts; the hidden rooms of the people who served me restaurant meals, kept the floors of my local grocery store swept clean, restocked the clothes littering my fitting rooms—even the people tuc
ked into doorways at dawn wrapped in donated blankets, sleeping through the shuffle of early commuters. I was still young enough to see myself in their lives.

  At night, when I come home from work and should collapse into bed, I sit in my living room and stare out across the swallowing blackness of Puget Sound. And I envision Bobbie’s house. Maybe a white clapboard bungalow with chipped green trim around the windows and front porch columns. Maybe a chair on the porch, the old kind of outdoor metal chair with curving arms and a curved metal tube for the base, so she can rock while she watches a swing set rust in her front yard. Maybe she sits there at dusk listening to the new emptiness in her life and looks out to the lights of downtown Seattle, the lights of Pioneer Square, my home, dangling like pearls out of reach.

  It has been five weeks now, and I still dissect the choices I made in the hours between singing Jolene to sleep and telling her mother that she was dead. I imagine myself on a witness stand, before a jury or before Bobbie Jansen, explaining the sequence of my thoughts on that day, trying to convince my listeners that each decision was issued from a calm and confident physician, detached and objective, clinically critical, never stalled by emotion for the pivotal moment that might have made all the difference. Had I waited too long to turn her over and start chest compressions? Had I given too little epinephrine, too much anesthetic gas, too much narcotic? And if Jolene had a congenital heart defect, one of the dozens of malformations described in any anesthesia textbook, what would I have done differently? If her autopsy proves I missed that diagnosis in the pre-op interview, does it prove I caused her death? Even if any physician might uncouple her heart from her death, I doubt any lawyer would.