The Possible World

by Liese O'Halloran Schwarz

  “Just go for it,” says Sheila. “He’s obviously not feeling anything.”

  “Right,” says Alice. She dips the tip of the catheter into the sterile lubricant jelly and leans forward.

  Just then, the curtain at the entrance to the trauma room is pulled back with a shriek of metal rings. Two men stand in the doorway, gawking at the tableau before them.

  “Jesus, Dave, what the fuck,” exclaims one of them. “Let’s go.”

  The patient’s eyes open.

  “What the hell took you guys so long?” he says, leaping from the stretcher, Alice jumping aside. The Foley tray falls to the floor, the pool of disinfectant spilling in a long brown stream down the sheet.

  “Whew,” Dave says, looking from Sheila to Alice to me, clutching the balled-up cotton gown against his groin. “That was close.”

  “Sheila, call security,” I say.

  “Not necessary, Sheila,” says one of the men in the doorway, grinning. He flashes a police badge.

  “I’ll explain later,” says Dave, grabbing the plastic bag with his clothing and following the others at a run.

  I have to be quick to get to Trauma Alley before the three of them are through the double doors at the end of it. Police lights outside the ambulance bay spill red, then blue, then red through the glass, then move away.

  “Never a dull moment,” says Sheila, standing behind me. Shaking our heads, we go back into Trauma 1, where Alice stands, still holding the bladder catheter aloft, instinctively keeping it sterile. “You can throw that away now,” Sheila tells her.

  Alice goes back out to the Big Room, and Sheila and I stay to finish the documentation. The chart will be filed as an elopement, the term for a patient who leaves the ED without official discharge, but how to record the details? I decide on a straightforward telling: patient absconded before Foley catheter placement; he appeared alert and oriented with good mentation and speech. I see again the white buttocks disappearing through the ambulance bay doors. Normal ambulation.

  “It’s gotta be a full moon,” Sheila says, pressing the button on the wall to alert Housekeeping. “We better get ready for some whackadoo shit tonight.” It’s such a common theory that it actually has been formally studied. And conclusively debunked: the phases of the moon are not associated with bizarre Emergency Department presentations. “Speaking of which, did you hear about that resident?” Her voice gets low and serious as we walk together toward the door to the urgent area. “She goes to a birthday party last weekend with her kid and some psycho breaks in and murders everyone in the house.”

  “What? A resident was killed? How did I not hear about that?” It’s no mystery, actually. I don’t keep up with local news, and my social life could best be described as vestigial. As the dust has been settling and sides taken, all our friends turned out to be his friends. Why not? He was the one who went for drinks or dinner or barbecues or Game Nights while I worked or slept. I remember a handful of bleary brunches, some movies I dozed through. They call you my imaginary wife, he told me once. Why hadn’t I paid more attention to that?

  “He killed two moms and three kids,” says Sheila. “I think she was Dermatology? I didn’t know her.”

  “I can’t believe I didn’t hear about it.” I pull my phone out, tap a text to Karen, an anesthesiology resident and also my first fragile postmarriage friendship.

  WTF a derm res was murdered?

  We’d met a month ago while grabbing a coffee during the break on ACLS recertification day, and giggled like bad children through the afternoon small-group session. We’d texted intermittently since then, and managed to meet for a couple of lunches, always meaning to get together more often, but schedules hadn’t sorted that way yet. A hard fact of not-so-young adulthood: making new friends is harder. Deep friendship is generally born out of lazy time, and there’s no lazy time in this stage of life, the period during which most people are coupled and parenting, when every minute is spoken for already by work and family. I had old friends, of course, but they’d been sidelined by residency. A passive act, a product of circumstance; I suppose I’d fully expected to bring them back into my life when the furor of training was done. Now abruptly uncoupled and nearing the end of residency, I’ve got patches of free time I didn’t have when married, but I’m in a strange town now (it’s only four years, I’d told Joe when ranking residency choices at the end of medical school; after this you’ll get to choose where we live), and all those sidelined friends are far away and also busy, the Lucy-shaped holes I’d left in their lives closed over long ago.

  “They all died, except one kid,” says Sheila. “Turns out it was her kid, the resident’s kid.” Then, impatient, “Come on, you heard about this.” I shake my head. “Wow. Okay, well, they caught the guy. They think it was totally random; he didn’t even know them.”

  They all died except one kid. A bell is ringing in my memory.

  “I saw a child from a murder scene last weekend,” I say. “He was the only one left.”

  “That must have been the survivor. I heard he came through here on the way to Psych.” She swipes her ID badge through the sensor, and the doors between Trauma Alley and the Big Room swing open. “How’d he look?”

  “Bloody.” No response to my text yet. Oops, it’s nearly midnight, Karen’s probably sleeping. A double infraction, since she has a child. When she’d mentioned that, I’d felt both impressed—how brave to go ahead with single motherhood, especially during training—and also ashamed of the selfish thought that crept beneath my admiration, that her free time would be limited. I remember her fond voice. My little guy was reading at two; that genius-only sperm bank wasn’t kidding.

  I pull up a search and poke terms into the browser, trying doctor stabbed birthday murder. The news reports spring up with a shocking speed. The name makes my mouth go dry.

  “That’s my—” My what? Not my friend, not really. My acquaintance? But it had been more than that; there had been the spark of friendship, of a kindred feeling that I have only recently begun to understand as rare.

  “You knew her?” Sheila’s interested.

  I feel a jarring sadness, and an accompanying feeling of fraudulence: I have no right to claim this loss.

  “Not well.” Which is the truth, and also not. I remember the boy alone, drenched in blood (Karen’s blood?), his button eyes staring.

  Shake it off, shake it off: the hours ahead have a claim on my full energy and focus, nothing to spare.

  * * *

  FIRST STOP DURING the relative lull: the Tank, the corner of the Big Room that serves as our holding spot for overdoses and EDPs, emotionally disturbed persons. A euphemism for what is most commonly intoxication—crack or meth or bath salts or good old alcohol. An EDP with health insurance gets a regular urgent-area bed and a pysch consult; for the rabble it’s the Tank, a no-frills cluster of three rooms, ten stretchers, ten sets of leather restraints hanging ready on the railing outside, and a security guard on a rolling stool in the hall. Best to give the Tankers a good once-over before the shift gets wild.

  We have six drunks in various stages of sleep and foulness; I shake each of them awake, interview them, and do a quick check-over for injury. They’ve all been Breathalyzed (if cooperative and capable) or had their blood drawn (if uncooperative or too slack-mouthed drunk), and the Tank nurse has entered the blood alcohol number on each chart. From those, I calculate the “sober time”—the time each patient will reach legal sobriety and will need to be reassessed and discharged. The theoretical drop is twenty milligrams per deciliter per hour, but for these hard-core drinkers with their highly tolerant livers, it’s closer to thirty—they’ll sober up faster than the textbooks predict. Like The Price Is Right, it’s important to get the sober time right without going over, since the main goal with Tankers is to get them outside on the street in time to find their next drink and avoid the DTs. Delirium tremens has a high mortality rate, even when fully treated. Once when I was an intern, I let a Tanker sleep throu
gh his deadline, and suffered the poisonous hate-eyes of the ICU resident who had to admit him, her whole tight-lipped affect radiating disgust at the waste of a critical bed on a drunk. What a difference three years make: now I fudge the numbers upward or downward according to the indicators at hand (odor, filth, depth of sidewalk-suntan, number and condition of teeth) with easy confidence; my drunks will be ambulatory but not tremulous or hallucinating when they go out the door. I write their sober times on my forearm with a ballpoint pen; as I discharge each one I’ll wipe the numbers off with alcohol. In between initial evaluation and discharge, unless they become obstreperous, I can basically ignore them.

  The last Tanker is wide awake. He’s not a drunk, but a frequent flyer. More than that, he’s a B&B’er—one who presents multiple times a week with various ailments, as a way to avoid the shelter and get a sandwich and a bed for the night.

  “Hey, Freddy.” He doesn’t smell as bad as usual tonight; he must have gotten a shower somewhere. “I like your hat.”

  He puts a hand up to the orange ball cap, as if to confirm that it is still there.

  “I just got it,” he says.

  It is bright and stiff with newness, a contrast to the dingy hodgepodge of layers on the rest of his body: a quilted hunting vest over a T-shirt over a long-sleeved shirt, camo pants cinched with a belt over blue jeans that peek out in a raggedy, dirty fringe above his sneakers.

  “Nobody hurt me, and I don’t want to hurt myself,” he says, unprompted. He knows the drill. “My knee’s bad, though.”

  “Bad as last time?”

  He considers that, looking down at the skinny cylinder of muscle swimming in the fabric layers.

  “I think it’s got worms in it.”

  “Well, we’ll take a look.” There aren’t going to be any worms, of course; there never are. I’ve examined that knee so many times I know it better than my own. “Did you get a sandwich?”

  “Uh-huh. And cookies.” His face splits into an Oreo-blackened grin.

  The worm delusion argues an intrinsic thought disorder, but he’s also got a divot in his skull, a caved-in area the diameter of a golf ball, spanned by a well-healed scar. I’ve asked him for details, but he can’t or won’t share them. God knows what his life was before the injury, where his family is, or if they know where he is. Some people don’t belong in houses, he’d told me once when I asked.

  * * *

  SORE THROAT, PNEUMONIA, punched a wall, angina, groin lump, ran out of meds, infant rash, something in my eye: the puttering mix of urgent-area patients makes a droning backdrop to the critical cases. At 3 a.m. when the overhead bells go off again, Sheila and I go to Trauma Alley and wait. When the doors open, we can see that the patient is fighting, nearly twisting off the stretcher, despite the straps and the paramedics holding her down. It’s an EDP, too wild for the Tank.

  “She’s a biter,” cautions one of the paramedics as they go into Trauma 2.

  “Vete a la verga, bitch,” the patient says without opening her eyes.

  I put my stethoscope to a bit of chest wall accessible between the straps: clear breath sounds, rapid heartbeat.

  “Called in for peeing in a flower bed,” says the other paramedic. She’s sweating but cheerful. “This is definitely my cardio for the day.”

  “Cuero del diablo,” the patient hisses at her.

  “Now, now, you don’t mean that. One, two, three,” and we pull the backboard onto the trauma room stretcher.

  “You speak Spanish?” I ask the paramedic. I know conversational gems like Have you vomited, Was there blood, and Show me where it hurts.

  “Yeah, but that’s not Spanish,” she says. “That’s the universal language of crack.”

  “Maldita cuero,” the patient spits, kicking a leg out. Her feet are bare and dirty.

  Sheila holds up the spray of monitor leads. “Can we Haldolize her, please?” she asks me. Toneless. She’s hit her wall tonight, already over this shift and ready for 7 a.m. “I don’t feel like going MMA to get these on.”

  “Did you get a D-stick?” I ask the female paramedic.

  “Hundred and twenty.”

  Damn. Hypoglycemia would have been so easy.

  “Vete a la chingada,” the patient shouts. “Menca cabrona.” She shakes her head violently side to side, an oxygen prong slipping from a nostril, and twists a hand where it is pinned at the wrist by one of the straps. With a mighty grunt she pulls it free.

  “Five IM Haldol and two of Cogentin,” I say, stepping back from the waving hand, the pinching fingers. Sedation will make getting information from her impossible, but it seems that will be impossible anyway.

  The miracle of vitamin H: in minutes she is unconscious. We unbuckle the straps and roll her onto her side, sliding the backboard out. The tech scissors clothes off and attaches monitor leads; on the screen above the bed the waveforms flutter and catch. I examine her while the nurse slides an IV catheter into one of the now-limp arms and attaches the Vacutainer.

  “Hooray for Haldol,” Sheila says as the blood pulls silently into one specimen tube, then another. “Good for what ails you.”

  But what exactly ails her? The monitor shows normal sinus at eighty-five; she’s breathing regularly. No evidence of trauma: pupils reactive, no dark cloud of blood behind the tympanic membranes, face not swollen or bruised, teeth intact. Neck, abdomen, pelvis, and extremities all unremarkable. Her clothing, now puddled in ruined strips on the floor, is basic East Providence housewife, yoga pants and a clean cotton sweater. Her hair, though disheveled, looks as if it has recently been styled. Her skin is soft, smooth: no junkie-acne or bruises or scars, and the veins in her arms are healthy hoses, no knotting from needle tracks. Some of her fingernails are broken, but her cuticles are nicer than my own. The grime on the soles of her feet is enough only to account for a couple of blocks’ stroll down a city sidewalk. From the looks of her, she has a home of her own, and a toilet in it, somewhere not far from where she’d been found. Why then had she been squatting on a neighbor’s lawn? She could be a psych patient off meds, but that kind of slide is gradual, not abrupt, and this woman looks like she went crazy in one short minute tonight. Another puzzle, like Coma Cop from the start of the shift.

  “We’re running a special,” I tell Sheila.

  She gets the reference immediately. “Yeah, maybe this one will pull a badge out of her vag and run out the door.”

  Perhaps she has epilepsy, and this is simply the confused, combative state that can follow a seizure. That would be the best scenario. In that case, she’ll be waking up in a little while, embarrassed, after a lot of negative tests. I hope for that outcome, but my job isn’t to presume the most benign situation, it’s to imagine the worst. You must believe that each patient you see, no matter how mild the complaint, is trembling on the precipice of death. How many times have I told medical students and junior residents that? I can’t remember now who first taught it to me.

  It could be poison. She’s sweating, though, so nothing anticholinergic. No excessive oral secretions, so not organophosphate. Could be a spontaneous rupture into the brain from cocaine or congenital aneurysm. Or a brain tumor; although they grow slowly, they can present with sudden symptoms.

  “Could it be a cockroach in the ear?” ventures the tech. “That was a question on one of our practical exams.”

  Theoretically, an insect in the ear can make a person berserk. However, every case that I’ve ever seen, and I’ve seen plenty, has been completely unmysterious, the triage note reading cockroach in ear and the patient grossed out but totally rational. If only this patient could be cured that easily, a little mineral oil in the ear canal to drown the culprit and then a few tedious minutes with tweezers pulling out the corpse in soft, oily pieces. I’ve already checked her ears, though; no varmints there.

  “Not this time,” I tell the tech.

  “Usual suspects?” Sheila asks, labeling the tubes of blood with a felt-tip pen: Juanita Doe 756755001.

  �
�Add a thyroid panel and a tox screen and a head CT. Get an LP tray too.” A spinal tap will rule out encephalitis.

  I am turning away from the stretcher when I see it: a tiny area on the scalp where the black hair is a little blacker than the hair around it. I bend for a better look. It’s a clot of blood, smaller than a dime, just above the hairline on the left temple. I pull the curls up and away, carrying the flattened clot with them, revealing a stellate wound underneath. Four lines meeting at a single point, the whole thing not much more than a centimeter across. The lines buckle outward in the center of the X, an ooze of ivory-colored material bulging through, minutely veined.

  No more mystery. No need for a spinal tap. This one won’t be waking up with negative tests, embarrassed.

  “Cancel the LP tray,” I tell Sheila, who’s hanging the Foley bag on the edge of the stretcher. “Let’s make that CT stat.”

  “What is that?” she says, coming over and looking down at the scalp.

  “Gunshot wound.” The escaping gases in the blast from a muzzle pressed right against the skull can lift the skin in flaps, making an X like this one. I roll the patient’s head away to look: no exit wound. “Ancef, tetanus, load Dilantin, call Trauma and the Providence PD.”

  “What’s that stuff coming out—oh no.”

  “Oh yes. That would be brain.”

  Her CT scan shows a ragged streak of white running from the thin temporal bone on the left side straight toward the other ear. The rough oval of skull on a head CT should properly be filled with gray and black: gray walnut of brain, black of cerebrospinal fluid. White means blood, or metal, or bone. The bright-white track on this scan crosses the posterior frontal lobes in a diagonal so shallow it is almost horizontal. Move it just a few inches forward and this could be a Dr. Walter Freeman classic, the barbaric transorbital lobotomy from the 1950s, performed without anesthesia. He’d tip the head back, insert an ice-pick-like tool under the upper eyelid, and use a mallet to tap through the thin plate of bone. Then a slice left and right to disconnect the frontal lobes from the brain. Ten seconds to maroon all passion, all rage and joy and lust, in the anterior frontal lobes forever.