Gemini: A Novel

by Cassella, Carol

  Charlotte started the day with her usual list, a computer printout of her patients’ names with her own notes penned in the margin—who had a CT scan or procedure scheduled, who was going to the OR, what lines needed to be changed, what critical labs were still pending. She had developed a system over the years, using different-colored pens to highlight different levels of urgency. Jane Doe’s name was nearly blotted out by red. Despite some trickles of good news, this morning’s lab work showed that she would have to be dialyzed soon if things didn’t turn around. And why should they turn around? Charlotte asked herself, then answered, Because sometimes, now and then, despite the APACHE II scores and SOFA scores and Glasgow Coma Scales—despite every imperfect predictor nailing the coffin closed, someone lived.

  When their loved ones were unconscious and on the brink, family members would sometimes press Charlotte for any intuition she might have about their survival. She was too clinical to wade into that subjective tease, and saw it as little more than fortune-telling spun by doctors to give families a false sense of control. Instead, she gave them the best statistics she had to offer and tried to walk them through the pros and cons of necessary decisions. But in her heart she knew she did have a second sense about patients’ survival, something closer to hope than fact. Hope for another day outside, another birthday party, another meal taken through the mouth rather than a feeding tube. She could sense it around some patients like a visible luminescence. And some not—as if they were ready to move on, crumble back to the organic matter and energy they had started with. She knew better than to share this nameless second sense. She had not always been right. And it did not take many miraculous recoveries to decide that her job was not to decide when life ended—it was to give nature as much time as possible.

  She jumped when Felipe Otero put his hand on her back, then laughed at herself and pulled his arm over her shoulder. “Daydreaming,” she said. “And you were the one up all night! How was it?”

  “The usual fun. Three a.m. heroin overdose. Want a coffee while I report?”

  They walked to the lounge at the end of the hallway and compared their lists, Felipe filling in the gaps from the day and night before, Charlotte adding a different opinion about one patient or another—the ICU beds were completely full this morning and she knew there would be pressure to move someone out. She looked up with a question and caught Felipe smiling at her; he had a dark scruff over his chin and his hair was a mess of luxuriant black waves after working all night. “What’s funny?” she asked.

  “This is how Bonnie and I trade the boys now, a morning report at handoff.”

  “Felipe? You didn’t tell me. You moved out?”

  “Last week. I couldn’t say it.”

  “I’m sorry. I really am.”

  “I am too. We’ll see—nothing definite yet.” He rubbed his hand over his face quickly, the brush of skin against stubble at odds with his usually conscientiously groomed appearance, and the humanness of it somehow made his loss more palpable for Charlotte. “You know there’s a meeting about Jane today,” he said.

  “I didn’t get an e-mail. Did I? I get too many. What’s it about?”

  “She has a professional guardian now—I think Helen Seras wants her to meet us. The ethics board too.”

  “What did Helen do? Look at Jane’s hospital bill?”

  “Watch out—the walls have ears. My hope is that when they finally identify her, she turns out to be an heiress. They’ll name a new wing after her handsome donation.”

  “The Jane Doe Memorial Wing—I can see it now. When she’s identified I wonder if the hospital will call her insurance company before they call her family. Assuming she’s insured.”

  “You assume so optimistically. I’m going to take a shower and shave before the meeting—save me a seat.”

  —

  There were no seats to save; Charlotte edged behind the filled chairs toward the back corner of the room. Helen smiled at her. “We’re a little tight. The larger conference room was booked.” It seemed to Charlotte that Helen was always smiling, as if she had been hired to smile—to make it clear how completely at peace she was announcing the hospital’s policy decisions, whatever they might be and however the staff might respond. Felipe had enough business sense to appreciate Beacon’s perpetually increasing debt and balance Charlotte’s tendency to mistrust their motives, but Felipe wasn’t here and this room was already putting Charlotte into a dour mood. It was usually reserved for family conferences and Charlotte had broken too much bad news at this table, guiding wives and sons and daughters across the gap between the possible and the probable, circling surreal definitions of meaningful life.

  There were four or five people here from the ethics board, a medical social worker, and some of the nurses who’d taken care of Jane. Charlotte saw Anne trying to look invisible, tucked into a folding chair at the back with her eyes half-closed like she was dozing, though she was likely memorizing every word. Sitting next to Helen was Keith Sonnenberg, Beacon’s guardian ad litem, wearing his signature dark tailored business suit and jazzy bow tie, his wiry gray hair sticking out above one ear after he took his glasses off. He’d been to the ICU twice in the last week to see Jane, and something in his contemplative response to Charlotte’s medical explanations made her trust him—the way he cupped his hand over his mouth with his shoulders hunched while she described what the fat globules dislodged from Jane’s femur had done to her brain, mulling it pensively for a moment before saying, “Hmm. I see,” to himself, and then moving on to his next question. Sitting next to Keith was a woman, probably in her early forties, whom Charlotte had never met.

  Helen started. “I’m sure you all recognize that Jane is a unique case for Beacon. We’ve never had an unidentified with us for so long—an unconscious patient with no family. No voice, essentially. It’s a difficult position for the hospital. For all of you. Beacon has filed a petition of guardianship and Keith, our GAL, has been able to expedite that with the commissioner. So I . . .”

  Anne’s hand shot up. “Sorry—in the dark over here. A petition for what?”

  Keith looked like he was about to explain but Helen jumped in. “Guardianship. A certified professional guardian, or CPG. Given how critically ill Jane is, at some point she may need someone to speak for her—to address her medical directive.”

  “You mean whether we should keep going or pull the plug,” Anne added, and when Helen went silent, “I’m just trying to be clear about what you’re saying.”

  “We have no idea what Jane Doe—who has an actual name and personal story—would want if she can’t recover. It isn’t Beacon’s place to decide whether she should be artificially kept alive or”—Helen’s lips pressed into a tight line and Charlotte knew she was tempted to spit back Anne’s own words—“allowed to die naturally. And we aren’t there yet. I’m not suggesting that. Keith? Would you like to introduce Ms. Herrand to everyone?”

  Keith did not look wholly comfortable being the diversion from this hiccup, but he gave a considered “Hmmm,” slowly got to his feet, and explained that the commissioner had reviewed Jane Doe’s case and officially designated her as an “alleged incapacitated person, or AIP” (which struck Charlotte as a malignant twist of legalese—anyone who walked into Jane’s room would know her incapacity was way beyond “alleged”) and, given this official stamp, the commissioner had assigned Jane a CPG.

  Now the woman on Keith’s left stood up and Keith let her take over the discussion. Christina Herrand wore no makeup, but it suited her well-defined, lightly lined face. Her voice was so quiet everyone in the room stopped moving in their seats or shuffling papers in a collective effort to hear her. “As Ms. Seras said, this situation presents an unusual dilemma. Most Does are identified long before the legal process catches up to the point of designating a CPG, and certainly there’s hope that this patient will find her loved ones—well, they will find her—before an
y critical decisions need to be made. The legal system can’t replace family. You all know that. Even for professional caretakers there can be emotional attachments that feel”—she paused and looked at the faces around her—“offended, for lack of a better word. On the other hand, a complicated case like Jane’s can stir different opinions about end-of-life choices within the care team, particularly when there is no family member to advise them on the patient’s wishes. My job, as a professional guardian, is to become that adviser. So for now, think of me as Jane’s family. The one who can speak for her until she can speak for herself.”

  Felipe walked in just then, gracefully introducing himself to the whole room and reigniting Helen’s smile. That Latin charm—Charlotte had told him more than once that he was wasting his best asset by being a doctor; he should be an ambassador, a Ferrari salesman, or at the least a highly paid gigolo. The conference went on for twenty more minutes as Helen called on various specialists to discuss Jane’s multiple failing systems and medical options. From across the room Charlotte watched a patchwork of notes collect on Christina’s yellow legal pad, some circled or boxed and connected with lines or arrows. The Christina Herrand Mind Map of Impossible Decisions Made Simple, Charlotte thought. Christina didn’t look old enough to be in this job. Only someone who had raised children and grandchildren and buried parents could have sufficient wisdom to be a mandated guardian—a stranger yesterday and as powerful as nearest kin today.

  Charlotte knew the patient better than anyone here, and when it was her turn to speak, Christina seemed sensitive to that—her face softened; she attended every word. But it was more than that. There was a sympathy in her eyes that reached out to Charlotte, almost an apology, like she knew she was hearing more than clinical facts. Christina asked Charlotte to explain in lay terms what had probably happened during Jane’s initial surgery immediately after the car accident. Charlotte went step by step through the evidence that the fat emboli from Jane’s leg had caused her brain damage and seizures. “It isn’t like a stroke, is it?” Christina asked.

  “Sort of. Think of the bits of fat as a shower of sparks hitting the brain, and every spot they hit is injured.”

  “Permanently?”

  Permanently? Charlotte hated that question—nothing about the human condition was permanent. “There is a good chance that parts of her brain will never fully recover. But I think you’re asking if Jane could have a meaningful life again and I can’t answer that until she’s off all the sedatives and her blood chemistry is back to normal. She needs more time. All the time we can give her.” And a universally acceptable definition of “meaningful,” she was tempted to add.

  Felipe was the last to speak, and Charlotte heard the hint of accent that crept in whenever he was tired after a night on call; it lent a sadly romantic note to his discourse on Jane’s history and likely future. He explained that the latest complication was her kidneys, initially shocked by the low oxygen levels and low blood pressures she had suffered after her surgery and then, just as they were recovering, she had developed an infection and her blood pressure had dropped again. She would probably need dialysis in the next day or so.

  Helen Seras asked, “Can you tell me, Dr. Otero, if she isn’t dialyzed, how long might she survive?”

  “That is perhaps the only easy question you have asked. Her potassium level will rise about one point a day, and when it exceeds seven, her heart will fibrillate and she’ll die. Painlessly.”

  At noon people began to leave the room for other patients and other meetings. Felipe waited for Charlotte and as they neared the door Christina Herrand intercepted them. “Dr. Otero, what do you think the chances are that Jane will survive this?”

  “Survive? There are many ways to survive. Do you mean will she wake up? Go back to her life as she knew it before? Those chances are slim, Ms. Herrand.”

  “Slim,” she repeated the word to herself like that might reveal more than Felipe had said. “Could you make a percentage guess?”

  Felipe glanced at Charlotte and she knew what he was feeling—they had been here before with patients, had this same conversation with actual relatives, people who shared blood or name or love with someone so near death. They wanted numbers. Numbers were comforting, numbers were the Dow Jones average and mortgage rates and the statistics of lightning strikes. “Okay,” Felipe finally answered. “Eleven percent of slim.”

  —

  Christina asked Charlotte to introduce her to Jane. The nurse who’d been covering for Anne during the meeting reported that Orthopedics had scheduled Jane’s cast removal for the next day. She’d needed to suction Jane’s tracheostomy a few times but otherwise the patient was stable. Stable, Charlotte thought, seeing Christina react to her first view of Jane. Stable, meaning no deterioration. No improvement. The downhill tumble arrested but the monumental climb back up barely begun.

  Christina walked to the bedside and turned to look at Charlotte, waiting for her. “Why does she have a tracheostomy?”

  “We put in a trach anytime a patient needs long-term ventilation—when they’ll have to be on the breathing machine for more than a few weeks.” Charlotte whispered the words out of habit as much as for any valid concern that Jane might hear them. Early in her career she had seen a supposedly sedated patient open her eyes when an oncologist had described her tumor as “a death sentence.” And once, freakishly, a cardiac patient had gone into ventricular fibrillation and been coded for forty-five minutes with chest compressions and electric shocks—as close to dead as a live person can get. He’d survived, miraculously, and the next Christmas, Charlotte got a nice card from him that contained a miracle of its own—a postscript quoting an exact phrase she had used to convince the code team to keep going for just three more rounds, “my lucky number,” before they called it off.

  Jane’s face was pale, flaccid, and swollen from the fight to balance her fluids and blood pressure. The stuffed toy raccoon Charlotte had bought for her had rolled facedown into the corner of the bed. With each delivered breath the coiled plastic tubing that tethered Jane to the ventilator moved like something alive. Charlotte leaned near and said, “Jane, someone is here to meet you. Her name is Christina Herrand.” Then she pulled a chair to the bedside for Christina, left the two of them, and started working on chart notes at the computer. After fifteen minutes or so she looked up. Christina was still there, sitting quietly with her head tilted slightly, her hand resting lightly on Jane’s casted arm. Charlotte couldn’t see her face from this angle and wondered if she might have dozed, she was so still. Finally Christina stood and gathered her purse and briefcase, brushed her fingers against Jane’s cheek, righted the toy raccoon, and then walked over to Charlotte. She whispered, “You won’t know how much she’ll remember about the accident until you can take her off the ventilator?”

  “Her MRI showed the fat emboli injured a lot of her brain, as I explained in the meeting. On top of that her blood pressure and oxygen levels were low for a long time.” She paused, trying to assess whether Christina understood how critical that was. “We really can’t know how much permanent brain damage she has yet. It could take months.”

  “Or years? Years spent . . . like this?”

  She said it kindly, inoffensively, but the phrase piqued Charlotte, as if Christina Herrand were already predicting a contest. Charlotte wanted to give her the benefit of the doubt, though. This case was “an unusual dilemma,” to quote Christina. This Jane Doe had family, most likely. Somewhere. God forbid they pop out of the woods after Beacon and its legal teams and guardians, these strangers, made an irreversible decision.

  Just then an aide came into the room and called out, “Good morning, good morning!” She walked to Jane’s bedside. “Hello, Ms. Doe, it is a beautiful sunny Tuesday and it’s time for your bath!” She turned on the faucet at the sink and with a clatter of plastic and metal she filled a pink bucket with warm water.

  “That’s nice
—they bathe her?” Christina asked.

  “Oh, yes. She gets physical therapy too,” Charlotte said. “Christina, may I ask, have you had much intensive care experience?”

  “Actually, this is only my second medical case, and the first was for financial guidance.”

  “Do they give you any medical training? For your work?” Charlotte asked.

  Christina seemed to weigh Charlotte’s intent. “CPGs work in many different areas, whenever someone needs help with legal decisions because they’re too overwhelmed or unstable.” She paused. “I have no specific medical training. No. But then neither do most family members.”

  The aide placed the bucket on the chair Christina had left at the bedside and pulled the sheet back. Christina was visibly startled and took a step toward Jane. “What’s wrong with her hand?” Three of Jane’s fingers were blue black.

  “It’s ischemia. When her blood pressure was low for so long, her limbs weren’t getting enough flow.” Charlotte eased the sheet off Jane’s lower body. All of her toes were a mottled purple and the lower portion of her right foot was obviously dead—black sunken skin edged with a serpentine line of bright pink. “It isn’t infected, so we’re leaving it alone for now. She’ll have to have it removed eventually. If she recovers.”

  Christina brought a hand to her mouth. “My God.”

  Yes, thought Charlotte. My God, indeed.

  —

  Charlotte, Eric, Pamela, and Will had decided to meet for dinner the next evening at a restaurant on the pier. Charlotte arrived late, as often happened, this time held up by a phone call about Jane from the orthopedics team just as she was leaving the hospital. She found them drinking cocktails at a table in the back that overlooked Elliott Bay, all of them bathed in summer sunlight reflected off the water. Pamela hugged her as if they hadn’t seen each other in months, though they rarely went a week without talking. Eric stood up to pull out Charlotte’s chair; after three years together he still treated her with manners her grandmother would have demanded.