The Beauty in Breaking

by Michele Harper

  Minutes later, when Jenny’s X-rays came in, I looked at them. Pediatric films can be challenging because a child’s bones are immature, but nothing acute jumped out at me: clear lungs that were well inflated with no pneumonia, fluid, or pneumothorax. Her CBC and chemistry were unremarkable. The patient had been accepted to the nearest children’s hospital, which was conveniently less than a mile away. The hospital was sending its ambulance unit to pick her up. Seconds later, EMS bundled the child back onto the gurney to leave. I clicked back into her chart and saw that her LFTs had just come back: They were five and six times the normal limits. Just as I registered concern, I got a call from radiology.

  “Hello, Dr. Wechsler of Radiology here. Do you have the child just X-rayed for febrile seizure?”

  “Yes, baby Jenny.”

  “Okay. No source of infection here, the heart and lungs look good, but there are fractures. Looks like different stages of healing. Mostly old and well healed. Possibly one or two newer ones, I can’t say that for sure, but I can say this is not good.”

  I looked back to see the gurney rolling out of the department, the father following close behind, his face twisted in fright, his knit hat clenched in his fist and drawn close to his quivering lips as he asked the paramedics if his baby would be okay. Her mother had arrived and was being comforted by an older woman who appeared to be either her mother or his. The family trailed out behind the gurney of the child who was broken by one if not all of them.

  “Thank you, Dr. Wechsler. This is bad, very bad. I’d better call Children’s Hospital to update them before the patient arrives.”

  I called the accepting physician, whom I had spoken to just minutes earlier. “Dr. Pierre, Dr. Harper again. I want to give you a terrible update. The child is on her way over to you. Just as EMS rolled her out the door, I got these last two pieces of information. Her LFTs are significantly elevated, and she has multiple rib fractures on X-ray. I’m really concerned this child’s altered mental status is the result of blunt trauma, probably liver injury from blunt trauma as well, which explains why the LFTs are through the roof. She certainly needs a trauma workup. I’m sorry.”

  It was possible the child had some critical metabolic issue that had led to liver failure and recurrent seizures. It was possible those fractures were from those same seizures and had gone undiagnosed. Yes, that was all possible, and there are case presentations written on this very phenomenon. There are also times when your gut tells you otherwise, when you’re in the presence of another body and can’t help but feel its energy and hear the whisper of its silenced story. This limp, semiconscious child had been beaten—beaten to convulsion, beaten to fracture, beaten to a bleeding liver.

  “Got it” was Dr. Pierre’s response. The accepting doc at the other end of a transfer call never says much. The case isn’t real until it arrives. The information isn’t true until it’s verified. Right now, my call to her was only adding to her workload, so “got it” was a reasonable response. Plus, we ER docs stand witness to human suffering too frequently. It was draining and depressing, and often left us with only enough hope to muster those two words.

  So, days later, when the update came that the father had been charged with abuse, that he had caused the retinal hemorrhages, cerebral contusion, multiple fractures, and liver laceration, we couldn’t say we were surprised. It wasn’t because he “fit the part,” whatever that means. My snapshot of him in the middle of the ER hadn’t fit any particular stereotype. No, we weren’t surprised because this is what we do. I imagine every forensic examiner has the same reaction. It’s horrifying and sad when you realize something terrible about another human being, yes. But—and this is a disturbing commentary on humanity—it can no longer be called surprising. It wasn’t yet known if the mother, who had stood by for the past twenty-two months as he abused their daughter, would also be charged: The calculation as to what extent the “bystander” is complicit, it seems to me, is always complicated and often tortured.

  As I ended the call with Dr. Pierre, Nurse Carrenza approached me.

  “EMS just rolled in a respiratory arrest that they intubated in the field from a nursing home. Only the rotating dental resident is in there now, so we could really use you.”

  “Of course,” I said as I followed her to Room 20.

  As I entered the room, one paramedic was bagging the patient and a tech was doing chest compressions. One nurse was placing the patient on a monitor, and another was obtaining a second IV; EMS had already placed one.

  “Hello, all. I’m Dr. Harper. What’s the story?”

  “Hey, Doc. Ms. Mary Giannetta is a seventy-eight-year-old woman with diabetes and a heart condition,” one of the paramedics explained. “She was in distress at the nursing home. Actually, her family found her and alerted the staff. Did the nursing home call for notification?”

  We all shook our heads.

  “Geez. Of course not.” The paramedic sighed. “When we arrived, she was barely breathing, and then lost what thready pulse she had. PEA on monitor. Unknown downtime. She’s been with us about fifteen minutes and has had three rounds of epi. The last dose was given approximately one minute ago. Accu-Chek two-fifty. We put a twenty-gauge in her right AC and obviously intubated in the field.”

  “Thank you. Y’all did everything,” I said as I walked over to Ms. Giannetta’s right side. “Now that she’s on our monitor, can we hold CPR to get a pulse check and switch roles so EMS can be on their way? Respiratory, please hold bagging, too, while I listen to the chest. No breathing, no breath sounds.” I placed my second and third fingers on the patient’s carotid artery while watching the monitor. “No pulse.” One slow line snaked across the screen with mild variations. “PEA. Please resume CPR with compressions, bagging, and let’s give an epi.”

  I looked over at Crystal, the nurse who was recording for the code, and asked her to please advise me at two-minute intervals so we could keep track of our pulse and rhythm checks as well as when medication administration would be due. Over that time, I completed my physical exam: Good air entry in both lungs, and the patient’s oxygen saturations were in the high nineties, with the respiratory therapist’s continuous bagging, both signs pointing to the endotracheal tube being in good position. The patient’s fine salt-and-pepper hair bounced with each chest compression. Her plump olive skin was segmented by deep laugh lines, giving her face a wise and honest cast. Her heavy lids were coated with shimmery peach eye shadow and charcoal eyeliner; I lifted them to reveal large black pupils that were fixed and dilated. Her body showed no signs of trauma and no signs of movement save for the give-and-take of CPR. Her belly was soft.

  “Four minutes. It’s time for epi this time,” Crystal announced.

  No pulse at the neck. No pulse at the groin. The same fine line slithered across the screen, but this time it was almost entirely flat.

  “Another epi, please, and let’s resume. Can someone go get the ultrasound for the next check? She’s down at least nineteen minutes, with no return of circulation and no meaningful rhythm. If people don’t disagree, I think we should call it at the next check unless there’s a change.”

  “Definitely,” Crystal said. Heads nodded all around.

  “Is anyone here with her?” I asked.

  Tina, the tech, responded. “No. EMS said the family stayed behind because they had to make some phone calls. They should be arriving soon.”

  “Okay,” I said.

  We heard a clanking, crunching sound.

  “There goes a rib!” said Jared, the nurse who was performing compressions.

  “Yeah, but what’s the clanking?” Crystal asked.

  We looked around the room. The bed was locked, and no equipment had fallen. Tina, the tech on the left side of the bed, lifted Ms. Giannetta’s left arm, raising her hand. Her nails were painted with frosted pearl polish. On her ring finger: a two-toned wedding band of yellow and white g
old curled around three tiny antique diamonds whose settings resembled a row of gilded baby’s breath buds. Her fingers curled limply over Tina’s palm.

  Tina looked up at us. “Her ring. Her wedding band is hitting the bars.” She then lowered Ms. Giannetta’s arm gently to the bed and positioned it closer to her body. No more rattle.

  “Time!” Crystal said again.

  No pulse. No heart sounds. No breath sounds. An increasingly fine and slow slither across the monitor that was now arguably flat by all measurements.

  “Nuthin’, guys,” I said and pulled over the ultrasound machine. “Let me just check her heart for any beating.” I squirted a quick blob of jelly over the center of her chest and then placed the probe on her anterior chest wall, over the region of her heart. Turning my gaze to the screen of the ultrasound machine, I saw the thick gray chambers of the heart lying flat, with stagnant black holes for blood. The only movement was my hand swiping back and forth as I viewed the still, silent organ.

  I removed the probe and replaced it in its holster. Looking up at the clock, I announced, “Time of death, four twenty-nine p.m.” I continued: “Okay, I’ll get to the documentation and calls to the medical examiner and organ donation. Can y’all please tell me if and when the family arrives.”

  “Sure thing,” Crystal replied.

  I sat at my desk, asked the clerk to get the medical examiner on the phone, and opened my chart to document the code.

  “Doc . . . Doc?” A voice called out in hesitant upspeak.

  I turned to see Crystal with one foot in Ms. Giannetta’s room and another pointed toward me.

  “Yeah?” I said.

  She was looking at me quizzically, her mouth open, but instead of words, she let out a sigh.

  “Ummmm.” She narrowed her eyes and pursed her lips. “You know, I think you should just come back here and see.”

  I felt a kind of instant dread. You never want to hear one of your colleagues say, “I think you should take another look at this.” Just as you never want to look down to see that the ultrasound-guided peripheral IV it took you four attempts and twenty minutes to place has red blood pulsing up into the IV tubing.

  After two deep breaths, I followed Crystal back into the room.

  Tina looked up at me with wide eyes as Crystal closed the curtain behind me. “Doc, she’s breathing!”

  “What are you talking about?” I asked.

  Tina pointed. “Doc, look.”

  Condensation and slow swooshes of air rose and fell in the endotracheal tube. I listened at the patient’s chest to confirm. The monitor still showed a flatline. No pulses at the carotid. No pulsation at the femoral.

  “Crystal, can you come over here and check, too?” I asked.

  Crystal walked slowly to the left of the bed and placed the pads of her index and middle fingers to the neck. “Nothing,” she reported. Then she shifted to the left groin. “Wow . . . nothing.” She shook her head in disbelief.

  We looked at each other.

  I frowned and crossed my arms. “I’ve never seen anything like this.”

  “Doc, I’m a heck of a lot older than you, and I’ve never, ever seen this happen. I mean, what the heck?!”

  “Jackie!” I called out to the clerk. “Please tell the medical examiner never mind.” I looked back at Crystal. “I guess we have to cancel that time of death stuff and continue the code. While the ACLS algorithm doesn’t specify a case like this, I’m pretty positive I can’t pronounce someone dead who is still breathing. How she’s all of a sudden breathing while still having no cardiac activity, I have no idea.”

  Crystal went back to the code sheet to document this new turn of events and called the crew back in.

  “Jackie, please call Dr. DeLaurentis, since he’s covering the ICU. Luckily, he also happens to be her cardiologist. I’ll have to run this by him, I guess, for the sake of completeness. Can you also please call Respiratory to hook her up to a ventilator and page for portable chest X-Ray to confirm the endotracheal tube placement while we sort all this out? Crystal, she has two good peripheral IVs, so let’s start dopamine in one, since there’s clearly no blood pressure. Peripheral access is good enough for now, since I don’t know how far we can go with this.”

  “Sure. Uh, I guess we kinda have to, don’t we?” Crystal said.

  My medical training was little help in explaining what Ms. Giannetta was experiencing. Not only was this not the stuff of medical science, but it demonstrated its limitations in comprehending life on this plane.

  “Dr. Harper, Dr. DeLaurentis on the phone,” Jackie called out.

  I picked up my phone and relayed the whole fantastic story to him. He was a kind, gentle doctor, and I imagined that was why he received the story much better than I would have if someone had called me out of the blue to assume care of a patient who was, technically, not really alive.

  I hung up and told the team: “Dr. DeLaurentis will be right down, and he’s gonna call the family, too. He knows them well.”

  Within moments, Dr. DeLaurentis appeared in the ER. One never recalls exactly the details of an exchange with Dr. DeLaurentis because he swoops in mesmerizing. After the interaction with DeLaurentis, you know you’ve seen a man approaching in a smart Italian suit with coordinating classic leather dress shoes and belt, there’s the black hair combed back with a slight wave, and then the smile that illuminates the whole ER with its sincerity. But then the details of the conversation become hazy; you simply recall that he was there, and that made everything better. He approached me with outstretched arms.

  “I don’t know what to say. I mean, when you called, I believed you, but I didn’t really believe you. I just examined her, and what?”

  “I know!”

  “Well, let me have a talk with the family, since I know them and I’d be the one to admit her. I’ll take it from here and let you know how it goes.”

  “Please let me know if you need anything.”

  It was always a lovefest with the debonair Dr. DeLaurentis. Later, after the family had arrived and he’d spoken to them, I had just finished repairing a leg laceration in Room 6 when he pulled up a chair next to mine.

  “I had a long talk with the family. I was honest with them. I told them that given how long she’s been down with her heart not beating, there’s no way she’d have any meaningful brain function if, on the slim chance, she were to survive. They all said this is not what she would have wanted; she wanted to go peacefully and with dignity when it was her time. We turned off the vent and the dopamine. They’re sitting with her now. They’re just waiting for one of the daughters-in-law to arrive. Do you mind if we use your room for a little while longer? If this goes on too long, I promise we’ll move upstairs.”

  “Not a problem. Please keep me posted.”

  “Will do,” he responded before returning to the room with Ms. Giannetta’s family.

  I saw a woman in tears being escorted by the triage nurse to the room only several steps behind Dr. DeLaurentis. This must be the family member they had been waiting for. I saw Dr. DeLaurentis open the curtain for her and then close it. After a moment, the beeps of the monitor stopped. Soon after, Dr. DeLaurentis returned.

  “She passed away. Stopped breathing.”

  “Just like that?” I asked.

  “Just like that. Thank you for your room. The family is collecting their belongings and should be out soon. They’re calling a funeral home for arrangements. You can let your nurses know they can take the body down to the morgue. Of course, since she was admitted to me, I’ll call the ME and Organ Donation. She’s my patient anyway, so I’ll do the death certificate.” He patted me on the shoulder, smiled, and left to go back to the ICU.

  I walked over to the counter to get the pen I’d left there and stood writing my follow-up notes on patients. In truth, I wanted to get a glimpse of Ms. Giannetta’s room. I
counted three, possibly four generations around her. Then her family came out in pairs—toddlers clinging to parents and aunts, middle-aged couples, elderly adults who appeared to be siblings. Tina and Crystal removed the monitor and folded the sheet gently around Ms. Giannetta’s arms. I marveled at how she had waited, how she had known. I marveled at how she hadn’t left until all her family had arrived. How she had returned to say her last good-byes and only then had taken her final rest.

  I felt a tap on my shoulder that made me jump.

  “Oh, sorry, Doc. Just me.”

  It was Al, one of the custodial staff employees. He’d always check in with me about his health goals. He’d lost weight, which had allowed him to wean himself off most of his medications for high blood pressure and diabetes. I was happy to cheerlead him along from the sidelines.

  He smiled, opening his arms. I leaned in to return his hug.

  “What’s going on?” he said. “You look spooked. How’s your day going?”

  “Where to begin, Al? Where to begin?” I laughed.

  Should I start with the little girl who had been beaten unconscious by her father? How would I tell him that her silenced body had called out to be heard, cared for, saved? I wondered if I should go into detail about how the body can house a million truths that may not be readily apparent on the surface, or how so much wisdom flows beneath the skin. Or should I begin with the old woman who had returned from death to say her final good-byes to her family? How would I tell him that her body had been ready and at peace, but that there had been one final task for her spirit to complete before she transitioned? Should I explain that nothing in my medical books or in “science” could explain that when she was dead, she came back just long enough to wait for her loved ones to gather by her side?

  Or maybe I should start by telling Al that this had been a most painful year—or rather, series of years. Should I tell him that it was probably exactly because the challenges I’d faced had taken me to the brink of despair that I had been able to uncover a newfound freedom? Should I explain that my body was punching out a message to my heart and soul, that I had learned to tap into the message again and again between shifts and heart tugs, trying to translate, but that I hadn’t yet fully grasped the dialect? Should I add that I felt it had to be a message to love more no matter what, to be happy now no matter what?