That much sound meant a lot of patients. Too many.
"Morning, Dr. G.," the triage nurse greeted him. She was a cheery woman in her mid-twenties. He knew her mask hid three rings in her right nostril, and slightly spiked but short black hair stuck out from beneath her surgical cap. She glanced up from taking the blood pressure of an elderly lady who had frizzy white hair and lay gasping for breath on an ambulance stretcher, a red handbag clutched to her chest with both hands. She also was masked, and her frightened eyes stared at him over its tight-fitting rim. The material puffed in and out with each respiration.
To the left the walking wounded, equally well masked, kept their distance, prowling a waiting room meant to hold half their number. On the right another sliding door led to the inner sanctums of ER, where patients unable to sit or stand would be parked on stretchers.
"Morning, J.S.," he replied, raising his voice to make himself heard above the chatter of a hundred conversations.
The initials stood for Jane Simmons. They'd used call letters to address each other since shortly after she came on staff. It began, as did many traditions between people in ER, during the rush of a resuscitation. The intensity often cemented first impressions- for better or worse- and her impact on him had stuck for the better. Despite dressing the part of a punk rocker, she had good hands when it came to starting IVs in the worst of veins, and her calm never cracked- not then as a new kid, and not since, even during the toughest cases.
"Need any help?" he asked her. The elderly woman's rapid breathing had automatically put him on alert.
" Nan." J.S. reassuringly patted the lady's arm. "Meet Mary."
"Hi, Mary, I'm Dr. Garnet, the guy who runs the joint." He placed his gloved hand over hers and gave it a gentle squeeze.
"Only a touch of heart failure," J.S. continued, "but this little sweetie's going to be just fine as soon as we give her oxygen, relax her airways, and get her peeing."
Some of the fear drained from the old woman's gaze, and she appeared less forlorn despite the puffy circles drooping over the upper edge of her mask. An orderly whisked her through the inner door and down the hallway to a treatment room.
"Ready to whip another crop of greenhorns into shape?" Earl asked J.S. while glancing over the ambulance sheet to see what calamities the city of Buffalo had delivered up overnight. He mentally ticked off the cases that he could use as good teaching material for introducing first-year residents to ER.
The corners of her eyes crinkled, and he knew her infectious, crooked grin had appeared. She lifted an upper tie to loosen the corner of her mask and blew a strand of loose hair off her forehead. "Just let me at 'em."
Before he could remind her that she shouldn't breathe unfiltered air, even for a second, a single low growl from a siren announced the arrival of another ambulance. The signal meant they'd brought in a patient still breathing, but barely, who needed help fast.
J.S. pivoted and charged out the door leading to the garage.
Several nurses darted from the inner corridors to follow her. They passed where a teenage boy sat clutching a skateboard and doubled over in pain. J.S. must have deemed him stable enough to wait, but Earl didn't like the greenish tinge and sheen of sweat that no mask could completely hide. "Do you need to lie down?" he asked, walking over and kneeling at the young man's side.
"I need to vomit, sir."
"Just hang on." He rummaged through the equipment racks behind J.S.'s triage area, dug out a bedpan, and shoved it into the youngster's lap.
The sounds of more ambulances pulling into the unloading area reached his ears.
Busy day to break in a fresh crew, he thought, hurrying inside to marshal his staff for the onslaught. At the door he stopped to double-glove and double-gown, the added body armor required for anyone working ER. He also donned another prerequisite for anyone on the front lines of medicine these days: a cast-iron attitude of que sera sera.
An hour later they'd diuresed a liter of pee from the woman in heart failure, identified a ruptured spleen in the skateboard kid, and resuscitated the case that had so alarmed the ambulance technicians: a diabetic stockbroker in his fifties named Artie Baxter. He'd skipped breakfast after his morning insulin, then collapsed and seized. "I had a great tip before the market opened," he'd explained when a shot of IV glucose woke him up. "So I phoned all my clients instead of eating my usual toast and cheese…"
A few of the nurses scribbled down the company's name and ran for the wall phones.
"Can I see you outside a moment?" Earl said to Susanne Roberts, the head nurse, and led her by her elbow to a quiet spot in the hall.
"What's up?" Her pixie haircut peeking out from under her OR cap made her appear young, and only the lacework of tiny lines that fanned out at the corners of her eyes hinted at her age. She'd been on staff in ER for nearly as many years as he had, but she'd kept her passion for the job long past the point at which most lose it. Like all gifted leaders, she brought out the best in those around her.
"I'm going to try to make the end of the orientation session for the residents," he told her. "But I'm worried about this guy. Keep him on the monitor with the IV running."
"You expecting trouble?"
"His story doesn't add up. A man who's been on the needle for years and he pulls a stunt like that? I think he's not telling us something. And all that stock talk- a little too smooth for my liking. He got a wife?"
"She's on her way in."
"Ask her if he's been as well as he claims."
The speeches were almost over when he let himself in through a side door near the front of the auditorium stage. The audience occupied a steeply raked semicircle of seats, providing a wall of OR green before the speaker at the podium, Dr. Stewart Deloram, St. Paul 's resident genius in critical care. His mop of jet-black hair sprang out from the sides of his headgear like burst springs, flopping about as he animatedly extolled the virtues of a quiet, calm demeanor while dealing with life-and-death situations. "Especially when working on a patient who has suffered cardiac arrest," he emphasized in a grave, sonorous voice.
As the director of the intensive care unit, and one of the hospital's biggest screamers, he ought to know.
The two-thirds of the audience who were familiar with Stewart's antics tittered. Those who weren't dutifully jotted down what he'd said. Yet every single resident who had just laughed would also willingly double their allotted time with him in ICU, so brilliantly did he teach the art of critical care, or "raising the dead," as he called it.
Earl didn't care how loud Stewart got during a resuscitation, so long as he got the job done. The patients sure were in no state to hear him, and besides, other geniuses made noises when they worked. Just listen to undoctored recordings of Glenn Gould. Or to Monica Seles when she served.
Earl spotted the chief of surgery, Sean Carrington, a giant of a man seated in the front row, and slid in beside him. He wielded enormous influence in the hospital and more than once had used it to save Earl's hide politically. But Earl appreciated him most for his zany sense of humor. Sean could cut through the suffocating bureaucracy of academic medicine like a blast of oxygen. And his bushy red eyebrows, highlighted by his mask, whipped up a laugh all by themselves when his jokes failed.
He nodded to Earl, leaned over, and whispered, "Stewart must be in anger management classes again. You know, the ones where they chant, 'Teach it, and the shit you spout will come true.'"
Earl swallowed a chuckle. "Did he brief them about SARS yet?"
The fun went out of Sean's eyes. "Yeah."
"Who's left to speak?"
"Just you, Dr. Vice President, Medical, sir, and chief poo-bah, or whatever it is we get to call you these days."
"Now don't you start. I get razzed enough by my department."
Sean reached over and pretended to knuckle-rub the top of his head. "Hey, what are old friends for but to keep you from getting too high and mighty up there among the ruling class?"
Earl knew that Sean too
k the epidemic as seriously as anyone, but apart from the mandatory discussions about it at meetings, he never dwelled on it, let alone voiced his personal fears. If anything, his joking had increased as the hospital hunkered down to meet the crisis. What with the general atmosphere of gloom, they could do with more like him. And Earl read this latest tease as a hint to lighten up himself. "High and mighty, with the bellyfull of problems you bums dump on me every day? Fat chance."
The vice president, medical held authority over all doctors in their practice of medicine at St. Paul's Hospital. Only the CEO had more power. The position also meant a mountain of trouble for whoever filled it, especially in times such as these. Yet two weeks ago, under pressure from most of the other chiefs, Earl had accepted the appointment. Why? "Because it's a responsibility I can't refuse," he'd told most people who asked. And he hadn't lied, just dressed up the real reason: it would be easier to run ER with himself in charge rather than some of the other bozos who might get the job.
"How's Janet taking you being named boss of bosses around here?"
"Cutting me down to size, as usual. I don't think she got the memo-"
A gentle cuff to the back of his head cut him off. "Hey, quit bad-mouthing your superiors," Janet whispered, loud enough for people two rows away to hear, as she slipped into a seat behind him. She whipped off her surgical cap, setting a sunburst of blond hair free with a shake. Then, quickly replacing the headgear, she gave him a masked kiss on his masked cheek. "And no memo's going to make me treat you differently."
Earl heard a few snickers.
Dr. Janet Graceton, obstetrician and recently named director of the hospital case room, held command over him as friend, lover, and wife. Some in the hospital eagerly awaited an issue where the VP, medical would have to confront the case room director over something or other. According to the rumor mill, odds of that matchup stood at eight to five for Janet.
"Hey, you look great," Sean told her.
"That's because OR greens and gowns make perfect maternity wear, don't you think?" She molded the layers of material over her abdomen, accentuating the swell of her stomach. Even with her in her thirty-fourth week of pregnancy, operating room garb hung so loosely on her tall and normally slim frame that nobody believed her due date could be six weeks away. Nor would her workload tip them off. Some women might have cut back their time on the job by now. But Janet would have gone nuts staying home at this stage under any circumstances. She relaxed through work, finding a contentment in it that her colleagues, male and female, envied. "And a happy mom usually means a contented fetus," she'd told thousands of women, helping them discover their own unique needs during pregnancy. Little wonder she gave herself the same right to decide what would be best for her baby. While carrying their first son, Brendan, now six, she'd done her last delivery a mere twenty-four hours before going into labor herself.
Not that her bravado didn't worry Earl.
"Now a word as to your night schedule," Stewart droned, and flipped open his laptop computer, where he kept house staff duty rosters. On the screen behind him a barely decipherable set of lists came into view. "As in last year, only second- and third-year residents will be on for ICU, the intensive care unit, CCU, the coronary care unit, and SICU, the surgical intensive care unit. If you learn nothing else, you'll at least be able to impress family and friends with all these neat acronyms."
A third of the audience laughed. The remainder groaned. Stewart made this same joke every year.
"And if you lose your handouts, feel free to make yourself floppies. This laptop is at your disposal, and the password is Tocco, T-o-c-c-o, my dog's name…"
Earl tuned it all out, mentally preparing what he would say to sum up the session. The SARS outbreak had catapulted doctors into a level of risk that hadn't existed in North America since the 1918 flu epidemic, and forced them to adopt protective measures unprecedented in modern hospitals. No one in this room had planned to take on that kind of danger when they chose medicine as a career. How the hell did he address that?
"… and while during the day you may be internists, surgeons, gynecologists, et cetera, residency cutbacks necessitate that at night you will cover a multitude of services, again like last year…"
This time Stewart got a howl of disapproval from the newcomers. High up in the back row a kid who had black Brillo pads for eyebrows and who looked lost in his voluminous OR gown leapt to his feet, teetering over the similarly attired confreres sitting in front of him. "What if we need help?" he yelled.
Equally youthful looking colleagues joined in.
"… yeah…"
"… a lack of supervision…"
"… violates our contract…"
Earl marveled at how they could get so exercised over such a traditional complaint as the on-call roster when the new normal they faced loomed so large. Odds were that the first-year people, with so much to learn, would slip up more than anyone else when it came to all the protective measures they must practice. As a consequence, no other group in the room stood a greater chance of ending up sick, maybe even dead.
Stewart waved them quiet with the palms of his hands. "Easy, people, easy. We'll also have full-time staff doctors in the critical care areas I mentioned. That frees the R-twos and R-threes on duty there to come and assist you on the floors when you call them. It's a system that's worked well."
A few of the rookies continued to mutter, and some rolled their eyes in exasperation. The second- and third-year people remained silent and slumped in their chairs. They were all too aware that scheduling arrangements didn't matter much against an unseen threat ready to get you on any shift, at any time.
"What about ER?" a lone voice inquired from somewhere behind and above. "Will R-two and R-three people there be expected to back up arrests on the floors as in the past, or did you finally get that note from my mother saying we needed our sleep?"
This brought a much-needed laugh from everyone.
Earl smiled, recognizing the easy drawl of Dr. Thomas Biggs, his own emergency medicine protege. He looked around and saw the lanky Tennessee native sprawled in his seat a few rows from the top with the laid-back air that he had made his trademark. Even with his mask on, the bottom margin of his black beard could be seen under his chin. On either side of him sat the other men and women in the ER program. Thomas, in his last year of training as an emergency medicine specialist, would serve as Earl's chief resident and supervise teaching during the next three months. After that he'd begin a final rotation through all the other critical care areas Stewart had just mentioned. Judging by his performance so far, he had the potential to be a real star and would undoubtedly make a major contribution wherever he ended up.
Stewart stiffened. "Right, Thomas. I should have included ER. Night coverage there will be the same as in the critical care units- a staff presence twenty-four seven plus second- and third-year folks who'll offer backup on the floors." His voice took on an edge that hadn't been there before. "Now, before I turn over these proceedings to Dr. Earl Garnet," he went on, his tone even more clipped, "our chief of ER and recently appointed VP, medical- in other words, the other guy around here whom you should listen to besides me-" He paused for the expected laugh, but the coldness in his voice had drained any fun out of the crack. He shrugged and continued. "Our hospital chaplain, Jimmy Fitzpatrick, would like to have a moment with you." Stewart unceremoniously gathered up his notes and plumped himself down in a chair behind the podium.
The atmosphere went flat.
Earl had long since stopped trying to figure out Stewart's mood swings, having concluded years ago that the man had a narcissistic personality to go with his prodigious talent. But diagnosing him didn't render him any less annoying. He could take the simplest inquiry as a personal affront, as if whoever questioned him questioned his competence. Yet everyone also excused this prickly side of him, just as they did his tendency to yell a lot, again because of his extraordinary ability to pull off miracles. Thank God, he would usually apo
logize afterward when he did lose his cool and pull one of his snits. "I'm just not used to anyone challenging me," he'd once told Earl. "Most of my patients have tubes down their throats." But sometimes he could prolong holding a grudge, and over the stupidest things.
Jimmy, a muscular man wearing the same protective gear as everyone else, stepped up on the stage. His square jaw stood out beneath the covering of his mask, and not even layers of green could hide his well-proportioned physique. "Top o' the mornin' to you," he began when he reached the microphone, sweeping the audience with intense black eyes that had a magnetic pull to them. "Oh, I bet you're thrilled t' hear from a preacher. The ones fresh out of medical school, having never found the human soul in all those studies, are always the most skeptical that it exists." His lilting Irish brogue and mischievous squint instantly reanimated the room. People leaned forward to hear what he had to say. "So I'll keep it short. The Pastoral Services Department is here to serve the emotional and spiritual needs of patients, family, and staff. To learn more, give me a call. I want to stress we're open to all, whether a person has a formal religious affiliation or not. Remember, people of all stripes get scared in here, and even if we just provide a sympathetic ear…"
But Earl kept his gaze on Stewart, then glanced back at Thomas. Presumably Stewart's display had to do with Thomas's question. Understandably the resident remained oblivious to any wrongdoing on his part, and chatted easily with the R2s immediately to either side of him, both female. No surprise there. He had a way with the ladies.
Yet Stewart kept scowling toward the young man, as if trying to catch him in some other act of inexcusable insolence. After a few seconds, however, the ridges in his forehead flattened, and his expression softened.
Good, Earl thought.
Stewart's pique over imagined slights occasionally grew to the point that it interfered with work. One time the tension in ICU had gotten so bad that Earl slapped a notice in red ink above the entrance: PROS LEAVE THEIR GUNS AT THE DOOR. The job of setting him straight usually fell to Earl because no one else in the hospital would dare criticize Stewart about anything. Earl figured he got away with it because of the year he'd been Stewart's chief resident at New York City Hospital twenty-five years ago. That kind of seniority over a junior can stick for life.
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