Just Here Trying to Save a Few Lives

by Pamela Grim

  You duck your face back down, ashamed, and reapply yourself to the suture material. Your hands are shaking.

  It's almost impossible to see. There's blood that just reaccumulates with every swipe of gauze. You make a guess for the next two loops, hoping you don't stick J. T. again. How could you have done anything so stupid?

  You make a final loop. As you do, J. T. eases his fingers out of the way. The loops hold; there is a little leakage of blood but not much. You've nailed one of the bullet holes.

  You cut the silk with the Metzenbaum, and J. T. gently massages the heart.

  “I think we've got some blood circulating here,” J. T. tells you. “Heart feels fuller.”

  So all the fluid you are pouring into this kid is starting to do some good.

  “We've got a carotid pulse with compressions, guys,” Donna says, her hand on the kid's neck.

  “I've got this one,” you say to J. T. “Go change your gloves and wash your hands. Donna can do this.”

  Donna speaks from over your shoulder. “There's no way you are getting me to come one inch closer to that heart than I already am.”

  “Just keep going,” J. T. says.

  There is, you see, a technique to this. For the next hole you move J. T's fingers gently out of the way and pinch the hole shut with two fingers of your left hand. It's easier to sew now, although you can't stop that shaking. At least you are less likely to pop J. T. again.

  You can see better now that neither of these entrance wounds is bleeding. You can keep the field somewhat clear of blood. The second one goes more easily than the first.

  “Nice,” J. T. tells you. He lifts the heart somewhat to give you better access to the back side and you both bend down, peering at the holes J. T. has plugged with his fingers.

  You realize now that if either of the bullets passed through the heart's septum, the wall between the left and the right ventricle, on its way out of the heart, you are sunk. There is no easy way to get at a hole inside the heart. Still, it looks as if they both exited through the bottom part of the left ventricle. Maybe this cat still had a few lives left.

  You use the same technique to close the posterior lacerations. You pinch the bullet hole shut with your left hand and whipstitch with your right.

  Once you close the last laceration, you let the heart fall away from your hand. The field stays fairly clear of blood. J. T. takes his hand away as well.

  The heart just sits there quivering. It doesn't make sense until J. T. says flatly, “V-fib.”

  The heart is fibrillating.

  You are such a creature of habit that you don't believe it until you look up at the monitor and see the green electronic squiggle of ventricular fibrillation marching out across the screen.

  “Well,” you say, “get the paddles.”

  To defibrillate the heart, you pass an electrical charge through it, stunning the entire myocardium—the heart muscle cells—all at once. If the circumstances are right and you are very, very lucky, then the heart may restart itself in a normal rhythm. Usually in ambulances and ERs and such, you do closed-chest defibrillation. You pass the charge to the heart through the entire chest wall. Now, though, you have the heart entirely available, open right here in front of you. You can apply the electrical charge across the heart itself, so you need less voltage.

  You use two long-handled paddles and position the two paddles so that the heart is between them. It's like holding a wad of Jell-O between two metal fly swatters.

  J. T. attaches the paddles to the defibrillator cords. You take the handles and sandwich the heart between the two metal pads.

  Twenty joules. Not much. Even so there is the sudden smell of burning flesh that arrives seconds after the first shock.

  Everyone looks at the monitor. V-fib still.

  “Again,” you say.

  Another shock. More burning flesh.

  “Epinephrine,” J. T. says. Adrenaline. “I'm going to give it intracardiac.”

  Donna hands him the syringe. J. T. unsheathes the needle and jams it into the muscle of the heart. You can't give adrenaline any faster way.

  J. T. goes back to cardiac massage. Everyone stands for a moment looking up at the monitor.

  “Let's shock again,” he says.

  You are ready with the paddles. J. T. slides the heart between them. Another shock, this time at 40 joules.

  There is the flash and that terrible smell again. Out of habit, nobody watches the actual heart; everyone looks up at the monitor.

  There is—after some jiggly artifact—normal sinus rhythm: rate 99.

  “Just like on TV,” J. T. says.

  You all look down at the heart, which is doing this weird shimmy as it contracts. It's beating! you think.

  It is only now that you recognize that someone is shouting out in the hallway.

  “Where's my patient? Where's my patient?”

  The trauma doors swing open, and in comes Dr. Wu, the thoracic surgeon on call. He's a small, fierce-looking man, now wrapped in a wet trench coat. It must be raining, you think. Somewhere out there is a real world of night and rain.

  “What are you doing?” Dr. Wu shouts before he even gets up to the bed. Dr. Wu is a character and not a pleasant one. He yells at the nurses and the patients, given any excuse. He throws instruments in the OR, he hectors the medical students, and when a patient goes sour, he shouts at anyone in his path. (He meets a mixed response to this, since no one can understand his English when he gets angry.)

  However, he is a very good surgeon. You would want him to do your bypass surgery should it come to that.

  Jesus, you think suddenly, and turn to Donna.

  “Lidocaine. Bolus and drip.” That's to keep the heart from going back into fibrillation. You could kick yourself; you almost forgot. That one mistake could negate everything you've done so far.

  You present the case to Dr. Wu as he peers down into the chest cavity. “A sixteen-year-old kid. Two through-and-through gunshot wounds to the chest. Both nailed the left ventricle. See.” You show him.

  “You sutured!” Dr. Wu shouts.

  “We had to do something.”

  “Pledgets!” he shouts. “You sutured and you did not use pledgets!”

  “Pledgets?” you reply stupidly.

  “Cotton pledgets! You must have cotton pledgets to sew the heart. Where are pledgets?”

  Donna, who is afraid of no one, wheels on him. “Dr. Wu, this is the ER, not the OR. We don't have pledgets down here, so get over it.”

  Dr. Wu, sensing a dead end, immediately switches to another problem. “Who called OR? Is OR there? Where is Anesthesia? Why isn't Anesthesia ready? You people have gotten nothing done.”

  “Dr. Wu…,” you say.

  Donna is after him, though. “I'm sorry we haven't gotten anything done, but we were busy trying to save this kid's life by sewing up the holes in his chest. And if you quit having a temper tantrum because you got called in on an emergency case, then maybe you could help us out.”

  Dr. Wu wheels around, his mouth open, ready to say something. He looks at Donna, closes his mouth, nods and tries again. Finally, he spits out the only thing, apparently, that he can think of. “I am going to scrub. Bring the patient to the OR.”

  “Fine,” Donna says, arms folded. “You do that.”

  You go back to the patient, basically thrilled to see Dr. Wu here no matter what his mood. At least he didn't ask you to cross-clamp the aorta.

  That was the procedure that the photogenic doctors on TV were trying to enact. (“Do you see the aorta?” “Yes, yes, I see it clearly!”) The reality is this open chest, a bare beating heart and blood everywhere. To cross-clamp the aorta, you have to find it, and this means you have to root around in the darkest recesses of the chest. You remember the last time you did it—three years ago. That was another kid, nineteen, who was stabbed in the belly—complete transection of the aorta. After you resuscitated him, the young man went up to the OR. The surgeon repaired the aorta—a
miracle—then the kid spent a month dying in the ICU. You remember talking to his gaunt, frightened parents, breaking the news. And then there was the death, finally, thankfully. Never again, you told yourself, no more miracles. And here you are again.

  You realize that you faded out there for a moment. Donna is looking at you. “What now?” she asks.

  The only simple part. “We take him up to the OR.”

  “What about his blood pressure?” J. T. asks. You look up at the monitor. Systolic blood pressure of 60. Normal is over 100.

  What now? You think and you realize you just don't care. You just want to get him to the OR.

  “Let's restart cardiac massage,” you tell J. T. “At least until we get him upstairs.”

  It takes a while to get everything ready. You have to transfer all the monitor leads to portable monitoring equipment, change the oxygen supply, sign and break down the chart. Meanwhile, J. T. is standing there, pumping the heart patiently. You change gloves and take over.

  The little procession bangs out the door and down the hallway. You take over clutching at the heart. Clenching, unclenching, clenching, unclenching.

  You have to take the front elevators. It's still before six A.M., so the back elevators aren't working yet. (They shut them down between midnight and six A.M. to save money.) You have to take one of the visitors' elevators up.

  The bed just barely squeezes into the elevator cubicle. Everyone presses in around it. Bill presses the button for the fourth floor. This all seems pretty anticlimactic compared to what came before.

  As the elevator levitates, you stand looking up at the ceiling, pumping away at the heart. Something occurs to you. A weird thought and you say aloud, “Maybe this kid will live.” Even you can hear the touch of disbelief in your voice. “Of course he's going to live,” Donna says. “He's nothing but a stupid, punk kid who, was out where he wasn't supposed to be, doing what he wasn't supposed to be doing. These guys always make it.”

  You look sideways at her. It seems that as cynical as you have become over the years, you haven't gotten cynical enough to go that far, to feel that way. Then you remember J. T. and the needle stick. You nailed J. T. with the needle. No matter what happens to this patient, no matter how well he does, you would unravel the whole procedure just to take that needle stick back.

  At the third floor the elevator stops. Everyone groans as the doors open; the OR is on the fourth. Standing in front of the door is a middle-aged woman, obviously waiting to get on the elevator. She doesn't look like one of the employees; she's dressed too nicely. Maybe she is an early morning visitor here to see one of the patients. What she sees with the elevator doors now open is a patient on a gurney with his chest pried open and you mashing on his bare heart while a motley crew of exhausted-looking health care professionals look on. Her mouth O's. She stands there frozen for the thirty seconds the door remains open. It closes again, and you ascend the last few feet to the fourth floor and the OR.

  More anticlimax. Dr. Jan M. Radjike, the on-call anesthesiologist, wanders over, looking sleepy. Next to him an OR nurse stands waiting for you, arms folded, looking peeved. You feel for the first time a sense of relief, mixed with disappointment. Here is where you will pass the torch; you will go no further. The bypass pump technician waddles up. He scans the scene coolly; after all, he sees open chests and naked, flailing hearts every day. There are other nurses now as well, padding around in their blue surgical booties, surgical caps in place. Everyone looks grumpy and sleepy. No one wants to face this case first thing in the morning.

  Chances are, you think to yourself, one in a hundred. And that's assuming you have an OR team that's awake. You shake your head.

  “Ready or not,” the bypass tech says as he takes over heart massage.

  And it's over. Just like that.

  J. T. and you take the elevator back down. The hospital is waking up now. You check your watch: 6:14. The golden hour is over.

  Now for the parents. They turn out to be two ordinary people, raincoats pulled over their pajamas, who look too stunned to be grief-stricken. Your job is to “lay crepe,” that is, to prepare them for the likely death of their son while pointing out that technically the boy is still alive. One in a hundred, you think.

  “If there's a miracle in the OR…,” the mother says. All families cling to that word miracle. They think miracles are an everyday thing in medicine, whereas you, knowing the odds, feel as if you are only leading them astray. You try to explain but quickly you see that you are not getting through. The only thing that matters to them now is the word miracle.

  So that's the story. You dig it up sometimes when you need it: the story of the sixteen-year-old kid who came in with two gunshot wounds through the left ventricle. Went to the OR with you doing open heart massage in the elevator. You are cheating when you tell it, but you are not alone. Doctors don't often tell stories about the patients they didn't save, or mistakes they may have made, or medical events they didn't understand. You are like that too, since, over the course of your career, you've opened a hundred chests or more, but you never tell the stories of the vast majority of them. You just tell the story of one or two you managed to save.

  It's a sleepy afternoon, maybe a year later, maybe more. You are sitting writing on a chart. (Scientists have proved that ER physicians spend 50 percent of their time writing on charts. This is another thing they don't show on TV). Donna is standing above you, discharging a patient. “Now,” she says to him, pointing to the bottom of the discharge instructions. “Put your initials here.”

  “I don't have initials,” the patient says to her seriously. “I only have a name.”

  You put your face down into your hand so that the patient can't see you laughing. To get away, you stand up and go over to the chart rack and pick up the next player. Chest pain in someone seventeen years old. Practically no one with chest pain at the age of seventeen has any significant health problem. The only clinical skill needed is getting rid of the patient both quickly and gracefully.

  The nurse had already gotten an ECG. You go into the room and ask the pasty-faced young kid there a few questions. Your first sense, strangely enough—that sixth sense you use a lot to make a diagnosis—is, “But this kid is okay. He's a nice kid.” You're not sure why that is relevant here, but the kid understands. He looks up at you, cocks his head and says, “Do you remember me?”

  You have just taken down his gown to reveal a wide swath of scar from the breast bone to the axilla, the scar still a little raw. There's also the upper terminus of a healed celiotomy incision, a remnant of an abdominal exploration.

  The miracle here is not whether you remember him or not. It's that he remembers you. You wonder for a moment about those end-of-life things, the light at the end of the tunnel. You imagine the patient's spirit watching a resuscitation over the medical team's shoulders as everyone frantically tries to save that body's life. How else could he ever have remembered you? But you don't say anything about that. If the kid was at all sane, he would think you were crazy. You just close your eyes, pass a blind hand over the trail of the scar, the palm flat on the chest, palpating for the apical impulse, as you say, “How could I ever forget?”

  6

  THE GOLDEN MOMENT

  I.

  ONCE I WAS TRAPPED IN A BAD TRAFFIC JAM. Up on the hill ahead was a three-car accident. One car was overturned and burning. The scene was packed with fire trucks, ambulances and patrol cars. I eased out onto the shoulder and ran a quarter mile along it beside the traffic. I was almost at the accident scene when a motorcycle cop pulled me over.

  He ambled up to my car in typical cop swagger style. “What the hell…,” he said to me as he leaned down toward the window.

  “Listen, Frank,” I said, “you want me to be at where I am going.”

  The officer took a closer look at me. “Hey, Doc,” he said flatly. He waved a hand to dismiss me.

  “How bad is this?” I asked him, but he was already walking back to his mot
orbike. He slapped the rear fender of my car. “They're gonna need you,” he told me over his shoulder. That was all.

  The ER staff and cops are natural allies. Only people from the ER know what cops know. Only cops and ER doctors and nurses know about provocation—that special in-your-face quality people in the street can have. It's the intuitive ability, perhaps the only talent these guys have ever displayed in their lives, to worm their way into your hidden store of hatred. Often it is hatred that you never knew you had and would otherwise never have suspected was there. It's invisible, even to the people who have a vested interest in finding it—ex-wives, lawyers, teenagers. Only a mean drunk in the middle of the night knows it's there and knows how to make you burn because of it.

  Not long ago we had a patient come in with a gunshot wound to the abdomen. The bullet had entered the epigastric area, the midpoint of the belly, and exited out the right flank, well away from the spinal cord. A fixable injury. But it didn't take us long to figure out why the man had been shot.

  The nurse asked him: “How old are you?”

  “Look, don't waste my time asking a bunch of stupid questions,” the guy said.

  We were searching his pants for his driver's license and came up with over $9,000 in hundred-dollar bills stashed in his coat pocket.

  “Do you have any health problems?” the nurse asked.

  “No, I don't have any goddamn health problems.”

  The surgical residents started to arrive. The first surgeon to walk in was the second-year resident. He looked at the guy and said, “Who shot you?”

  “That's none of your business,” the patient growled.

  “Do you have any health problems? Take any medicines?”

  “What the hell is this with all these questions? I just told somebody about my general state of health, and I told somebody about all the fucking medication I take. I'm not going to sit here answering the same fucking questions over and over.”

  “Sir, there are going to be a lot of us taking care of you. We're all going to be working hard to make sure you are okay, so you have to answer us.”