by Pamela Grim
Or that case last month when a sixteen-year-old driver struck another car that was driven by a woman who was eight months pregnant. It was just a fender bender, neither of them more than just shaken up. When the police arrived a few minutes later, the kid told them, “It was my fault, my fault.” Ambulance 19 brought the woman into your ER, where you watched her for a couple of hours and then released her. The kid refused ambulance transport, went home, shot himself in the head and came in, just as the woman was leaving, as a traumatic arrest. He had left a suicide note that you found pinned with a safety pin to his plaid flannel shirt. The note read in its entirety: “Brain dead.”
There was the thirty-four-year-old mother of three whose mild right-hand weakness on admission evolved into a massive stroke that left her completely paralyzed, but—and this was the saddest part—still alive. You were in the grieving room for what seemed like years that day, sitting across from the husband, watching him sob helplessly, while next to him the three kids, the oldest only eight, watched him and cried as well, although they didn't know why…
There was the beaten baby, dying as you tried desperately to get an IV in somewhere, anywhere…
And there was that mother of a gunshot victim, a kid shot by the police in a drug raid. You went out to talk to her, and she stood there in the middle of the ER waiting room, screaming right up in your face that she would kill you, you motherfucker, she'd kill you if anything happened to her son. And you were pissed.… “For Christ's sake,” you screamed back at her, “why are you yelling at me? I didn't shoot him. I'm just trying to save his fucking life.…”
Then comes the day of the industrial accident, the day you almost get killed.
It started at a freeway overpass, a city construction project that city hall is trying to get done on off hours so the traffic doesn't get backed up. One of the crew, who is up on a ladder, leaned out too far trying to disentangle a piece of rebar and fell twenty feet onto a cement truck. He came in a total train wreck. It took an hour just to sort all the injuries out. Bilateral ankle fractures, a femur fracture, a pelvic fracture, a distended, tender abdomen and a depressed skull fracture. Your job now is to try to patch this guy back together enough so that the surgeons can take him to the OR. It is a routine couple of hours of adrenaline-fueled chaos. Fluids, intubation, x-rays, calls to the orthopedic surgeon, the thoracic surgeon and the neurosurgeon. You are working frantically—running back and forth from the patient to the CT scanner, to the x-ray view box, and then back to the patient—when at one point your way is blocked by a patient in a wheelchair, one leg rest hoisted up, who has wheeled himself out into the hallway. He grabs at your coat as you pass. “When am I going to be seen?” he growls.
You take him in with a glance: sport coat, tie, leather briefcase at his side, clearly an entitled asshole with an ankle sprain.
“Sir,” you say, “we had a bad trauma case. We're all tied up with that. I'll see you as soon as I can.”
“I have been waiting for over an hour.”
You are not in the mood to humor idiots today. “You're going to be waiting a little longer. I've got a sick guy in here and he comes first.”
“Well, get me another doctor.”
“I'm the only ER doctor here,” you say grimly and stomp back to your critical patient, muttering darkly to yourself. By now the orthopedic surgeon has arrived. He stands tsk-tsking over the x-ray images at the view box. You pause behind him and both of you stand there marveling at how badly bones can break. “Humpty-Dumpty,” is all the orthopod says.
The neurosurgeon shows up shortly after. He is in a pissy mood. You are not sure why; after all, this is the first patient with insurance you've had him see all summer. But the neurosurgeon barely looks at the patient; he just stands mooning over the CT-scan images. Apparently he sees a small subdural hematoma, a crescent of blood clot located just under the skull fracture. You missed it when you hastily reviewed the scans.
The neurosurgeon is livid. “If I'd known this…” he tells you pointedly, jabbing the scans with a finger that looks too wide and stubby to belong to someone whose job it is to tinker within the brain. You stand scratching your head; you can't think how it will change the management all that much. The patient needs to go to the OR and have the depressed skull fracture fragments lifted back into a seminormal position. So the neurosurgeon has to vacuum out a little blood clot as well? What's the big deal?
“Why didn't you tell me this guy was a total fucking disaster?” the neurosurgeon whines on. You shrug. You thought you made that pretty clear. “And what about his heart? If I'm going to take this guy to the OR, I would like to know more about his cardiac status. Did anyone even think of calling in cardiology?”
You pedal back across the hallway to ask Mary to page the cardiologist on call. By this time, also by the desk, the man with the ankle sprain is standing squarely on both feet, yelling at Mary, “I need a doctor now.” Then, when he sees you, he shouts out, “I can't walk!” You hadn't noticed he was crazy before, but now you see that the suit coat is shabby polyester, several sizes too large, and that the tie is a weird bloody-maroon color that no businessman would wear.
“Well, you are doing a great job of standing,” you tell him irritably as you pass by. Beyond him, a police officer leans up against the desk beside a hunched-over man in handcuffs. Even from behind you can see, by the way he has his head ducked down, that the man in handcuffs is sick.
“What's going on?” you ask the cop. You know this cop. Mike something. Everyone calls him Mikey. You treated him for an ear infection the week before.
“Heroin withdrawal,” Mikey tells you.
The man turns toward you. His face is that putty color you usually see only on the freshly dead.
You had forgotten that this is Sunday, heroin withdrawal day. It's a police thing. They like to bust heroin addicts late Friday afternoon, just after the courts close. Then an addict can't get bonded out until Monday morning, when the courts and the bail bondsmen open back up for business. An addict will be stuck in jail with no hope for dope all weekend. Friday night, Saturday morning, noon and night. Withdrawal time. By Sunday at noon—after thirty-six hours off the stuff—a hardened career criminal who wouldn't tell a cop the time of day if he thought the cop wanted to know, was now clinging to the officer's leg, ratting out his own grandmother, anybody, everybody, just to get out and get another fix. That's when the cops would start asking serious questions.
So this was just another Sunday morning heroin withdrawal patient.
You pat Mikey's back. “You should be in church,” you say.
“Mea culpa,” Mikey responds. You pause for an instant to glance at the patient.
Usually you have a less than compelling clinical interest in these patients, but today there is something that touches you about this man. It's always hard to guess an addict's age, but he looks over fifty—an old man for a smackhead. A survivor. But survivor or no, you can tell he is at the end of the line. You pause beside him for a moment, wondering how often lately you've felt exactly that way—the way he looks now, the sorry bastard—and, as you think this, you feel a weird sideways beat of your heart accompanied by a murmur of melancholy. Well, you think, at least you can do something for this burned-out dude, since there seems to be nothing you can do for yourself…
It isn't that it happens so fast that you almost don't see it, it's that it happens so casually, almost as if the man with the ankle sprain is reaching into his own pocket instead of over to the officer's holster, where he fumbles for a moment before coming up with a gun, the officer's gun. The other hand pats at the maroon tie as the man steps back out of Mikey's reach. With the gun wobbling in front of him, the man begins looking beyond the heroin addict next to him and then beyond Mikey. He lifts the gun, which seems to wobble drunkenly in your direction. It takes a moment for you to understand he is trying to aim that gun at you.
You stand there, frozen. Someone else shouts, although it seems to come from your thr
oat, “Look out! A gun!” That's when the ankle-sprain patient, trying to control the trembling gun, lifts his arm, still aiming right at you. There is a hollow noise, like fake gunfire on late-night TV. Move, you scream to yourself, and finally you unfreeze and go down to the floor, rolling around to the other side of the desk.
There is shouting from everywhere and echoes of the gunshot that recede immediately. All sound suddenly vanishes, evaporates. Then the patient screams, “I—want—my—x-ray—now!”
You huddle against a file cabinet, not sure if you have been shot. There is blood on your hand and you wipe it on your shirt, wondering if this means you are going to die soon. Then it seems as if a moment dilates, doubles and triples, because you find the time, really no more than a single soft heartbeat, to think, No, no, no. I'm alive. It's okay. I can't be hurt, I can't die, I'm immortal. Then with another heartbeat you wonder how many people go down, all the way down to their death, with that thought in their mind.
Then you think: Mikey! Did he actually get shot? Was the gun really pointed at him and not at you? Where is he? And just as you think this, you realize that Mikey is right beside you, down on his knees looking away from you. That's also when you realize that you can't see where the man with the ankle sprain is. He looked straight at you as he shot. Now you know he is searching for you. As you sit there, back against the file drawers, you realize that the patient with the gun is going to come around the corner any second and here you are, the sitting duck.
You turn to get on your hands and knees, then you creep to the edge of the desk and peer around. On the other side of the hallway, behind the crash cart, two of the nurses, Nancy and Jesse, lie, heads flat on the ground. Are they shot? Are they dead? Beyond them, issuing from the acute room, is the only sound—the magnified electronic bleat of the monitor pacing off the heartbeats of the industrial-accident patient.
Just as you recognize that sound, you hear another, a crack, which you realize is not the sound of another shot but the sound, resonating through the suddenly noiseless ER, of someone out in the triage area stepping onto the rubber floor mat to trigger the electronic door to open. Didn't they hear the gunfire? you wonder. What idiot was trying to get in here when everyone else is desperate to get out?
The door swings slowly open with a buzz you had always heard but never really noticed. You know that when the door opens all the way, whoever is standing there will be completely exposed to the patient with the gun. You also know that if you shout something, try to distract that patient, whoever is at the doorway might have a chance to get away. But then the patient would be doubly sure where you are. The small shout that you muster dies in your throat. You can only put your hand out, and as you do, you see the door swing wide open. A woman in a blue suit, no—a police officer—a woman police officer, Mikey's partner, is now standing in the open doorway. She must have been out in the waiting room. She has her hands up, clasped before her, pointing a gun into the room. There are three sharp booms. Glass breaks; then there is a loud cascade of thumps as something weighty strikes the desk, tumbles and then hits the floor.
The officer lets the gun drop a few inches and then fires again, twice more. Then she stands there in the doorway, the gun still pointing out in front of her into the ER. You stay frozen, too, a hand to your heart.
A shadow forms behind the officer. It is Mary Ellen, the triage nurse of the day.
“It's okay,” she tells the officer. “It's okay now, it's okay.” She put a hand out and brings the woman's arm down. The only other sound is the echo and reecho of the gunfire in your ears.
You and Nancy are the first ones up, both of you scrambling out to the front of the desk. The ankle-sprain patient lies crumpled, face forward, on the linoleum tile. He has one arm flung out; the gun is just beyond his fingertips. You go for the gun first, and as you heft it, you realize it is just as dangerous in your hands as in the patient's; the weight alone feels lethal. Beside you, Nancy has put her hands down around the patient's neck, an intimate gesture, as if she was gently choking him. Then you realize she is checking for a pulse. You look up at her.
She shakes her head. “I'm not getting anything.”
“Get a gurney,” you tell Mary Ellen.
It is more of a brawl than a resuscitation. By the time you get him up on the gurney, the guy is cyanotic, purple-hued and gasping like a fish. His shirt blooms with red blood, exactly the color of his tie. You tear open his shirt and find a bullet hole on the right side of his chest between the sixth and seventh ribs. You grope around and find the exit wound just under the armpit. Through and through; nailed him in the lung.
“Get a chest tube set up,” you yell at Jesse.
You could be a Keystone Kop. Every piece of equipment slips out of your hands; you can't find the landmarks; your hands shake as you heft the scalpel. But you get the chest tube in and when you do, the blood pours like a mighty tidal wave from that sucker's chest. Miracle: you get a pulse back and then a blood pressure. You've saved his life, for the moment anyway.
The bullet must have hit a major blood vessel in the lung, though, because blood just keeps pouring out of the chest tube, almost as fast as you pour type O blood in. This patient's pressures hang in the 80s, systolic. He's confused and combative, fighting off everything and everyone while you frantically try to find a surgeon willing to come in and take him to the OR. The thoracic surgeon on call is still up with the industrial medicine patient—removing his spleen, it turns out, and every other surgeon on staff is either in the OR or otherwise conveniently unavailable. Nobody wants this guy. Who can blame them? You are asking a surgeon to cancel an afternoon of paying patients in order to take some madman to the OR. One of the surgeons tells you bluntly: “It's not my problem. I'm not on call.” Meanwhile, back in the trauma room, security is strapping the patient down while Donna shouts, “Sir, could you lie there and be quiet so we can save your fucking life?”
Finally Dr. Love, who wears his cowboy boots even into the OR, cancels the rest of his appointments for the day and waltzes in, a hero of the first water.
The only other injury in the whole disaster is to you. You aren't sure when it happened, but you now sport a bloody streak on the left side of your neck. Either you brushed against something sharp or a bullet brushed against you. You retreat into the bathroom to check it out and find the police officer on her knees on the floor, vomiting into the toilet bowl.
“I'm all right, I'm all right,” she keeps saying, trying to wave you away.
By now the place is acrawl with cops and plainclothes detectives. Everyone wants statements, but all you can remember is a trembling gun pointed like a nightmare right in your direction. His gun, her gun. You can't be sure.
You and Donna, the charge nurse, sit for hours working on the incident report, the standard method of reporting any hospital problem. Donna's bitching; the cops are all bitching as well. “I'm going to be filing reports for the next fifty years,” the district officer tells you bitterly. This is what terror devolves to: paperwork.
Then it's over. And yet it's never over. Your hands shake on the drive home, but after a stiff drink, you fall into a sleep that is deeper than any you have had in years. You have this dream that you still have every once in a while. This first time you have it, it doesn't even feel like a nightmare. You wake up fine—at least that's what you tell everyone. “Not to worry.” And everyone seems to believe you, though they probably don't believe you as much as you believe yourself. This job can't get to me, you think, not me.
The truth is, though, that it already has.
Six months later comes the day you blow up, the day of the great temper tantrum. In one way what happens has nothing to do with the day the man with the sprained ankle tried to kill you. In another the two events seem ineluctably welded together. A line connects one day to the other, a line that points straight down.
It is another busy Sunday, so busy you can't possibly keep up. Patients are pouring in—no one sick—just the walki
ng wounded. But there are so many…And nothing is going right. The labs are taking forever; the x-ray tech disappears and is finally found sleeping in the break room. Because of two call-offs, you are two nurses short; three if you count the fact that you are working with Louis, the world's most incompetent ER nurse. The first patient of the day is a full arrest, an elderly woman with multiple medical problems. Her death shouldn't have come as a surprise. But the family goes bananas, screaming, wailing, carrying on out in the waiting room. “It's your fault she's dead,” her daughter screams at you. “I'm going to sue this hospital for everything it's got.” Then the blood gas machine breaks down. And through it all you keep getting ambulance call after ambulance call. “This is seventeen, we're coming to you with a forty-four-year-old woman with a headache.…This is twenty-four…ninety-year-old female, first-time seizure…nursing home patient…DNR.…Ambulance eight…John Doe found down…bystanders were doing CPR but it looks like this guy is just dead drunk.”
You stand for a moment and watch the paramedics unload a drunk old man who looks like he doesn't have many binges left in him. Maybe, you think idly, maybe you can develop a yardstick to measure that sorry-assed, end-of-the-line look, that look of loneliness and late-night sorrow. If you could, you would have a new vital sign, a clinical tool that could tell you how close someone was to life's dead end. You could use it on all heroin addicts, on the would-be suicides and burned-out cocaine addicts, the hookers, the police officers, the late-night truckers, the other night dwellers. Above all you could use it on yourself.
About one o'clock you pick up a new patient's chart. It's a woman whose boyfriend has “the drip.” That means another pelvic exam, and you have already done three today. You wade back to the “pelvic” room and find a sullen woman with an even more sullen boyfriend crouched in the corner. “You have to leave,” you tell the boyfriend, who rolls his eyes and takes his time ambling out the door. He is wearing a T-shirt that reads NUMBER ONE COP KILLER on the back along with a splash of fake red blood.