by Pamela Grim
But no more. It is time to come back to the present. Donna, now, is turning on the heart monitor and disentangling the spidery, pentapod set of monitor leads. The respiratory therapist has shown up, looking dazed by the light. Tim, the x-ray tech, has wheeled in the portable x-ray machine. He now leans against it, eyes closed.
I check my watch, wondering where the surgeon is. We all stand now in various slack postures, waiting. For what, nobody knows; we never know. Anything could roll through those doors. As I stand here, another trauma comes to mind. A year ago we had a kid come in via EMS, twenty years old—front seat, non-belted driver, airbag deployed—who seemed to have nothing wrong with him except his feet were slightly blue. Nothing, maybe, except he kept telling me he “felt funny.” Just as we were getting his chest x-ray, he crashed and burned, no blood pressure, no pulse, nothing, nothing. He died, right there in front of us. We never got anything back. His autopsy showed he had a ruptured aorta—a common injury in those accidents that involve an airbag and someone with no seatbelt. I was the one who went out and told his wife. They had been driving to Florida for their honeymoon. They had been married for six hours.
“But he was fine afterward,” she kept saying. “He said he was just fine.”
Inexplicable, another in a long line of inexplicable patients. What was God thinking?
As I ponder this, I can hear the warning buzz of the ambulance as it backs up into the ambulance bay. Here we go.
I think suddenly of B., in his white coat, demonless, sitting out in the ER proper. Aren't I still missing the point? I ask myself. Doesn't the ultimate case of the inexplicable boil down to me, my story? Who really cares about B.? What am I doing here? Was it really my grandfather? Is that how I came to be standing here in a trauma room in a smoldering ghetto in some rustbelt of a town in the heart of the Midwest at 2:47 in the morning, without enough sleep and with too much coffee, waiting for whatever might roll through the door? And in this case, whatever comes through the door could be thought of as, truly, anything.
The doors open. Mary shuffles in.
“Where's Surgery?” I ask her irritably.
She raises her hands. “Surgery's coming,” she says. “Don't get your knickers in a twist.”
Donna, fiddling with the monitor in the corner, says, “Sweet Jesus,” about something we cannot see.
The doors bang open again. This time it's the paramedics wheeling in a cart followed by some EMTs, some firefighters and a police officer. “Walking down the fucking street,” the firefighter is shouting as she comes through the door, while the lead paramedic shouts over her, “We've lost the pulse.”
The room fills quickly. Another typical disaster, routine chaos until I realize what's on the cart—a child, no more than three or four. A little boy. And the paramedics aren't in their usual sweating, paramedic mode. They look terrified.
“Talking at the scene,” the rear paramedic continues. He is holding a bag of normal saline aloft while trying to negotiate the turn with the gurney. “Family just got home from Alabama. Grandma was walking the kid to the house when the other car lost control. It hit him and then he hit a tree, we think.”
“How old?” I say but don't listen for an answer.
Donna is shouting, “Move it, move it, move it,” as the respiratory therapist stumbles past her trying to get at the Ambu bag. I push Mary Ellen out of the way to try to feel for a pulse at the kid's neck. As I do, everyone else crowds up, trying to pull the kid off the gurney onto the cart.
I grope for the pulse. There's nothing. The kid is blue, not breathing.
“Let's start CPR here, come on, come on. I've got to intubate.” I fight my way to the head of the bed, past Bill, who has climbed up on the stool to start CPR. There it is, all my equipment. But the endotracheal tube I have laid out is adult size, no way it will fit a four-year-old.
“I need a five, I need a size-five ET tube,” I shout as I paw helplessly through what's before me.
Meanwhile Donna is shouting, “Damn, damn, damn, damn, damn. We have a rhythm on the monitor here, folks. If that means anything.”
“Weird,” Bill tells me after a moment, “very, very…”
“Hold CPR. Check for a pulse again,” I say. I've found the size 5 tube and pull out a 4 just in case. I turn back to the patient. The respiratory therapist now lifts the mask away for me, and I get my first view of his face. It's bloodless, gray-white, blue at the lips. This is a very dead child.
“Heart rate of forty. Still no pulse.”
So here it is. How often have I seen it, that nightmare confluence of velocity and deceleration, cell disruption and denatured proteins, rarefaction and sudden impact, all that blind science of night and darkness that I know as surely as I am blind to the workings of all those other great mysteries, including the workings of my own heart? I stand there helplessly for a moment and then think, Intubate, intubate.
“Restart CPR. Epi, atropine. We need another IV.”
Who's saying this? Me? Donna? Mary Ellen?
I slip the blade into the mouth and peer down. This time it is going to be easy. There are the cords and I can see the beveled edge of the tube slip right through. No struggles here. It's textbook.
I straighten up, pulling the stylet out. “We're in,” I say. “Hold CPR.”
“I'm tellin' you,” Bill says, halting, “something feels very weird here.”
The respiratory therapist starts bagging and I watch the chest rise and fall as I fumble for my stethoscope—but this doesn't look right. Only the left side seems to expand. I listen: once, twice. Something, some kind of breath sound on the left, but not much. And on the right there is this weird hollow resonance, but not even a whisper of real breath sounds. I listen over the stomach—nothing there. The tube is in the right place, I'm sure. What is going on?
“You're not in,” the respiratory therapist says.
“No, no,” I tell her. By now I have my hands down on the patient's chest and feel for the first time the right chest wall. It gives way a little as I press, collapsing inward. Rib fractures. Several. I can feel them and I can feel as well fine crepitance, bubbles of air in the chest wall that collapse under my touch.
“That's all we need tonight,” Donna says. “A fucking dead kid.”
“No!” I say.
I know now what is going on. I press on the chest wall, which gives again, just like before. “Tension pneumo,” I say. “We've got to needle the chest.”
“Heart rate thirty-five,” Mary Ellen says.
Tension pneumothorax. The kid's rib fracture has torn a hole in the lining of the lung and as the lung collapses, a pocket of air forms next to it. With each breath the air pocket has gotten larger and larger, and now the lung has completely collapsed up against the heart, squeezing it so that the heart can no longer pump. Deadly, deadly, unless you fix it, and it is actually easy enough to fix. Just put a hole in the chest wall and let the air escape. The lung collapses back into place and the heart can start pumping again. You can save a life that way—once in a while.
I glance at the clock. The boy has been here for a little over three minutes, three precious minutes.
“Give me a fourteen.”
A 14-gauge angiocath, a whopper-sized needle to any doctor or nurse or paramedic who tries to fit it in a thread-sized vein, but still, so slender, really, no bigger than a very small piece of straw.
I take the package from Mary Ellen, strip off the paper cover and fold the plastic back. The needle, the plastic catheter sheath, the flange, the hub. I don't even look; I know what's there. I gently nudge Bill to move him out of the way. Now for the easy part. Go to the middle of the collarbone and then drop down about an inch or two until you are just above the third rib. Steady your wrist against the chest wall and then don't think, just act. Push the needle through the chest wall and keep going. Especially don't think about the fact that if you are wrong, you are making things much worse, tearing a hole in the lining of the lung—causing a pneumothor
ax, if one wasn't there before.
Push now. Now listen.
What you are listening for is a rush of air, the sound of a deflating balloon only just barely audible.
“I swear I hear something,” I say. “Check for a pulse.”
“Nada,” Donna says. She has her hand on the child's carotid.
Mary Ellen is looking up at the monitor. “Heart rate is coming up, though.”
We all look up. There it is: 52…54…55.
“Whoopee,” Bill says without enthusiasm.
“More epi?” Donna asks and then, “Wait a minute. I swear I feel something.”
My heart is everywhere at once. I put my hand on the child's right groin, searching for a femoral pulse. “I think…I think…Recycle the blood pressure cuff. Get the Doppler…Have we got that second IV? We need a blood gas for Christ's sake.” I keep barking orders, but as I do so I remain just standing there, not thinking, not moving, just feeling with my fingertips. Yes, no, yes, no.
“Seventy-five,” the respiratory therapist says. I look up at the monitor. Heart rate: 75…76…77.
“There is a pulse here,” Donna says. “Now I really can feel it.”
The blood pressure reading comes up: 45/30. Terrible. But there. The kid has a blood pressure.
“Would you look at that,” one of the paramedics says. I didn't realize they were all still in the room but they've stayed on. But then, this is why they are paramedics—because of patients like this.
“I don't believe it,” Mary Ellen is saying, a voice filled with wonder.
“Well, let's keep going, guys,” I prod. “We need a blood gas, chest x-ray. And where is Surgery by the way?”
But I don't want to go on. I've done this for so long that I know how deceptive things can be—maybe this is a tension pneumo, a save maybe, but saves tend to go sour again. Fix one thing and then discover something else just as lethal that you can do nothing about What I really want to do is just stay here in this moment. But I know what I need to do, go back to check out the lungs again, the heart, those pulses. Cut off the rest of the clothes, do a limited neurological exam…
Even here, in my mind's eye, I balk. It is one thing to save the rest of the body but what about the brain? How long had the kid been out without a blood pressure or a pulse?
“Repeat blood pressure seventy-four over fifty-two.”
“Miracle,” I breathe, despite myself.
Donna must have been thinking along the same lines as I because she sighs. “Let's hope it's not one of those bad miracles.”
“His hand is twitching,” Bill says.
We all look down. His right hand is motionless.
“No way,” Donna says.
Then it does twitch; we can see it. It jerks and the fingers start wiggling.
“The kid needs a chest tube,” I say. I finally unstick myself and go to the head of the bed, back in ER mode now, back to myself again, brusque, emotionless, and thinking, What next? what must I do next? because that's all that matters. Look after the kid's heart, stop thinking about my own.
The kid's other hand is moving now, fingers wiggling as well. I look down at the child's face. A small bruise runs along his right cheek. I think of his parents…his grandmother walking him to the house…all those parents…grandmothers.…I think of Nigeria…the little boy whose life we saved with that tiny IV cannula. I think of the tools in front of me, the laryngoscope, the blade, an ET tube, a monitor, a defibrillator, the chest tube, my hands…
“Leave this world,” I think suddenly, and despite myself, despite where I am and what's going on, I laugh. As if anyone, anyone here, could ever truly leave.
I can see now as I strip open the chest tube tray that there are no certain answers for me, no absolute solutions, no wise moves that will ensure my happiness. There is only the late night and Donna and Mary Ellen, Bill and me, the paramedics, Mary and the rest, all of us bent over this tiny figure, naked, hopelessly fragile, yet resiliently young and, I hadn't noticed before, now suddenly radiant—radiant with a kind of roseate flesh that seems lit up from within. I stop for a moment to look up at the monitor. Oxygen saturation: 100 percent; blood pressure: 129/68. Well, perhaps there is no clear future for me, but for this little one, I believe with all my heart, the future is an open book.
The paramedics start drifting out, satisfied, while we bustle around like mad, mumbling orders, repeating them, bumping into each other, swearing. It looks like chaos and it is chaos, but if you have specially trained eyes, you can see what all of us are thinking, and you can hear, as we stumble through our paces, what all of us are mumbling.
It is that this little one is going to wake up and live.
FOLLOW UP
BAFTI, HIS BROTHER IRFAN, AND DINI are currently studying in the United States.
Doctors without Borders won the Nobel Peace Prize despite my contribution to their overall efforts.
Dr. Daiquiri voluntarily surrendered his medical license after pleading guilty to thirty-one felony counts of trafficking in drugs. He was sentenced to five years in prison.
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