by Robin Cook
The central, cutting question remained: why should I be allowed to make such a decision? I felt somehow an accomplice of evil, an agent in this man's death. It's true that if I hadn't done so, someone else would have pronounced him dead; I was not necessary to the drama. That’s easy enough to say if you're not involved, but I couldn't dismiss the matter so quickly. I had made the decision without which the bearded man would not have been technically dead at this moment. We'd have had him all wired up by now, and we would have been pushing on his chest, breathing for him, keeping him legally alive. So I felt that, because I had cut off this possibility, I was the one responsible for his being dead.
Had I been too hasty in calling him DOA, in taking the easy way out? As soon as I said it, all the medical doors clanged shut. Had the decision gone the other way, in favor of an attempted resuscitation, my first move would have been to insert an endotracheal tube so that we could breathe for him. I had always found this a very difficult task. Maybe I had pronounced him DOA partly to save myself the trouble. Or maybe it was because I knew all the beds up in ICU were full, and figured that even if we did manage to resuscitate him, he'd only be another vegetable anyway. I now think these are questions without answers, but at the time they were driving me crazy. In that state, I walked out into the hallway to face the wife and child. The wife was tall and thin, almost gaunt, with dark, deep-set eyes. She wore sandals and some sort of floor-length granny dress. Up against its ample folds, really wrapped in it, was a little girl of about seven.
The situation was right out of a prime-time television program—"The Interns" or "The Young Doctors" — ingredients for either a dramatic or a terribly sentimental confrontation. The reality, again, was nothing Ben Casey would have recognized. Facing the dreadfully concerned and frightened wife and child was neither dramatic nor sentimental, only one more hurdle for me to jump. Perhaps an omniscient third party would have read more into it. I was hardly that. I knew what had happened in the room behind the curtains, but I had no idea what these people were thinking, what they needed to hear. Worst of all, I was hopelessly swamped in my own crazy thoughts about death and responsibility, about what might have been. I wanted to beg them to hear my lectures on the Krebs cycle or some other medical elegancy. How poorly medical school had prepared me for this. "Just get the concepts, Peters. The rest will come." The rest — death — you learned about by trial and error, and finally, gratefully, you did fall back on the comfortable stock phrases of television.
"I'm very sorry. We did all we could, but your husband has passed away," I said softly. The banal words rolled out, seeming good enough, really quite satisfactory under the circumstances. Perhaps I had a future in television. The only bothersome part was that business about doing all we could; we hadn't done anything. What I said, however, was only a stupid self-serving hypocrisy. It would pass. Wife and child simply stood there, frozen, as I turned and walked away.
Thank God no other patient was waiting to be seen. I signed the sheet of paper making it official that I was the reason the bearded fellow was dead, and then I went quickly into the doctors' room, slamming the door behind me. In the process I jarred off the wall a picture a drug firm had given us of a bunch of Incas opening up some poor devil's skull; but the Playboy calendar opposite only rustled a little in protest, and Miss December hardly seemed disturbed. I sank into an enormous old leather chair. It was a large room, with blank walls except for the Inca picture and Miss December. A low, crowded bookcase stood at one end, and a small bed and a lamp at the other. The chair I sat in faced the pale green wall that was supporting Miss December. I longed for my mind to become as empty as that room, and as placid.
Miss December helped; in fact, she had me mesmerized. What did Playboy have against body hair? Aside from the required abundance on top of her head, Miss December was as smooth as a piece of marble — no hair around her breasts, under her arms, or on her legs, and apparently none between her legs, either, although that was difficult to tell for sure because of the artfully draped Christmas stocking. Maybe Playboy was misjudging a good part of its market. I didn't think pubic hair was so bad. In fact, remembering the night before, I decided that Joyce Kanishiro's pubic hair was one of her most appealing features. No offense meant — if s just that she had very pretty pubic hair, and a lot of it. When she was naked, you saw it no matter what position she was in. I thought it would be hard to put Joyce on a Playboy calendar.
Miss December, Joyce, and the esthetics of body hair couldn't drive the bearded man entirely out of my mind. It certainly wasn't the first time death had confronted me in the ER. In fact, on my very first day on ER service, when I trembled to see even a patient with mild asthma, an ambulance had pulled in, its siren trailing off, and disgorged a twenty-year-old boy on whom the ambulance crew had been performing artificial respiration and cardiac compression. I had stood on the landing virtually wringing my hands and hoping that someone would call a doctor. This was ludicrous. I was the person they had been racing to, running red lights, risking life and limb.
I had looked down at the boy and seen that his left eye was evulsed. Its distorted pupil looked off into nowhere. What on earth could I do with that eye? Actually, I didn't have long to think about it, because the boy wasn't breathing and his heart had stopped. The crew rapidly informed me that he had not made the slightest movement since they picked him up, in response to a call from a neighbor. As they rolled him onto the examining table, I glimpsed a wound in the back of his head. I tried to get a better look at it, but my view was blocked by little pieces of brain oozing out of a hole about an inch in diameter, and I suddenly realized that he had been shot, that a bullet had gone through the left eye and out the back of the head. The nurses and ambulance crew stood by, panting from their efforts, while I went through my routine. It was sheer nonsense to fuss with my stethoscope — nothing would make any difference — but for lack of another strategy I put it on his chest. All I heard were my own thoughts, wondering what to do next. The intern is always expected to do several things, yet this boy was so dead he was practically cold.
"He's dead," I had said finally, after feeling for pulses.
"You mean DOA, Doctor? No arrest, is that right?" That was right, dead on arrival, The medical jargon was reassuring; it made me feel secure. That boy with the hole in his head had been very different from the bearded man. Sure, the hole had scared me half to death, and I had been greatly relieved to be rid of the responsibility of figuring out what to do with that eye. The main point, however, was that he had had a big hole right through his head that preempted any action by me; hence, I had felt little responsibility. On the other hand, even now, without the sheet that covered him, the bearded man would look quite normal, as if in a deep sleep. That's the thing about death from asthma. You don't find much even at an autopsy, unless the victim has had a massive heart attack.
Sitting in the doctors' room, I tried to picture Joyce Kanishiro in the center fold of Playboy. That would be something. She even had a few black hairs around her nipples. They'd have to touch up the photo a bit.
Joyce was a laboratory technician with a strange schedule like mine. That was no problem, but she did have one gigantic drawback: her roommate was always at home. Every time I took Joyce back to her apartment, the first few times we went out, her roommate was there eating apples and watching television. There was a bedroom, but it was never opportune for us to go into it. Anyhow, the roommate, a confirmed night person, would probably have still been there staring at the test pattern when we came out at 5:00 a.m. After a few nights of situation comedies followed by the late news and the late movie, I knew Joyce and I would have to change the locale.
My reverie about Joyce was interrupted by another memory, an episode that had taken place in the late afternoon some two weeks after I started ER duty. The same routine — siren/ red flashing lights — and this fellow had looked normal, too. As the attendants unloaded him and rushed him inside, they told me he had fallen fifteen stories on
to a parked car. Had he moved? No. Tried to breathe? No. But he looked normal, quite peaceful, somewhat like the bearded man only a lot younger. How long did it take to get him here? About fifteen minutes. They always exaggerated on the low side, to forestall criticism. With an ophthalmoscope, I looked into the fellow's eyes, focusing until I saw the blood vessels. Concentrating on the veins, I made out clumps that could only represent blood clots. "DOA," I said. "No arrest." I had been pretty upset about that case, too, although falling fifteen stories onto a parked car was generally conclusive.
Then the family had started arriving, in spurts— not the immediate family, at first, but cousins and uncles, even neighbors. It seemed that the man — his name was Romero — had lost his footing while painting the outside of a building. After the nurses called his wife to tell her that Romero was in critical condition, word of the accident had spread quickly, and by the time Mrs. Romero arrived the place was jammed with people demanding to know how he was and waiting to see him. As I informed Mrs. Romero of the death in my best quiet and confidential tones, she raised her hands to heaven and began to wail. Taking their cue from her, the rest of the crowd began wailing, too. For an hour or so from that moment I witnessed the most incredible and frightening performance by the Romeros and their friends as they, continued to drift in and engulf the ER. They beat the walls, tore their hair, screamed, cried, fought with each other, and finally began to break up the waiting-room furniture. I had no time to brood over the metaphysical implications of the case, being much too busy protecting myself and the rest of the staff. Interns have been killed in the ER That’s no joke.
Later I had seen in the pathologist's autopsy report that Romero's aorta was severed. That made me feel a little better. But I knew that the pathologist would probably find nothing so plainly wrong with the bearded man.
Dozing and musing in the old leather chair, I played with such thoughts and memories while Miss December's gigantic, almost hilarious breasts seemed to grow even larger. Joyce didn't have breasts like that. We had moved to my room to avoid the TV addict, and I vaguely remembered waking up at four-thirty that very morning as she left via the back door before anybody else was up in the quarters. It was her idea; I couldn't have cared less. But that was how we got away from Miss Apples and TV. It was a great schedule. During my twenty-four hours off, I surfed in the afternoon, read in the evenings, and then about eleven, after her work, Joyce would arrive and we'd go to bed. She was an athletic girl, who liked to bounce all over the place. She had great endurance, really insatiable. When she was around I didn't think about anything else.
But the hospital bed in my room made a hell of a lot of noise, and it was pretty small. When Joyce got up to leave at four-thirty or so, it always felt delicious to expand all over it, luxuriating in the spaciousness. For a while I had gotten up with her — it seemed the courteous thing — and waved as she went down the stairs and drove away. But lately I had just propped up on one elbow, watching her dress. She didn't seem to mind. This morning she had come over to the bed, all starchy white, and kissed me lightly. I said we'd get together soon. She was an okay playmate.
When the phone rang to wake me up three hours later, such a short time had elapsed that I half expected to see Joyce still standing there. I must have fallen asleep before she got out the door.
Saturday, busiest day of the week in the ER, 7:30 a.m. Even though I had been in bed for eight hours, I felt physically bankrupt and out of phase. It was that twenty-four-hour baloney. I had followed my usual routine, which started when I balanced against the sink and studied my bloodshot eyes and ended with my arrival at the ER at one minute after eight, as always. Strangely, despite a general tendency toward tardiness, I always managed to arrive promptly at the ER to relieve my colleague, who would slink off gratefully with blood-spattered clothing and drooping eyelids.
Until the arrival of the bearded man this had been a relatively quiet Saturday morning, with no big problems, only the usual procession of people who had dropped a steam iron on their toes or fallen through a plate-glass window. Everything had been handled quickly.
A half hour had come between me and the bearded man, and obviously nothing untoward had happened outside the doctors' room, else I would not have been allowed to sit there musing. My watch showed 10:00 a.m. I knew it was only a matter of time!
After a perfunctory knock, a nurse entered to say that a few patients were waiting. Feeling almost relieved at being tugged from my reverie, I went back into the daylight and took the "boards" the nurse had prepared. My hat is off to these nurses. They routinely escorted each patient into the examining room, took all the administrative detail, the blood pressure, and even the temperature if they thought it was necessary. In other words, they screened the patients very well. Not that they decided whom I should see, because I had to see everyone, but they did try to establish priorities if the place was busy, or to give me a little peace occasionally if it wasn't. Whenever a new intern arrived, I guess the nurses were tempted to handle everything alone, because most of the stuff that came in really didn't rate as an emergency.
But I was the intern and in charge, dressed in white coat, white pants, and white shoes, stethoscope tucked and folded into my left pocket in a very particular way, equipped with several colored pens, a penlight, a reflex hammer, a combined ophthalmo-otoscope, and four years of medical school— apparently ready for anything. In fact, really, only for the ailments I had already seen and dealt with. Considering that the variety of bodily ills approaches infinity, I wasn't ready at all. My inadequacy was like a shadow that fell away only when the place was jammed with crying babies and suturing to be done. After about ten hours, I usually got so tired that even if there were no patients I couldn't think. So the morning was toughest, just getting through to the afternoon; the rest seemed to take care of itself.
The first of the two new patients were a surfer who had been hit in the head with a board, leaving a two-inch cut over his left eye. He was oriented and alert, with normal vision. In fact, he was fine except for the laceration. I called his private doctor, who, predictably, told me to go ahead and sew it up. That was the way it worked. The patients came in, and I saw them and then called the private physician. If they had no doctor, we picked one of them, provided, of course, they had the means to pay. Otherwise they were considered staff patients, and I or one of the residents would take responsibility for treating them. "Suture it up" was the invariable reply from private doctors on these laceration cases. During the first few days I often speculated as to whether the private doctors then billed their patients for the suture, although we weren't encouraged to investigate that.
Actually, I was now rather good at knot tying and suturing, by virtue of having forced my way into several operations, including three hernias, a couple of hemorrhoids, an appendectomy, and a vein stripping. Mostly, though, I had gone on holding those damn retractors and, occasionally, cutting off warts.
Cutting off warts is an intern's reward for behaving himself; if s about on a par with hemorrhoid removal, although hemorrhoids are rather higher on the ladder. We had taken off dozens of warts in medical school, during dermatology, since the procedure was essentially without risk and well beneath a surgeon's dignity. My first Hawaiian wart had come with the Supercharger, a surgeon nicknamed for his matchless slow-motion incompetence. We scrubbed together on a simple breast biopsy, which is normally a thirty-minute job, unless you find a malignancy.
Not so with the Supercharger. He rooted around for an hour or so before sending off a little wedge of mangled tissue to pathology. I stood by hoping that the tissue was benign — luckily it was — and then the Supercharger closed the wound. Being an assistant on a breast biopsy is not a thrilling procedure under any circumstances; this one was made worse for me because I hadn't done anything, not even retract. When the Supercharger finished tying the last knot, he had stepped back, snapped off his gloves, and magnanimously informed me that I could now remove the wart from the wrist, which
I dutifully did — to the accompaniment of a lot of bad advice from the Supercharger, who couldn't understand why I wasn't more grateful.
My next operation, however, had been more involved; in fact, it had almost wiped me out. It was a vein stripping, and the surgeon was a private M.D. I had never scrubbed with before. As we washed our hands he told me that he expected me to do a careful job on my side. I blinked a little, knowing he had mistaken me for a resident, but I let the misconception stand. When I answered that I would try to do a good job, he told me trying wasn't enough, and that I'd either do it right or not at all. I didn't have the guts to tell him that I had never done a vein stripping before. I had seen several of them, but only from behind retractor handles; besides, I wanted to try it.
Needing to follow the surgeon's lead, I delayed beginning until he was well under way. The patient was a woman of about forty-five, with bad varicose veins. Having been assigned to the case only a few minutes before it started, I hadn't seen the patient beforehand, so I had to guess what her veins looked like when she was standing. Although I knew the theory, I wasn't quite up to the practice. It was like having read all about swimming, knowing the names of the strokes and the movements, having watched other people swim, and then getting thrown into deep water. My job was to make an incision in the groin, find the superficial vein called the saphenous vein, and tie off all the little tributaries. Then I was to move down to the ankle, make another incision, isolate the same saphenous vein there, and prepare it for the stripper. The stripper was simply a piece of wire, which I would thread up through the vein to the groin; after tying the end of the stripper to the vein, I would pull both stripper and vein out through the incision in the groin. That was what I was supposed to do, and I knew it by heart; I'd read about it, watched it, and thought about it.