As usual the room was packed with everyone who was coming on, everyone who was going off, plus techs, nurses, and medical students. I excused myself and pushed over to Mac.
“Mac, how’s the kid with the gunshot wound?”
He frowned. “Svendsen, the one from Wayzata?”
“No, the one who came in yesterday. The one whose brother shot him.”
“Oh, yeah, that kid.” He rubbed his forehead. “Joe took out half his liver. We couldn’t get the damned thing to stop bleeding. Hell, we must have given him twenty units of blood in the OR. Then platelets, fresh frozen, everything.” He cupped his hands around his coffee and closed his eyes.
“So how is he?” I asked impatiently.
Mac’s head jerked upright again. He took a sip of his coffee. “Well, he made it through surgery. I don’t know what happened after that. Ask Jerry. He’s been up in ICU with him. I’ve been down here. We had a special on drunks last night. In fact, I personally established an all-time Mayo Clinic record. I had no less than four drunks tell me they were going to beat the shit out of me as soon as they got out of here.”
“Did you tell them they’d have to get in line?”
“No, jerkoff, I gave ’em your home phone number and told them you said they were a bunch of pussies and you could kick their ass.”
It was ten o’clock before I could get to the ICU to check on the kid. I looked at the chart next to his bed. Larson, that was his name. Jeff Larson.
His eyes were closed. I reached over his IV lines and touched him on the shoulder. “Hey, Jeff,” I said. He didn’t respond.
I started leafing through his chart. We were having trouble maintaining his pressure. His urine output was negligible. His lytes and labs were all over the place: SGOT up, hemoglobin down, amylase up, sodium down, BUN up, potassium down.
I looked at his belly and saw greenish-brown fluid seeping through the gauze. I wasn’t sure what it was—blood, bile, betadine, pus, feces? I had just finished changing the dressings when Joe Stradlack came in. I gestured questioningly at the drainage.
“Bile,” he said, “and a little blood, probably.” We stepped into the hall. Joe told me he didn’t think the kid was going to make it. “He had a hole the size of my fist right through his belly—liver, gallbladder, colon, intestines, everything. I don’t know how he didn’t bleed to death right there in the woods.”
We went out to talk to Jeff’s family. The parents, an older couple with their arms around each other, listened quietly. Jeff’s brother, the one who shot him, stood off to the side. He hadn’t left the hospital since they brought Jeff in. He was sober now, and I could see the anguish in his red-rimmed eyes.
We’d better be careful with him, I thought. He’s one who could go home and shoot himself when this is all over.
When Joe finished laying out the facts for the family I tried to help the brother. “You saved him,” I said. “Sticking that shirt in his wound kept him from bleeding to death. We never would have had a chance with him if it hadn’t been for you.”
He said nothing. He just shook his head and walked away.
I turned to his father. “Mr. Larson, there isn’t a lot you can do for Jeff, but your other son…” I nodded at the brother, standing alone at the end of the room, his back to us, looking out the window. “Accidents happen,” I said. “It’s no one’s fault. Your son, well, he’s taking this pretty hard.”
The old man held up a hand, and exhaled in disgust. Maybe he thought his son should take it hard. Maybe he blamed him for what happened to Jeff.
But I wasn’t going to let it go. Two weeks before we had taken care of a man who lost control of his car and hit a little girl. He had just a few cuts and bruises. The girl, however, was seriously injured. We weren’t sure she was going to survive.
The man was wracked with guilt. Although his blood alcohol was below the level of legal intoxication, he had been drinking, and had been given a ticket for negligent driving. He blamed himself for everything. He kept asking us if the girl was going to be okay. We assured him we’d do everything we could for her. But he continued to pace around, agitated and distraught. We finally got his cuts cleaned and dressed, and sent him home. Three hours later the paramedics brought him back. He had blown his brains out.
Jeff’s brother had that same haunted look in his eyes. I tried to spell it out as clearly as I could for the father. “Look, Mr. Larson,” I said, “if you don’t want another tragedy on your hands, you go to your son and tell him that you know it was an accident and you forgive him.”
The old man finally understood what I was saying. He looked shocked and then terrified. “Oh, Jesus,” he muttered. He turned, walked directly over to his son, and began speaking forcefully. After a minute, the son, who had been staring at the ground the whole time, lifted his head and looked at his father. They hesitated for a moment, then took a step forward, embraced, and began clapping each other gently on the back.
I was with Jeff when he died later that night. It was the first time I had ever seen someone die, and it wasn’t what I expected. It was so matter-of-fact, so ordinary. His pressure dropped, his heart quit, and he died. That was it. I stood there waiting for something momentous to happen, for someone to say something profound, but there was nothing. The nurse sighed and turned off the IV, the respiratory tech disconnected the oxygen, and the secretary called the morgue.
I still had the childish notion that since my life was so important, all lives were so important. Since my death would be so cataclysmic, all deaths would be so cataclysmic. When I saw that nothing happened when Jeff died, I realized that nothing would happen when I died. Life went on without Jeff Larson, and life would go on without Mike Collins. The nurse would sigh and turn off the IV, the respiratory tech would disconnect the oxygen, and the secretary would call the morgue.
I wondered if all the truths I would learn in medicine would be this difficult to ignore.
Chapter Six
October
Not every patient we cared for on ERSS had major trauma. Vern was a forty-year-old guy with a bushy red mustache and a fishhook up his nose. He had been fishing on Lake Pepin when his brother’s cast snagged him. The hook had embedded itself somewhere deep inside the nose. The eye of the hook, with a small monofilament knot still attached to it, glittered in the entrance to the left nostril.
Joe Stradlack thought this would be an excellent case for a junior resident to tackle. “If you do a good job,” he said, “we may let you lance a rectal abscess sometime.”
A rectal abscess. Oh, gee, could I?
I numbed up Vern’s nose, but after that everything seemed to conspire against me: the mustache, the lighting, the exposure, the bleeding. I shaved away part of the mustache, but still couldn’t see the tip of the hook. My plan was to use a small wire-cutter to snip the shaft, then I would try to wiggle the hook free. If I could spread the nostril a little wider I might be able to see better.
I had an idea. I turned to one of the nurses. “Get me a pediatric vaginal speculum.”
“Bull shit!” Vern bellowed from under the drapes.
“Vern, relax. It’s been cleaned and sterilized. It’s perfectly fine.”
“I don’t care what it is. You’re not sticking one of those things in my nose.”
So, did he want to go through the rest of his life with a fishhook up his nose?
“Fine,” I said. I turned back to the nurse. “Get me the nostril dilator.”
She stared at me uncomprehendingly. “There’s no such—”
“You know. The chromium-handled, fishhook-extracting nostril dilator?” I did everything but wink at her.
“Oh,” she said. “Oh, yes, the nostril dilator.”
She opened the gyne cart and handed me an instrument.
Fifteen minutes later I had irrigated away enough blood and had dilated the nostril enough to snip the shaft of the hook. Now I just had to tease the barbed point out of the tissue. It was not going well. Vern was having a
hard time holding still. Perhaps the fact that he had a vaginal speculum and half a hardware store stuffed up his nose was part of the problem.
“How buch logger is diss gudda take, Doc?”
“Hang in there, Vern. I just about have it.”
“Dat’s what you said tweddy bidutes ago.”
“Have you ever tried to take a fishhook out of someone’s nose?”
Finally, I slid a small, curved-needle holder deep into the nostril. I grasped the hook and pushed it through the tissue and out the skin of the nose. I reached around and pulled the hook out.
Vern let out a hideous scream and leaped off the cart. “Ow! Fuckin-A! Oh, my nose! Jesus Christ! Fer da love a’ Cry-yi!” The vaginal speculum was still dangling from his nose. I must have hit a small artery because bright red blood was gushing from both inside and outside Vern’s nose.
“Vern, would you please—”
“I’m outta here,” he said. “I’m the fuck outta here.”
“Vern, we’re all done. I just want to—”
“Fuckin’ right you’re all done.” He ripped the sterile drape off his chest and started walking to the door.
“You can’t leave. You’ve still got the—”
He reached up and grabbed the bloody speculum and yanked it out of his nose. He stared at the speculum, his eyes narrowing. “It is,” he said. “It is one of those things.” He gave me a look of disgust, threw the speculum in the corner, and stomped out the door just as Joe Stradlack came back.
“Collins,” he said, “what the hell’s going on here?”
“Mr. Merven’s not very happy. Apparently he has more pressing business elsewhere. I got the fishhook out, though.” I held it up for him.
“Took you long enough,” he said, looking at his watch.
I shrugged my shoulders and began peeling off my gloves. “So, does this mean I’m not going to get to lance any rectal abscesses?”
Twelve hours later I was assisting one of the senior residents on an appendectomy. Halfway through the case we were told there was an emergency in the ER. The senior resident let me close while he headed down to help. I finished up, brought the patient to the recovery room, and wrote the post-op orders. Then I spoke with her parents, letting them know everything had gone well. I took a minute to splash a little water on my face and then went back to the ER.
The place was packed. There must have been fifteen people crowded around a cart working on a young woman. I asked Amy Watkins, one of the nurses, what was going on.
“She ruptured an artery or something. No one knows,” Amy said. “She was in full arrest when she got here.”
“How long have they been working on her?”
“Long time,” she said. “The paramedics started CPR on the scene and we have been doing it for almost half an hour now.”
That meant her chances were poor. I glanced over at her. She was a young woman, about my age. Her gray face was partially obscured by the ET tube and the Ambu bag they were using to breathe for her.
“Who are all these people?” I asked, nodding at the crowd.
“Well, besides ERSS and the code team they have the Neonatal team here, too.”
“Neo? What are they doing here?”
“She’s forty weeks pregnant.”
“Jesus,” I murmured.
Joe Stradlack was standing at the foot of the cart running the code. The patient had three or four lines going in her. A team of anesthesiologists at her head was bagging her. Rollie Whitfield was doing chest compressions.
Suddenly Joe turned and looked into the crowd at the foot of the cart. “Is Neo here?” he asked.
“Yes,” one of the residents answered. She looked awfully young.
“Who are you?”
“Mary Whithers, Neonatal ICU.”
“What are the baby’s chances?” Joe asked her. He knew damn well what the baby’s chances were. I think he just wanted to see what sort of resident he was dealing with, whether he could trust her with what was to come.
“Well,” she answered falteringly, “even under the best of circumstances CPR will not adequately oxygenate the fetus.”
“So?”
“So the sooner you can deliver it the better—at least as far as the fetus is concerned.”
Joe nodded and turned back to the woman in front of him.
Oh, God, I thought. I know what he must be thinking. CPR had by then been going on for over half an hour. The woman had no rhythm. Joe had to make a decision. If he continued CPR, the baby had no chance. If he stopped CPR and took the child by C-section, the mother had no chance.
He hesitated just a moment, then grabbed a small cup of betadine, splashed it on the abdomen, and picked up a scalpel. He slashed once, twice, three times, spread apart the gaping wound with his hands, reached in, and pulled out a perfectly formed, full-term baby. He cut and clamped the cord, then handed the child to Mary Whithers.
Now everything changed. Now instead of being the anonymous observer in the back of the crowd, Mary was the center of attention. Everyone stopped and watched to see what she could do. Nurses, surgeons, anesthesiologists, and techs all stared at the child she now held in her hands.
The child, a girl, was still warm and slippery. Mary set her down, slipped an ET tube down her throat, and had one of the nurses begin bagging her.
“Does anyone else know how to do neonatal CPR?” she shouted. One of the anesthesiologists said he knew, so she let him take over the chest compressions. Joe did a cut-down on the child’s arm and got a large-bore IV going. Mary very calmly and systematically began giving resuscitation orders. She tried everything; she gave every possible drug, but the baby didn’t respond. Finally, in desperation, Mary tried intracardiac epinephrine.
Even when it became obvious that there was nothing else to do, she couldn’t bring herself to stop. This baby was not a premie. She was a fullterm, perfectly developed baby, the kind you see on the cover of baby magazines. This was supposed to be the beginning of her life, not the end.
After another ten minutes Joe Stradlack finally laid a hand on her shoulder. “Good job, Mary,” he said. “There was nothing we could do. We got them too late.”
Mary looked at him, too beaten to speak. She hung her head and let her hands dangle limply at her side.
As everyone started to drift away, I glanced at the still, gray figure of the mother lying on the gurney. The overhead lights were still trained on her. Someone had tossed a sheet over the lower half of her body. The ET tube dangled limply from the side of her mouth. Then I saw that one of the nurses had brought the baby over and laid her next to her mother. The two of them lay there side by side. I tore my eyes away. I couldn’t look anymore.
What the hell kind of world is this? I thought.
I looked at the tray littered with used syringes, needles, vials of meds, bloodstained 4×4s, scalpels, and hemostats: the paraphernalia of futility.
In the corner of the room Mary Whithers was standing by herself trying not to cry.
I thought Joe gestured to me to follow him. I don’t know, maybe he didn’t. I wouldn’t have followed him if I had known where he was going. This was the part I couldn’t handle, the human part. Joe had to go tell a young husband we had failed. His wife and his baby were dead.
Joe took the husband’s hand, and struggled to find words. “I…I’m so sorry to tell you that…”
He said we were sorry. We were heartbroken. We had tried everything. We would have done anything. Everything that could be done had been done. And then the man thanked us. He shook our hands, even mine—I, who had done nothing. This was too much. I wasn’t ready to be thanked. I wanted to punch myself, or the world, or someone. Mothers and babies shouldn’t die!
I let the man shake my hand, and then I walked out of the ER. I leaned against the wall rubbing my left hand over my right, overwhelmed by what had just happened. It was quarter to seven. The halls were full of clean, fresh, young doctors and nurses, reporting for duty. They had bee
n sleeping all night, had gotten up, showered, and come into work. For them it was the beginning of a new day. For me it was still one long yesterday.
I had a few minutes before morning report. I thought I’d better go check on that girl whose appendix we had taken out. Numbly, I waited for the elevator. When I got in, Jack Manning, showered, shaved, and bright-eyed, was standing there. He smiled and said hello. He could see I had been on call.
“Hey, bud,” he said. “How was your night?”
Chapter Seven
November
It was my last week on ERSS. I dragged myself in the back door, not watching where I was going. Eileen, who had heard the car pull into the garage, was sitting on the floor waiting for me. I stepped on her foot, stumbled forward, and whacked my shin against a chair.
“Goddamn it,” I barked as Eileen started to cry.
“You stepped on her,” Patti said, rushing to pick her up.
I sat down and rubbed my shin. “What the hell was she doing right inside the door anyway?”
“She was waiting for you. She hasn’t seen you in two days. And then you go and step on the poor thing.” She turned to Eileen and began stroking her hair. “It’s okay, sweetie. It’s okay.” Eileen, sobbing, shoulders shaking, was clinging to Patti’s neck.
I ran a hand across my face. I didn’t need this. I had managed only a half hour of sleep the night before and had been second-assisting at some boring-as-hell belly surgery since 10:00 A.M. I wanted to walk in the back door of my house and be left alone. I wanted peace, quiet, no one telling me what to do, no beeper, no demands. I wanted to turn off my brain and my senses.
Jesus Christ, I thought. Can’t I get two seconds’ peace in my own house? My kid is screaming. My wife is bitching. I don’t need this. I get enough of it all day and all night at work.
Six weeks on ERSS had taken a lot out of me. I had witnessed a seemingly endless procession of gunshot wounds, amputations, ruptured bowels, car crashes—and death. Yes, I had seen a lot of death. But I didn’t dwell on it. Dwelling on death wasn’t pragmatic, and above all I had learned to be pragmatic. Things that would have appalled me two months before now seemed routine. There were so many tragedies, and I was so busy, so tired. Resigned indifference was the only way I could keep myself from being swallowed up.
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