Hot Lights, Cold Steel

by Michael J. Collins

  My bloody hand, removing the last shred of Ben’s brachial plexus, was neither bloody nor mine. The plexus was neither severed nor brachial. It was merely a white target in a red-black hole. I could avoid the implications of my actions by ignoring the context in which they took place. They were isolated acts, devoid of meaning or greater significance. But I couldn’t deceive myself forever. The hand that emerged from that gaping wound was not the hand that had entered it, and the eyes that finally turned away from that mangled corpse were not the eyes that first registered the gory scene.

  I picked up my shaving kit and walked into the bathroom where I brushed my teeth and splashed some water on my face. As I dried myself I held the towel against my eyes for a few seconds, then draped it over the sink. I had no interest in seeing the face in the mirror.

  Why couldn’t I just take things as they came? Why was I continually looking for reasons and meaning? Reasons and meaning are not pragmatic. They are not the stuff of residencies. BJ Burke was not interested in what I thought or understood. He was interested in what I did.

  “If you want to learn to be sensitive and introspective,” he would say, “do it on your own time.”

  I imagined myself being called into his office. As I enter the room he is seated at his desk, reading the report in front of him. He makes certain I know I am being ignored.

  At length he looks at me over the top of his glasses.

  “Dr. Collins, what is your job?”

  “My job, sir?”

  “You have a job, don’t you? You get a paycheck, don’t you?”

  “Yes, sir.”

  “Well, what do you do?”

  “I’m a second-year orthopedic resident at the Mayo Clinic.”

  “Do you want to be a third-year resident someday, Dr. Collins?”

  “Yes, sir.”

  “What is an orthopedic resident supposed to do?”

  Where was this going? “Follow orders?” I venture.

  “An orthopedic resident is supposed to practice orthopedics, Doctor. He is not supposed to go around asking patients if they have ever considered the ontological implications of their fragile, mortal state.”

  “I didn’t exactly—”

  He jumps to his feet and points his finger at me. “We fix things. Do you understand that? We don’t analyze things. We don’t discuss things. We don’t wring our hands and cry about things. We fix them! If somebody wants to be analyzed they can see a shrink. When they come to the Department of Orthopedics at the Mayo Clinic they want only one thing: they want to be fixed.

  “Now get the hell out of here and go fix things. And I better not get any more reports of touchy-wouchy, hand-holding sessions in this department.”

  I wondered how my colleagues dealt with this issue. I suspected they did as I did: they tried to ignore everything but “the fixing.” But isn’t even the least perceptive of us eventually bound to question what he is doing?

  What we were attempting to fix was, as BJ said, “our fragile, mortal state.” But mortality can’t be fixed. We can rod a femur or plate a radius, but sooner or later we have to confront the absurdity of what we do.

  But, of course, BJ was right when he said what we understand doesn’t matter. All that matters is what we do. No one cares how philosophically perceptive their surgeon is. They just want someone to fix them. There would be time for “all that philosophical crap” later. But that philosophical crap doesn’t go away. It’s still waiting for you when you get back to your call room late at night.

  I discussed this once with Jack Manning. Jack never seemed interested in delving into the deeper meaning of his work. He was content to fix what he could, and let it go at that. When I told him what was bothering me, he very accurately articulated the problem surgeons face, and then succinctly enunciated the appropriate response to it.

  “Shit happens,” he said with a shrug. And then, looking up, “Fuck shit.”

  It was 4:30 I had to make rounds in an hour and a half. I didn’t even bother to kick off my shoes. I lay down, shifted the stethoscope in my hip pocket so it wouldn’t dig into my side, and pulled up the blanket from the foot of the bed.

  “Fuck shit,” I said, and closed my eyes.

  Chapter Twenty-One

  January

  We were slouched in chairs in a second-floor classroom of the Medical Sciences Building listening to one of the research fellows drone on about biomechanics. Behind me I heard a chair scrape and someone softly sigh. I looked out the window and watched the branches of a snow-clad elm rise and fall in the cold north wind. Next to me Bill Chapin was drawing an anatomically correct picture of a naked woman.

  I leaned over and pointed at the picture. “What kind of vector force makes them stick out like that?” I whispered.

  “These,” he said, blowing off the erasure debris and holding up the picture for scrutiny, “are yet another example of the beauty and symmetry of nature.”

  In front of the class Dr. Hai Wong was discoursing earnestly about an esoteric biomechanical principle known as the Right Hand Rule.

  “Many orthopedic residents never master the concept of the Right Hand Rule. This is very sad.” He frowned and stuck out his lower lip to be sure we understood the concept of sadness. “The Right Hand Rule is very important. It appears on the Orthopedic Board Exam every year. If you don’t know the Right Hand Rule, you will flunk the Board Exam. You will remain a resident for four more years, living on macaroni and cheese.” He nodded slowly to impress upon us the terrible culinary fate that lay in store for those who did not master the concept of the Right Hand Rule.

  I looked out the window again. It was a beautiful day for skiing. I was imagining myself schussing effortlessly down a long hill of powder. My eyes drifted closed and my head began to sink forward on my chest.

  “Dr. Collins!” Wong said sharply.

  My head snapped up.

  “Explain the summation of forces in the Right Hand Rule.”

  I realized that I was being asked to provide enough rope for the good doctor to hang me. I obliged by mumbling something about perpendicular forces in a three-dimensional construct.

  Dr. Wong’s eyes bulged and he began drumming his fingertips together in front of his lips. “Dr. Collins,” he said, “are you particularly fond of macaroni and cheese?”

  We were into the third week of our Basic Science rotation, a six-month classroom stint during which we studied histology, biomechanics, immunology, and other nonclinical disciplines. During this period we were relieved of all patient-care responsibilities—no call, no beeper, no clinics.

  The six months of Basic Science marked the dividing line between junior and senior residency. When we finished Basic Science we would be senior residents. It was a time for study, but there was plenty of time for relaxation, too. It was like going back to college.

  Some of us had no problem slipping back into a college mentality. Frank Wales innocently asked Dr. Wong one day if he knew how to “make a hormone.” Dr. Wong patiently replied that not all hormones were amenable to re-creation in the laboratory setting. Frank shook his head sadly and said that was “a gol-dern shame,” and that he “surely would like to see someone up there in front of the whole class trying to make a hormone.”

  It was with some misgivings I had started Basic Science. I looked forward to a relaxing six months, but I had no interest in histology and biomechanics and immunology. I knew they were important disciplines. I knew that histologists and biochemists and immunologists were the ones who would someday cure cancer and eradicate disease. I respected and admired them. I just didn’t want to be one of them.

  From the day I started medical school I knew I was meant to be a clinician, not a researcher. Basic Science, with all the academic grunt work, was just one more boring hurdle I had to jump before I could get on with the real business of medicine: seeing and treating patients.

  But I also realized that these six months of Basic Science would give me the opportunity to catch up wit
h my peers. Even though I had closed the gap considerably, I still felt behind everyone else. Basic Science would be my chance to draw even.

  When our last class ended at 4:30, we shuffled out of the Medical Sciences Building, notebooks under our arms. The sun had already set but there was still enough light to see heavy clouds drifting in from the west. It looked like more snow was on the way.

  “Who wants to get a brew?” Jack asked.

  Bill shook his head. “I was thinking about heading over to the Rec Center to play some handball.”

  Jack turned to me. “Mike?”

  “Not me. I’m moonlighting in Mankato tonight. In fact,” I said, looking at my watch, “I have to get moving. I’m on at six.”

  “With that car of yours you’ll be lucky to get there by 6:00 A.M.”

  “There’s nothing wrong with my car.”

  “Yeah,” Bill said, jumping in to defend me. “Just because it has no brakes, no shocks, no muffler, and is hitting on five of eight cylinders doesn’t mean something’s wrong with it. It’s a car with character, a car for the ages.”

  “Yeah, the Dark Ages,” Jack said. “Anyway, the hell with his car. Do you want to get a beer or not?”

  “Decisions, decisions. I don’t know whether to play handball or drink beer.”

  “The bars don’t close for another ten hours,” I said. “Why don’t you do both?”

  They looked at each other. “For a guy dumb enough to drive ninety miles in a death trap, that boy is all right,” Jack said.

  “I’ll stop at home, pick up my gym clothes, and meet you at the Rec Center in half an hour. Now, you,” Bill said, turning to me, “better get a move on. At this very moment, just outside the town of Mankato, there is a drunken, infected, child-molesting, workman’s comp, biker dude who’s got his Harley cruisin’ at about ninety. He is all set to crash head-on into a four-hundred-ton semi. This gentleman is going to require your tender ministrations shortly.” He smiled. “Good luck, Doctor. With that car of yours, you’ll need it.”

  I said good-bye to Bill and Jack and trotted out to the parking lot. I tossed the biomechanics notebook on the front seat of my car. As I swung out of the lot, I popped the top of a can of Coke and headed west. The roads were clear, my gas tank was full, and I had an hour and twenty minutes to do the ninety miles to Mankato.

  Chapter Twenty-Two

  March

  I moonlighted every chance I got during my Basic Science rotation. I hoped to pay off all our bills and even put away a little for the future. I moonlighted so often that I could almost do the ninety-mile drive in my sleep. Sometimes I think I did.

  Although I moonlighted because I needed the money, I was starting to realize how much valuable experience I gained while moonlighting. I reduced fractures, drained infections, repaired tendon lacerations. Even the nonorthopedic things I did, things like caring for heart attacks and treating ear infections, honed my diagnostic skills and made me a better surgeon.

  Some weekends at St. Joe’s could be relatively quiet, but this weekend I was earning every cent they paid me. I had been working for thirty-four hours and had just two more to go. I had gotten three hours of sleep Friday night and managed another hour the next afternoon. But Saturday night had been a nonstop succession of the ill, the injured, and the intoxicated.

  The guy with the chest pain had finally been admitted to the CCU. The college kid with the broken hand from the bar fight had been casted and sent home. I was just finishing the prescription for the baby with the ear infection.

  “Give him one teaspoonful three times a day,” I said, handing the mother the prescription. “We’ve given him his first dose here, so you can wait ’til morning to fill the prescription.” The mother nodded, folded the prescription, and put it in her purse.

  “Did you ever have an ear infection when you were a kid?” I asked her.

  “No,” she said, shaking her head wearily, “never did.”

  “Me neither. But every adult who ever had one says it is the most painful thing they can ever remember.”

  We both looked at the baby who, thank God, had finally fallen asleep. Being careful not to wake him, I ran my index finger up and down his chubby, little forearm, feeling the baby-soft skin.

  “The ampicillin will fight the infection,” I said, gazing at the sleeping infant, “but it doesn’t do much for the pain. Be sure to give him some Tylenol if he seems to need it.”

  She nodded in understanding and gave me a quiet smile of thanks. She lifted the baby to her shoulder and in a moment they were gone.

  I was just about to go to bed when Johnny called back to say Helen Youngberg was here again. Helen was a thirty-seven-year-old woman with multiple sclerosis. She was a regular at St. Joe’s ER. Her parents brought her in at least once a week with one problem or another. Although Helen’s MS was worsening, she ignored her neurologist’s advice to stay in a wheelchair; consequently, she fell a lot.

  Helen had suffered the ravages of MS for fifteen years. She could barely walk, and because of optic neuritis she could barely see. Connie Fritz, one of the ER nurses, had known Helen for years. Connie told me she thought Helen was deteriorating mentally as well.

  When her husband had left her five years before, Helen moved in with her parents who were in their seventies. Her ex-husband remarried, moved to Seattle, and had nothing to do with Helen. “As soon as the going got rough the son of a bitch took off,” her father had told me.

  Helen’s parents were tough old Swedes. They never complained, but it was becoming obvious they were having a hard time caring for Helen. Helen, however, adamantly refused to consider a nursing home or long-term care facility. She kept insisting she was fine at home.

  Johnny pushed Helen, who was in a wheelchair, back to us. Helen was holding her wrist. Her parents, heads hanging, shuffled slowly behind.

  “She fell again, Doc,” her father said. “We’ve told her a thousand times to call us if she has to go to the bathroom but she got up by herself. Looks like she broke her arm.”

  “Hi, Helen,” I said. She didn’t answer. Even though I had seen her several times before, Helen appeared not to recognize me. Her wrist was swollen and angulated. “I’m afraid your wrist is broken,” I told her. “We’ll get some X-rays, and then I’ll try to put the bones back in position.”

  She was back from X-ray in fifteen minutes. The films confirmed a displaced fracture of the distal radius. I explained to Helen and her parents that I would have to reduce and cast the fracture. I scrubbed her wrist, then injected some local anesthetic into the fracture area. This would help but it never eliminated all the pain. Helen gasped as I mashed the bone back in position.

  When I finished applying the cast I told Connie to get some post-reduction films. While we were waiting, Helen’s father asked if he could talk to me. We stepped into the empty waiting room. “Doc,” he said, “do you think you could keep Helen here for a day or two?” He rubbed a hand across his forehead. “I can’t bring her home. My poor wife is wore out trying to look after her.”

  A wrist fracture is not sufficient grounds to admit a patient to the hospital. But I couldn’t bring myself to tell him that. The poor man looked terrible. He was seventy going on a hundred. I knew I could admit her if I made up some bullshit about neurovascular compromise or something.

  “Let me see what I can do,” I told him.

  I went back to Connie and told her we were going to admit Helen.

  “For a wrist fracture? They’ll never let you admit her for that.”

  “Yes, they will. Tell the supervisor she is being admitted for observation of her neurovascular status. She may need surgery.”

  Connie looked at me like I was nuts. I put my hand on her forearm. “Connie,” I said, “we can’t send her home.” I pointed at Helen’s parents who were slumped against each other in chairs along the far wall. “Look at them. They’ve done what they can. It’s time to find another solution.” Connie nodded. She called the nursing supervisor to
make arrangements for the admission.

  The front desk was quiet except for the occasional, disinterested voice coming across the police radio. I signed a couple charts, then dictated a history and physical. There was no sense going to bed since Helen would be back from X-ray in a few minutes. I thought I’d take a quick break. I slipped on my lab coat, waved to Johnny at the front desk, pushed open the door, and stepped into the night.

  I hopped over the snowbank at the edge of the sidewalk and walked thirty or forty steps until I was away from the bright lights over the door to the emergency room. It was quiet out there. I leaned against a tree and looked to the west where the moon, almost full, was just setting. The Minnesota River was several blocks away, and although I couldn’t see it, on a quiet night like that one I could hear the faint, sibilant rush of its waters.

  It was cold, so I clutched my thin, white lab coat a little tighter about me. I felt guilty that I had lied to get Helen admitted—and yet I felt it was the right thing to do. Helen could hardly walk, could hardly see, and was growing demented. She needed more than her parents could provide. I didn’t blame Helen for trying to hang on to every possible thread of normality. I knew she thought if she went to a nursing home she would never come out. But I felt sorry for her parents, too. They were seventy years old and trying to do the impossible.

  I looked back at the hospital, thinking how far away it seemed, and how far removed I was from the mortal lessons being played out within its walls. But as I basked in my invulnerability, I began to feel vaguely troubled. There was something about Helen that struck a chord in me, something more than the usual empathy a doctor feels for his patient.

  I didn’t know why. One could hardly have picked two more different people. I was a young, healthy, active man. She was a sick, decaying woman. But despite our differences, I could understand her frustration and anger at what was happening to her.