As I stood there watching the long shadows of the moon stretch across the open field next to the hospital it occurred to me that maybe Helen and I had more in common than it seemed. Wasn’t I held just as firmly in the inexorable grasp of mortality? I didn’t want to admit it, but maybe that’s why I felt Helen’s situation so keenly. Maybe I found her story tragic merely because it was a distillation of my own. Maybe my empathy for her was just a disguised grieving for myself.
Behind me a faint smudge of gray streaked the sky behind the leafless trees. It would be dawn soon. I massaged the back of my neck, pushed away from the tree, and brushed the dirt from the sleeve of my lab coat. I took one last, lingering look into the night and headed back to the ER.
Chapter Twenty-Three
April
Her name was Julie and she had gone through a windshield.
She looked about nineteen, but it was hard to tell with all the blood. I watched as they unloaded her from the ambulance. The paramedics told me Julie’s boyfriend, who was driving, had missed a curve and driven off the road a mile this side of Janesville. Julie, who was sitting next to him, hadn’t bothered with a seat belt. She’d been hurled, face first, through the windshield. They found her on the side of the road fifty feet from the car. Her boyfriend, passed out, was slumped over the steering wheel, unharmed.
Julie’s face was a mess. Her nose was broken. One of her ears was half-off. A large flap of skin had been torn back from her forehead. From under the edge of the partially retracted flap I could see the glittering white frontal bone.
I closed my eyes and groaned. It was 2:14 A.M. I had been moonlighting at St. Joe’s for the last nineteen hours. I had been hoping to catch a little sleep, but it was going to take the rest of the night to put all this back together.
I examined Julie carefully. I could smell the alcohol on her breath, but she was conscious and oriented. Her vitals were stable. Her spine, her belly, her chest, all seemed okay. For a kid who had just gone through a windshield she looked pretty good.
Julie’s mother arrived a few minutes later. I could hear her screaming at Johnny at the reception desk. “Where is my daughter? Where is she? I want to see her right now!”
Julie was down at X-ray. I figured I’d better go out and talk to Mom.
“Mrs. Arndt? Hi, I’m Dr. Collins.”
She gave my hand a brief shake. “I want to see my daughter. What happened to her? How is she?”
“She’s been in a car accident, Mrs. Arndt. She’s conscious. She can move her arms and legs. She appears stable, but we aren’t taking anything for granted. She’s down at X-ray right now. She has a broken nose and some lacerations.”
Mrs. Arndt took a step closer and got right in my face. “What kind of lacerations?”
“She has some pretty bad cuts on her left ear and face.”
She put her hand to her mouth and staggered back. “Her face? Oh, God. Not her face.”
Maybe she misunderstood me. “Mrs. Arndt, I think your daughter is going to be okay. I don’t think she has suffered any life-threatening injuries.”
“Her face. Oh, God, no. This can’t be happening.”
Lady, did you hear what I said? All right, so she cut her face. Would you rather she was paraplegic or had a leg amputated? For Chrissake she went through a windshield. She’s lucky to be alive.
“Mrs. Arndt,” I said, “as soon as the X-rays and lab tests are back I’ll let you know.”
“Her face,” she kept repeating. “Her face.”
A week earlier I had been studying in the Mayo Medical Library. I spent a lot of time there during this six-month Basic Science rotation. I had been reading journal articles on intramedullary rodding of femur fractures when I noticed that someone had left a book on the table. As I pushed it aside I glanced at the title: Plastic Surgery of the Face by Sir Harold Gillies.
Oh, great, I thought, a book about fat, wrinkly socialites who want face-lifts and nose jobs. This was a book I wanted to hate. Before I opened the cover I was heaping scorn on the author and the patients.
I was not prepared for what I found.
The author was a World War I military surgeon who had treated hundreds of young soldiers with disfiguring facial wounds. On the basis of all the terrible injuries he treated, he became the world’s foremost expert on facial reconstruction.
The book was full of pictures. I gazed in awe at page after page of men with their noses shot away, their eyes blown out, their faces torn off. Men with bullet holes through their cheeks, with faces burned and scarred beyond recognition, with great gaping holes where their eyes or mouths should have been.
Gillies spent his career reconstructing the faces of those poor soldiers. Their hideous wounds awoke in me a profound respect for the men and the sacrifices they had made. I also felt a grudging admiration for Gillies himself. He was not what I had expected. I had always considered cosmetic surgeons little more than glorified beauticians fawning and fussing over trivial matters of appearance.
But now, in Mankato a week later, I realized that’s what I was about to do—fawn and fuss over a trivial matter of appearance. Why wouldn’t I just run some 2-0 silk and close her laceration in ten minutes? So what if she was left with a horrible scar? What’s wrong with a scar? It isn’t painful. It doesn’t interfere with the ability to see, to eat, to breathe. It has absolutely no functional significance.
Appearance. That’s all I was doing, fussing over appearance. Then why did I have this feeling that what I was about to do was terribly important, that it was imperative to make her face as close to “normal” as possible?
As I went on with my preparations, I noticed there were more nurses hovering around than usual. It took me a moment to realize why. They didn’t want this young girl to have a terrible scar. They wanted me to know I had to do a good job.
And I did know it. I was having a hard time explaining it to myself on a rational basis, but I knew it. I knew a hideous scar would change Julie’s life, would change it a whole lot more than mis-setting a radius fracture would. Mis-setting a radius fracture would cripple her arm. Leaving her with a hideous facial scar would cripple her life. I could acknowledge the reality of that statement, but I pretended not to understand it.
I had always scorned patients who wanted their wrinkles smoothed or their noses reshaped. What a waste of time and energy, I thought. Those people should worry about more important things. They had a lamentable preoccupation with appearance.
But now I was beginning to wonder. If appearance doesn’t matter, then why not leave the baby with a cleft lip alone? Why not let her grow up with a deformed face and then tell her that looks are not important and that she has a lamentable preoccupation with appearance? And why not tell Dr. Gillies to leave the disfigured face of the soldier alone, too? Why not tell the soldier to shut up and quit complaining?
What I seemed to be saying was that babies with cleft lips and soldiers with burned faces deserve cosmetic surgery, but middle-aged socialites with double chins do not. But who was I to impose my value system on middle-aged socialites? Who was I to say they should accept what they have and stop whining? What if one of them got in a car crash and smashed her facial bones to smithereens? Would I still say she should not have cosmetic surgery? What if it was Patti who was in the car crash—would I want her to go through life with a disfigured face?
I wanted to be consistent. I wanted to say that it wouldn’t matter to me if Patti’s face was horribly disfigured. I would still love her. Her essence, her inner self, would not have changed. Why would rearranging a few folds of dermis, or changing the relationship of the maxilla to the mandible matter to me—or to her?
If I truly loved her, loved the essence of her, I shouldn’t care about the outward shell. She was still my wife, my soul mate, despite whatever happened to her zygomatic arch. Why would it matter to me if she had two less, or more, skin folds on her cheek? Didn’t, shouldn’t, love transcend such things?
But this was all sil
ly sophistry and I knew it. Appearance matters. Never mind why. It matters.
Julie’s blood tests and X-rays were back in fifteen minutes. Everything was normal. When I finished reading the X-rays I went to talk to her mother.
“Mrs. Arndt, Julie’s X-rays look good. She has a broken nose, but her spine and skull films look good. All her blood tests are good, too. It appears that she has no serious internal injuries.”
“Can I see her?”
Oh, boy. This was going to be touchy. If I didn’t let her in, she would probably go bonkers. But if I did let her in, she was likely to flip out when she saw Julie’s face.
“Mrs. Arndt, she’s pretty bloody. Are you sure you want to see her?”
“Yes. I want to see my daughter.”
I led her back to the trauma area. “Just for a moment,” I said. “I still have to repair the lacerations and that’s going to take quite a while.” I pulled back the curtain where Connie was just giving Julie a tetanus shot.
“Oh, my baby, my baby,” Mrs. Arndt said, wringing her hands in front of her. Connie had dressed the forehead and ear with a gauze wrap, but blood was soaking through.
“I’m okay, Mom. I’m okay.”
Her mother stared at her from the foot of the cart, tears streaming down her face. “Oh, my poor baby,” she said. “Thank God you’re okay.” She took Julie’s hand in both of hers and kissed it. “Are you in much pain, sweetheart?”
“My head hurts,” Julie said, “and my ear.”
“I’d like to see her cuts,” the mother said to me.
“Mrs. Arndt, I don’t think—”
“I am her mother and I want to see them.”
I nodded to Connie who began unraveling the gauze wrap from Julie’s head. The ear, which had been held in place by the gauze, flipped over and hung upside down. On Julie’s forehead a large clot of blood slid from under the partially retracted flap.
Mrs. Arndt gasped and covered her mouth with her left hand. “Oh, God,” she said, grabbing the IV pole for support. Connie came around from the other side of the cart and took her by the arm. “This way, Mrs. Arndt,” she said, leading her to the waiting room.
“Julie,” I said, when her mother was gone, “your X-rays and tests turned out fine. It looks like your only injuries are the cuts on your face and your ear, and a broken nose.”
I slipped on a pair of gloves and dabbed at her forehead with a 4×4. I dropped the red, soggy mess in the kick bucket next to me and then inspected her cuts. She had a large flap that extended from the middle of her hairline down and into the left eyebrow, then back up and into the left temporal region. The ear was almost avulsed, being attached by a one-inch stretch of skin inferiorly.
I positioned her head on the cart, extending it a little to expose the laceration. Fortunately for Julie, even though there were small pieces of dirt and glass scattered throughout the wound, the edges of the laceration were fairly sharp.
“Is it going to hurt?” Julie asked from under the sterile drape.
“Only a little when I stick you with the needle for the numbing medicine.”
She was silent as I drew up the lidocaine. “How bad is the cut?” she asked.
Thank God she hadn’t seen herself in a mirror. She would have freaked out if she saw that flap of skin hanging from her forehead.
“Well, Julie,” I said as I began injecting the lidocaine around the periphery of the laceration, “it’s a pretty long gash, but I think I’ll be able to repair it pretty well.”
“Will I have a scar?”
Will she have a scar? Jesus Christ, she went through a windshield. She’s lucky she has a head. Does she think this huge gash is going to heal back like magic with no scar? Maybe I should have shown her what it looked like when she came in.
“Yes, Julie, there will be a scar. But I am going to do everything I can to make it as small as possible.”
“Oh.” She started to cry.
“I’m sorry, Julie. But still, you should be grateful. You went through a windshield tonight. Things could have been a lot worse.”
She was shaking with sobs now.
“Julie, honey,” Connie told her, “you have to hold still now so the doctor can sew you up.” She reached under the drape and took Julie’s hand. “You want him to do a good job, don’t you?”
“Mmm-hmm,” Julie sniffled.
“Okay, then, hold real still. If anything hurts you, tell Dr. Collins and he’ll numb you up a little more, okay?”
“Mmm-kay.”
I put in a couple stay sutures and began marking the skin with the sterile marker, mapping out the repair.
It’s a metaphor, isn’t it? I thought in a moment of clarity. The face, the scar, the repair. They’re metaphors. There’s something else, something deeper, something that explains all this irrational concern.
But that’s as far as I got. The repair demanded too much concentration for me to speculate on just what that “something deeper” might be. And of course my old friend, pragmatism, wanted none of it. What did it matter? I had a job to do. Screw the philosophizing and get those first few subcutaneous sutures in.
Two and a half hours later I put in the last suture. It was 5:30 A.M. The facial repair had gone well, but I was a little worried about the vascularity of the ear. Well, we’d just have to see.
Julie’s blood alcohol was .07—not legally drunk but enough to have made her sleep for the last two hours. It made things a lot easier for me, but God how I hated that alcohol breath. I felt as if I had spent half my life stitching up faces of people with boozy breath. Connie squeezed some Neosporin on a sterile tongue depressor and I applied it to the suture line.
“It looks really good, Mike,” she said.
“Yeah,” I said, “it came together nicely.” I twisted my head back and forth, stretching my neck muscles. My neck was killing me, partly from the tension and concentration, and partly from leaning over Julie’s face for the last two hours.
I whipped the drape off her face. She still didn’t wake up.
“Julie?”
“Hmmm?”
“Julie, wake up. We’re all done.”
“Huh? Where’s Martin?”
Who? I looked at Connie for help.
“The boyfriend,” she whispered.
“Martin’s gone home,” I said. Gone to jail, rather. The cops charged him with DUI. “Your mom’s here, though.”
“Mmmm.”
As I prepared to wrap her head in gauze I studied the repair. I had to admit, it looked pretty good. But there would still be a scar. I wondered if Julie or her mother would be satisfied.
It’s a metaphor, I thought. Someday I’m going to figure out what it all means. But not now. Now I’m going to bed.
Chapter Twenty-Four
May
At five to seven on a warm spring evening I swung the old Ponch into the parking lot of St. Joe’s hospital and shut off the engine. The car lurched twice, gave several consumptive coughs, and was still.
The ER was empty, thank God. I had been doing an awful lot of moonlighting while I was on Basic Science, and was praying for a quiet night for a change. I said hello to the nurses who were sitting at the desk listening to the radio. Mary was folding towels and Jenny was doing a crossword puzzle. No, I didn’t know a seven-letter word for a wet-nurse. And, no, they didn’t know what the cafeteria was serving for dinner.
I tossed my shaving kit on the bed in the call room and sprinted down the hall. I had two minutes before the cafeteria closed. A guy in a white apron was just closing the door as I got there. I squeezed by him, grabbed a tray, and glanced at the chalkboard at the start of the serving line.
“What the heck is Cheese Florentine?” I asked the woman behind the counter.
She shrugged and pointed her serving spoon at a steaming tray of amorphous green material. “Cheese Florentine,” she said.
I still had no idea what it was, but my only other choice was lutefisk, so I took the Cheese Florentine. I ate
the salad, the roll, the cherry pie, and the lemon square first. I was about to begin a cautious dissection of the warm pile of biochemicals on my plate, deciding where to make the first incision, when I heard the call for a code in the emergency room.
I dropped my fork and ran to the ER. A crowd of nurses, technicians, and red-jacketed ambulance attendants were gathered around a cart in the back corner of the ER, the spot reserved for critically injured patients. I pushed my way through the crowd and saw the motionless body of a little boy of about five lying on the cart. My crew of three ER nurses was doing all the right things: getting an IV in, starting oxygen, taking vitals.
“What have you got?” I asked Jenny as I scanned the child for injuries.
“Five-year-old boy, riding his bike. Hit by a drunk. He’s been here about a minute. Mary’s getting his pressure.”
The kid’s head was swollen to twice its normal size. The jagged shaft of the radius was sticking through the skin of the left forearm. He had a partially caved-in chest. I couldn’t feel a pulse. The boy was bleeding from his mouth, his chest, his leg, his arm, and his ear.
Mary pulled off her stethoscope and shook her head. “No pressure,” she said.
I opened one of his eyes and looked at his pupils. Fixed and dilated. For a moment all activity ceased. Everyone—Mary, Jenny, even the EMT doing CPR—stopped and looked at me. It was my call. Every bit of my medical training told me I should quit right there. It was hopeless. I looked at the others. They all waited, poised in mid-task.
Perhaps it was hopeless, but some things are just too terrible to accept. I pointed at the EMT. “Resume CPR,” I told him. I would not let this child be taken from us without a fight.
Jenny had started an IV. I ordered steroids and mannitol for the head injury. Being careful not to extend his neck, I slipped in an ET tube. I moved around the cart, barking orders. I did a cut-down and put in a CVP. I stimulated his heart with epinephrine. I put in a chest tube. I drew blood gases from the femoral artery.
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