The ambulance roared into the bay with full sirens going. The driver hopped out and swung open the back doors. The paramedics were doing CPR on an obese, cyanotic-appearing man. I followed them as they wheeled the patient in.
“Fifty-one-year-old guy,” the paramedic gasped between chest compressions, “chest pain for two hours…collapsed at home…his son, a high school kid, started CPR right away…we were there in eight minutes…never got a pulse.”
We cut off his shirt, slapped on the cardiac leads, and started an IV. I gave him some bicarb, then epi, then more bicarb. He was in V-fib so I shocked him. I went up to his head and intubated him, went down to his groin and drew a femoral artery blood gas.
During the first few furious minutes when I was trying to do ten things at once, I looked up and saw the anguished face of a high school kid with a letter jacket standing at the foot of the cart watching the feverish activity, watching his father’s cyanotic face and sightless eyes. A few seconds later someone whipped the curtain closed, and I never saw the kid again. He was the son, though. He had to be. I could see the resemblance.
I put in a central line and gave some more drugs. I tried the defibrillator again. It didn’t work, any of it. After another half hour I called the code. The man was dead.
As I sat quietly at the desk, filling out the death certificate, and the ER record, I remembered the kid’s eyes: the anguish and fear and confusion. How incredibly fast it must have come upon him. He sees his father clutch his chest and fall to the ground. There is a moment of confusion and panic. What is it? What has happened? Then the terrible realization that it must be a heart attack. His father needs CPR. Can he do it?
Oh, God, he thinks, why didn’t I pay more attention to this stuff in health class?
He begins, clumsily. Is this the way? Is this how you do it? Then the desperate, plunging chest compressions, the awkward attempts at mouth-to-mouth, the intense longing for the ambulance to get there. Oh, God, where are they? He pushes the hair from his face and goes on. He sees his father’s face growing purple, feels his lips growing cold. As he struggles on, he hears his mother’s anguished sobs behind him.
Finally the paramedics arrive and he is pushed aside. He doesn’t know if he did the right thing. Has he helped his father? Or has he killed him? He backs farther away, wedging himself into a corner, staring as the paramedics wage their desperate battle. Soon his father is spirited away in an ambulance. He and his mother follow in their car.
At the hospital, strangers are cutting off his father’s clothes. They are sticking tubes in him, shocking him with paddles. He stands at the foot of his father’s cart watching it all. He can hardly bear to watch, but he can’t tear himself away. Finally someone closes the drape and he can see no more.
A few minutes later a doctor in a white coat comes out to tell his mother that her husband is dead. The doctor never speaks to him. No one does. When he thinks of his father all he can see is the bloated, purple face with that tube sticking out of it.
Two hours later, when the code was over and the death certificate filled out, when the janitors had mopped the floor and the nurses had restocked the crash cart, when the PM shift had gone home and the coroner had come to claim the body, I was still slouched in a chair at the desk. I kept going over the code in my mind, asking myself what I could have done differently. I couldn’t think of a single thing. I ran a perfect code. But I kept seeing the look in the eyes of the kid with the letter jacket, and the fact that I ran a perfect code did nothing for me.
Death, suffering, failure. They were the enemy, but they didn’t play by the rules. Sometimes, even when I did everything right, they still won. I couldn’t give up the childish notion that things ought to be fair. When I ran a perfect code, when I did everything right, the patient ought to live. What more could be asked of me? What more could I give? Day in and day out I did the best I could, the best anyone could—and so often it wasn’t enough.
It had been four hours since I had started my car. I knew I should go out and start it. I grabbed my lab coat from the back of the chair and told Connie I’d be back in a couple minutes. She told me there was a guy in Three with an infected elbow.
“Get an X-ray, a CBC, and a sed rate,” I said as I left.
The ER doors slid open. As I stepped outside, every bit of warmth was sucked out of me. I groaned through gritted teeth and wrapped my lab coat around me as I opened the door of the Battleship and plopped down. I turned the key and the engine roared into life. Thank God. Within two minutes I was shivering uncontrollably. My head and shoulders were hunched forward, my arms clutched to my chest, my thighs squeezed together. My breath was condensing into a frozen mist on the inside of the windshield.
After five minutes, just as I was ready to shut off the engine, I noticed a trickle of warmth coming from the heater.
Why now? I wondered. I drove ninety miles and the damned thing never threw out a single bit of heat. Now, after sitting out in the cold for fourteen hours it decides to work. I revved the engine a couple times, shut it down, and trotted back inside.
Some questions, I realized, are never going to be answered.
Chapter Thirty
March
Sometimes it seemed there was so much bullshit. Patients could be rude to us and we had to take it. Attendings could abuse us and we had to take it. Silly, senseless jobs that had nothing to do with our education needed doing and we had to do them. Even though we were no longer junior residents stuck doing narc rounds and holding retractors, there was still plenty of ignominy to go around.
Boys. That’s what we called ourselves—Coventry’s boy or Romero’s boy or Kramer’s boy. We were at their beck and call. We did what they told us to do. We operated when they let us; we assisted when they didn’t. Sometimes they listened to our suggestions, sometimes they ignored them. When they wanted something done they issued their commands and we just nodded our heads and said, “Yes, sir.” We had to live with all the ambiguities of being thirty-year-old, highly educated men and still in positions of subservience.
Maybe that’s why I liked fixing fractures so much. Fractures appealed to me in a way no other part of orthopedics did. Unlike other areas of medicine (and other areas of life), everything about fractures was straightforward. Cardiologists might bullshit about whether the patient actually had a heart attack. Neurologists might bullshit about whether the patient actually had a stroke. But with fractures, there was no way to bullshit. As soon as the X-ray was developed, everyone knew exactly what the problem was, and exactly what the solution was.
With fractures you didn’t have to wait for weeks or months to see how things turned out. X-rays provided immediate, tangible documentation of our work. There was no hiding behind academic credentials, or how lousy your assistants were, or whether the night crew could find the Synthes set. The X-ray didn’t care about any of that stuff. The X-ray climbed to the top of the highest hill and held itself up for all to see. And if you had done your job well, you could take pride in comparing the shattered, malaligned bones on the pre-op X-ray to the perfectly reduced, plated bones on the post-op X-ray. There was your proof. There was your honor.
Even though I was a senior resident, I still had to take call—and I was having a very busy day. I had made rounds, seen a couple consults, drained a foot abscess in the ER, and fixed a hip fracture on one of the old Franciscan nuns who had worked at St. Mary’s back in the sixties. Tom Hale, the attending surgeon on call, scrubbed in on the case with me but let me do the whole thing, skin to skin.
“Nice job, Mike,” he told me as we looked at the post-op X-rays. “Everything looks perfect.”
Things slowed down around five o’clock, so I phoned Patti. She and the kids came over to have dinner with me in the hospital cafeteria.
“Eee-yew,” Eileen said, looking at the plate of food in front of her. “What is that?”
“That’s Swiss steak, honey,” Patti said. “Try it. It’s delicious.”
“It loo
ks like barf.”
“It does not look like barf. Now be a good girl and eat it.”
We were about halfway through dinner when my beeper went off.
“Dr. Collins, please call the ER, 5591, 5591, 5591. Please call the ER, 5591.”
I found a phone and was back in two minutes. “It’s a both-bone forearm fracture,” I said. “I have to go.”
Patti smiled and shrugged her shoulders—another ruined dinner. What a surprise.
I kissed Patti and the girls, rubbed Patrick on the head, and trotted down to the ER where Steve DeBurke, the junior resident on call, was waiting for me.
“Hey, Steve,” I said. “What have you got?”
“Joanna Haverman, a thirty-nine-year-old lady who fell at her daughter’s skating party. She’s got a nasty both-bone forearm fracture.”
“Open?”
“No, closed. She’s got a good radial pulse but her arm’s pretty crooked.”
I looked at the X-rays. Steve was right. Her arm was angulated almost sixty degrees. I went in and introduced myself to Mrs. Haverman. I told her she was going to need surgery.
I went over the operation with her, describing exactly what would be done, and what the risks were. Steve had already talked to anesthesia. An OR would be ready for us in half an hour. I called Tom Hale and discussed the case with him.
“Have you done one of these before?” Tom asked.
“Yes, sir. Several times.”
“Okay. Go ahead, but call me if you have any questions or problems.”
While I was talking to Tom, Steve brought Mrs. Haverman up to the OR. I couldn’t wait to get started. Fixing both-bone forearm fractures was one of my favorite operations.
I let Steve do the approach to the ulna. He hadn’t done much surgery and was thrilled to make one of the incisions and put in a few of the screws. I did the rest of the operation myself.
I was sitting in the recovery room leaning back in a chair when Steve brought me the post-op X-rays. “Looks good,” he said.
I held the X-rays up to the light. The fractures were in perfect position, the plates and screws right where they should be. I got the pre-op X-rays and put them up on the view box right next to the post-op films. The contrast between the crooked, shattered bones pre-op and the perfectly reduced and fixed bones post-op was striking. I smiled and thought how wonderful it was to do this for a living.
Steve plopped down in the chair next to me. The poor guy looked beat. I thought he could use a little encouragement.
“Nice job on the approach to the ulna,” I said.
He shrugged his shoulders as if he didn’t care. “Thanks.”
I could see that it was getting to him—all the long hours and the endless scut work. He seemed to have lost sight of where he was headed. I didn’t blame him. I remembered how I felt as a junior resident. But he also needed to learn to take comfort where and when he could. The fact that we had just done something wonderful seemed to have escaped him.
I wanted him to know how lucky he was to be able to do things like this. I took the post-op X-ray off the view box and handed it to him. “Look at this,” I said. “This is what makes everything worthwhile.”
Steve held the X-ray up to the light. He looked like he was still wondering what I was talking about.
“Hang in there, Steve,” I said. “You won’t be a junior resident all your life.”
I heard the recovery-room nurse talking to Mrs. Haverman who was just waking up. I grabbed Steve by the arm. “Come here,” I said. I went over and talked to Mrs. Haverman. I told her the operation went well and her bones were back in position. She moved her fingers for me and said her pain wasn’t nearly as bad as it had been before surgery. She had tears in her eyes as she thanked us. I could see Steve was touched.
“Bring it on, BJ,” I mumbled to myself as we were walking away.
“What?” Steve asked, frowning and leaning his ear toward me.
I laughed in embarrassment.
“I was just telling BJ Burke to bring it on—all the shit, and all the scut work, and all the abuse. To be able to do what we did tonight is worth any price. This is why I want to be a surgeon.”
Steve laughed. “Bring it on,” he echoed.
Chapter Thirty-One
June
I wiped my forehead with a lap sponge and said, “For a place that is so god-awful cold in the winter, it sure gets hot in the summer.”
I was sitting in the empty waiting room of St. Joe’s ER in Mankato. Mary and Rita, two of the nurses, were sitting with me. We were watching a rerun of Bonanza. We hadn’t had much business all day. This was the fourth day in a row with temperatures and humidity in the nineties. It was too hot for people to go out and hurt themselves.
The hospital was rumored to be air-conditioned but no one believed it. Rita, who weighed all of ninety pounds, was fairly comfortable; but Mary, who hadn’t weighed ninety pounds since she was six, was roasting. She was holding her long brown hair up over her head, and had draped an ice pack low across her neck.
“I don’t get paid enough to put up with this,” she panted.
It had been seventy-six degrees when I left Rochester at 5:30 that morning. A thick, steamy haze obscured the sunrise. At seventy miles an hour I kept cool enough, but I could almost feel my car slicing through the heavy air that smothered the fields and woods. As I passed Loon Lake, near Waseca, I could just barely see the figure of a solitary fisherman in a boat about thirty feet from shore lazily laying down casts on the surface of the misty lake.
About five o’clock that afternoon an ambulance called to say they were bringing in a guy with a broken nose and a cut on his forehead. Rita and I heaved ourselves out of our chairs and went to check him out. Mary wiped her forehead and said she’d be along in a minute.
Our patient arrived five minutes later. He was telling a joke to the paramedics as they wheeled him in. “…so then the plumber says to the guy, ‘I think I can save your wife but the bishop’s a goner!’ Ah-ha-ha-ha!”
The paramedic at the head of the cart shook his head and cracked a smile. “We gotta go, Sal,” he said, rubbing the patient’s shoulder. “You take care, and go easy on the brews next time.”
I motioned the paramedic over. “What’ve you got?” I asked him.
“The dumb shit spent the afternoon sitting in a lawn chair on his driveway. He had a cooler next to him, and his feet in one of those little, plastic baby pools. We found eighteen empty beer cans next to his chair. When he finally got up to take a leak he was so plastered he fell flat on his face. Did you see the guy’s nose?”
“Yeah, I saw it. There goes his chance for the cover of GQ.”
I said good-bye to the paramedics and went over to the cubicle where Rita was getting our patient’s vitals.
“You’re beautiful, baby,” the guy was saying. “You should be in Hollywood not here.”
Rita wasn’t buying it. “Sir,” she said, “please hold your arm still so I can take your blood pressure.”
His forehead was wrapped with a bloody gauze bandage against which he was holding an ice bag. I removed the bandages so I could examine his injuries. He had a long laceration across his forehead, and his nose wasn’t just broken, it had landed in another zip code. It was mashed way over to the left and flattened against his cheek. Dried blood rimmed his eye sockets. Apparently, however, he was feeling no pain.
“Hey, Doc, how’s it goin’, hah?”
“Mr., ah…” Dawn handed me his chart. “Mr. Pagulia. How are you, sir?”
“Listen, Doc, I gotta tell ya something.” He propped himself up on his elbows and leaned forward to speak confidentially. “The ice bag them ambulance guys gimme is leaking. Looka this shit,” he said, holding up the bloody, dripping bag. “It’s drippin’ all over me. In fact—” he paused and looked at me wide-eyed—“I think I’m getting water on the brain.” He burst into laughter. “Ah, Jesus! Water on the brain!” He fell back against the cart, shaking with laughter. He ja
rred his head enough to make his laceration start bleeding again. “Get it, Doc?” he said between belly laughs. “Water! On the fuckin’ brain!”
“An interesting observation, Mr. Pagulia. By the way, have you been drinking this afternoon?”
“What gave you that idea?” Rita whispered to me.
“Just a few beers,” he said.
“A few beers.” I nodded. “How many, do you think?”
“Ah, five or six maybe.”
“Five or six.”
“Maybe more. I dunno. Who’s counting? It was hotter ’n shit out there.”
“How did you hurt yourself?”
He struggled to sit back up again. “I got attacked, Doc.”
“You did?” I looked over at Rita. That’s not what the ambulance guys said.
“Yeah.” He nodded his head, making the laceration bleed even more. “Yeah, the fucking driveway hit me right in the face! A-ha-ha-ha.”
I wrapped a roll of Kerlex around his head and then sent him for nasal, skull, and C-spine films. A half hour later I could hear him down the hall as the X-ray tech was wheeling him back.
“Volare,” he was singing, “wo-wo.”
The tech laid the films on the counter and rolled her eyes. “He asked me to marry him,” she said.
“Cantare. Wo-wo-wo-wo.”
I picked up the films and was snapping them up on the view box when he called over to me. “Hey, Doc! You know ‘Volare’?”
“No, sorry. I took Greek in high school not Latin.”
He frowned and muttered, “What the fuck?”
“Well,” I said, walking over to him, “good news. Your skull and neck films look good. The only thing broken is your nose.”
“My nose? It is?” He reached a paw to his bloody face and felt his nose. “Son of a bitch. The old schnoz hung a Louie. Hey, Doc, the fuckin’ thing is pointing at my ear.”
“Don’t worry, sir. It can be fixed.”
“Shit, yeah,” he said. “I’ve had it fixed ten times before.”
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