Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (39 page)

While I was thinking this, I had walked out through the wheezing automatic doors, and now I stood in the well of the ambulance bay, looking out into the night. In the distance a siren began to wail. Was this the trauma victim coming to us this soon? I should be inside, I tell myself, starting to get the intubation equipment set up. But still I linger here, staring up at the night sky, listening to the siren. I hear it now as I heard it when I was young, before I became a doctor, back when that sound always stood for the lonely city, empty streets at three
A.M.,
rain, lost luck and the end of the line. Plus an echo of something more haunting; an echo of the long-ago sound of a freight train, a sound that spoke of other places, lives better spent and long, inexorable travels into darkness and night.

The siren passes. It's not for us.

One of the security guards now comes ambling down the driveway. He sees me, holds his arms up and out, leaning back to address the sky. “What are we doing inside on a beautiful night like this?” he shouts.

“Oh, you know,” I shout up at him in return. “The usual. Saving lives. All that.”

The doors wheeze open and Tony, the other security guard on tonight, leans out. “Trauma coming in,” he tells us.

“Yeah, okay,” I say. “I'm aware.”

“Well, they're waiting for you in trauma. Nudge, nudge, wink, wink.”

I sigh and trudge back through the electronic doors, away from the night and into the blue fluorescent light.

Donna and Mary Ellen are already in the trauma room. Donna is opening up the medication cart. Mary Ellen is laying out the form for record keeping. Bill, the tech, is doing pushups.

“Fifty-six,” he says, “fifty-seven, fifty-eight.”

“Anybody hear anything more?” I ask.

“EMS called again—they're transporting now,” Donna tells me. “A car hit a pedestrian and then ran into a bridge. They already pronounced the two in the car DOA. They're bringing in the pedestrian.”

“EMS pronounced people dead in the field?” I ask, puzzled. Usually our EMS transported anything that looked to be alive in the last thirty days.

“I don't know,” Donna says, leaning casually up against one of the cabinets. “I think they were
very clearly dead.
”

We both stand there thinking the same thing, I'm sure: decapitation.

“Beauty,” Bill says, rising up from the floor and dusting off his hands.

“So what about the pedestrian?” I ask. I start stripping off my dirty white coat and strapping on a blue plastic gown.

“Chest trauma is all they said.”

I hit the intercom with my elbow. “Call upstairs,” I tell Mary at the desk. “See if you can track down Surgery.” Her response is an electronic squawk.

I move to the head of the bed and run through the intubation equipment. I know these things as if they were a lover's face. The arched endotracheal tube with its deflated balloon cuff. The laryngoscope handle and, as I fit it into place, the laryngoscope blade. I open the blade up to ignite the light at the tip, the intubation “beacon of hope” or “sentinel of disaster.” As I do, I try to ignore the image that always sits in my heart, a well-worn image: that of a box, a plain cardboard box. While I organize the equipment I also mentally do what I am powerless not to do. I open the box and look inside. There they all are, all my failed intubations, every one of those times that, for whatever reason, I couldn't get the big tube down that little hole. Included are the times I couldn't get the tongue out of the way, or the vocal cords were so far anterior I couldn't get to them, or the patient vomited and I couldn't see, or any one of a thousand catastrophes.

There's a special section of the box devoted to blunt trauma, like what is coming in tonight. Blunt trauma victims are usually the worst kind of patients to intubate. The face can be mangled beyond recognition. Sometimes you're not sure at all where the airway is; you have to follow the bubbles down to their place of origin. What's more, you have to intubate without moving the neck at all, because if the patient has a fracture of the cervical spine and you move the neck, you'll pith him like a frog in some biology experiment. And there it is: lifelong paralysis—that knowledge sits in the box as well.

There's more stuff in the box. Can't get an airway through the mouth? That's when you need to do a “crike,” a crichothy-roidotomy. To do this, you take a knife and plunge it directly through the soft tissues of the neck and then into the trachea. Follow it with a small plastic tube you use to breathe for the patient. Connect the Ambu bag and there you go. It sounds easy.

It is not easy.

I pull on a pair of latex gloves and then slide another pair over them. HIV and AIDS have raised the ante for physicians who do invasive procedures. As everyone knows, any patients we care for could be infected. Years ago in Baltimore, researchers demonstrated that 15 percent of all trauma patients were positive for HIV. It's probably higher now. Ergo: any errant needle stick or mishap with a scalpel could change my life.

I thought about being with Doctors without Borders in Nigeria, smiling to myself. Perhaps no one put an actual gun to anyone's head, but each person had risked his or her own life in their own way—all that cigarette smoke and not a glove to be had. But then, they saved lives…so many lives.

Well, I think, as I set up the suction, I could leave all this—the failed intubations and the crikes, the nights, the drunks, the two
A.M.
train wrecks, the heroin ODs, the long-time shooters who will risk my life as much as they have risked their own. There I could be, harvesting hair sproutlets, Kenny G in the background, assisted by a nurse who would not say, as Donna is saying right now, apropos of something I did not catch, “…and I'm tellin' ya, fuck all of 'em. What the fuck do they know about this?”

I close my eyes for a moment, and as I do so, I see a hair transplant patient lying in a darkened room—something like a tomb—and me with my blue plastic gown on sitting over him, acting somehow like a Nazi doctor experimenting on bald heads. And the darkness of that room hurts my eyes like bright light.

I open my eyes again suddenly. Now I remember a woman patient I had last week. She was in a bad auto accident—luckily her only injury was a broken ankle—but that ankle had been smashed to smithereens. She would have to go to the OR to have it repaired. She was also an old shooter; she shot heroin IV. I found telltale needle marks, including fresh ones, all up and down her arms and legs. The skin rarely lies.

And she was pregnant.

As part of her workup I was going to order an HIV test. The hospital requires that the patient sign a form giving permission for the test. I gave her our form along with a pen advertising some antidepressant to sign it with.

“I don't want no HIV test,” she said, handing the pen back to me.

I was taken aback. “Why not?”

“I don't want to know what it shows.”

“Honey, we need to know. You're going to surgery.”

“I don't want to know.”

“But if you have HIV, there are drugs you need to take. Drugs that can make you live a lot longer.”

“I told you, I don't want to know.”

“And there are drugs you can take so your baby won't catch the virus from you.”

She fixed me with a baleful gaze. “I don't
want to know.
”

There it was again, the inexplicable. Just think, I tell myself, I could walk away from her and, in time, even get rid of her memory. That was the most important thing, the memory…

Other things, too, other memories. An eight-month-old boy had fallen out of bed and suffered a skull fracture. The mother was crying, Dad was stoical, but I couldn't look at either one, couldn't even stand near them. I had to walk away, shaking my head in disgust. That's because when we first got the baby, as we were cutting her little yellow jumpsuit away, we found the child also had a broken arm and large bruises on the legs. No kid gets that from rolling out of bed. It was child abuse and nothing but child abuse.

We lost the baby's pulse almost immediately on arrival, and after that it was all downhill. She died—officially—about forty minutes later; there was nothing we could do. It was the only time I ever saw Donna cry. I found her sitting out in the ambulance bay, smoking a cigarette, sobbing. “I just can't take this stuff,” she told me as I patted at her shoulder in an inadequate way. “I just never could take stuff like this.”

But no more. It is time to come back to the present. Donna, now, is turning on the heart monitor and disentangling the spidery, pentapod set of monitor leads. The respiratory therapist has shown up, looking dazed by the light. Tim, the x-ray tech, has wheeled in the portable x-ray machine. He now leans against it, eyes closed.

I check my watch, wondering where the surgeon is. We all stand now in various slack postures, waiting. For what, nobody knows; we never know. Anything could roll through those doors. As I stand here, another trauma comes to mind. A year ago we had a kid come in via EMS, twenty years old—front seat, non-belted driver, airbag deployed—who seemed to have nothing wrong with him except his feet were slightly blue. Nothing, maybe, except he kept telling me he “felt funny.” Just as we were getting his chest x-ray, he crashed and burned, no blood pressure, no pulse, nothing, nothing. He died, right there in front of us. We never got anything back. His autopsy showed he had a ruptured aorta—a common injury in those accidents that involve an airbag and someone with no seatbelt. I was the one who went out and told his wife. They had been driving to Florida for their honeymoon. They had been married for six hours.

“But he was fine afterward,” she kept saying. “He said he was just fine.”

Inexplicable, another in a long line of inexplicable patients. What was God thinking?

As I ponder this, I can hear the warning buzz of the ambulance as it backs up into the ambulance bay. Here we go.

I think suddenly of B., in his white coat, demonless, sitting out in the ER proper. Aren't I still missing the point? I ask myself. Doesn't the ultimate case of the inexplicable boil down to me,
my
story? Who really cares about B.? What am I doing here? Was it really my grandfather? Is that how I came to be standing here in a trauma room in a smoldering ghetto in some rustbelt of a town in the heart of the Midwest at 2:47 in the morning, without enough sleep and with too much coffee, waiting for whatever might roll through the door? And in this case, whatever comes through the door could be thought of as, truly, anything.

The doors open. Mary shuffles in.

“Where's Surgery?” I ask her irritably.

She raises her hands. “Surgery's coming,” she says. “Don't get your knickers in a twist.”

Donna, fiddling with the monitor in the corner, says, “Sweet Jesus,” about something we cannot see.

The doors bang open again. This time it's the paramedics wheeling in a cart followed by some EMTs, some firefighters and a police officer. “Walking down the fucking street,” the firefighter is shouting as she comes through the door, while the lead paramedic shouts over her, “We've lost the pulse.”

The room fills quickly. Another typical disaster, routine chaos until I realize what's on the cart—a child, no more than three or four. A little boy. And the paramedics aren't in their usual sweating, paramedic mode. They look terrified.

“Talking at the scene,” the rear paramedic continues. He is holding a bag of normal saline aloft while trying to negotiate the turn with the gurney. “Family just got home from Alabama. Grandma was walking the kid to the house when the other car lost control. It hit him and then he hit a tree, we think.”

“How old?” I say but don't listen for an answer.

Donna is shouting, “Move it, move it, move it,” as the respiratory therapist stumbles past her trying to get at the Ambu bag. I push Mary Ellen out of the way to try to feel for a pulse at the kid's neck. As I do, everyone else crowds up, trying to pull the kid off the gurney onto the cart.

I grope for the pulse. There's nothing. The kid is blue, not breathing.

“Let's start CPR here, come on, come on. I've got to intubate.” I fight my way to the head of the bed, past Bill, who has climbed up on the stool to start CPR. There it is, all my equipment. But the endotracheal tube I have laid out is adult size, no way it will fit a four-year-old.

“I need a five, I need a size-five ET tube,” I shout as I paw helplessly through what's before me.

Meanwhile Donna is shouting, “Damn, damn, damn, damn, damn. We have a rhythm on the monitor here, folks. If that means anything.”

“Weird,” Bill tells me after a moment, “very, very…”

“Hold CPR. Check for a pulse again,” I say. I've found the size 5 tube and pull out a 4 just in case. I turn back to the patient. The respiratory therapist now lifts the mask away for me, and I get my first view of his face. It's bloodless, gray-white, blue at the lips. This is a very dead child.

“Heart rate of forty. Still no pulse.”

So here it is. How often have I seen it, that nightmare confluence of velocity and deceleration, cell disruption and denatured proteins, rarefaction and sudden impact, all that blind science of night and darkness that I know as surely as I am blind to the workings of all those other great mysteries, including the workings of my own heart? I stand there helplessly for a moment and then think, Intubate, intubate.

“Restart CPR. Epi, atropine. We need another IV.”

Who's saying this? Me? Donna? Mary Ellen?

I slip the blade into the mouth and peer down. This time it is going to be easy. There are the cords and I can see the beveled edge of the tube slip right through. No struggles here. It's textbook.

I straighten up, pulling the stylet out. “We're in,” I say. “Hold CPR.”

“I'm tellin' you,” Bill says, halting, “something feels very weird here.”

The respiratory therapist starts bagging and I watch the chest rise and fall as I fumble for my stethoscope—but this doesn't look right. Only the left side seems to expand. I listen: once, twice. Something, some kind of breath sound on the left, but not much. And on the right there is this weird hollow resonance, but not even a whisper of real breath sounds. I listen over the stomach—nothing there. The tube is in the right place, I'm sure. What is going on?