Oxygen (14 page)

The dream begins
as a nightmare I’ve had countless times since medical school, a dependable thief of my sleep. I am in an operating room crowded with nurses and technicians and surgical assistants. The surgeon paces beside the table with a scalpel in his hand, ready to cut. My patient looks up at me for reassurance and I promise I will keep her safe.

Nothing is prepared—no drugs are drawn up, oxygen tubing dangles from the ceiling, disconnected and useless. I search through drawers filled with broken glass vials, dirty needles, empty syringes. Everyone in the room is waiting, staring at me. I inject a milky white liquid into the IV line and watch my patient’s eyes close in a slow, hypnotic saccade.

Then, at the moment the knife draws a blood-red welt down her belly—the only point of color I can see in the dream—she opens her eyes and screams.

In every dream it’s the same. I frantically break open more glass vials and flush more drugs into her bloodstream, but nothing puts her to sleep. Her screams go on and on until I wake up in a tangle of sweat-soaked sheets with my heart pounding, groping for the light switch.

But this time I don’t awaken, and the dream changes. The operating room doors swing open and I am in a small room, locked in—no, out—locked out, standing in front of a rectangular slab of rough wood, some kind of shed. Someone is crying inside, an infant maybe. Or a cat—it’s a cat crying to be let free. I rattle the iron latch and wrench the handle until my hands ache; the work of it drains my strength. I hammer my fists against the boards; my arms flail—heavy, impotent, as if pushing through a wall of water.

I know this place now. It’s the rotting garden shed on my grandmother’s farm. My sister and I have come here with our father; it is the last time we will see my grandmother until her funeral. We are young still, nine or ten—an age when we were equal—and we’ve come to adopt a kitten, the lone survivor of a premature litter of four. But by the time we arrive this kitten, too, is dead, caught and mauled by the scarred tom who dominates the feral cats of the barn and fallow fields. My grandmother has locked the tom in the garden shed as punishment. She will leave him inside this slat shed for three days with only water, to teach him compassion for the weaker strains of his own species. Lock him up for three days beyond any fleeting link a cat could make between the crime and the punishment, her cruelty blind to the hard truth that empathy for the offspring of strangers is a uniquely human quirk.

My father tries to explain when my sister and I cry over the imprisonment as much as for the lost life. “It’s the way on a farm. The natural world doesn’t lean toward coddling.”

But this last dream is not a dream, it’s a memory. I remember the cat and the mauled kitten. And I remember the shed.

It is 4:15
AM
and my pager is blaring from the bedside table. I had to trade call days in order to meet with Charlie Marsallis on the following Monday, so after one night of unfulfilling sleep I am back at work for twenty-four hours. I jump up and turn on the light, disoriented and squinting at the row of numbers glowing in the glass window of the hard black plastic case. It’s the emergency room. I dial the number, shielding my eyes from the overhead bulb and clearing my throat, hoping to sound more awake.

“This is Dr. Heaton, anesthesia. Someone paged me.” Two minutes later Jim Dahl picks up the phone. Jim is head of the Emergency Department, a young athletic guy who juggles his work shifts around various world marathons. He has a sort of flat-out stamina that serves him well in both arenas.

“Hey, Marie, sorry to drop this on you at this hour. We’ve got a ten-month-old who aspirated a peanut—don’t ask me how the kid found a peanut at three
AM
. His airway’s patent right now, but he’s stridorous. Noonan’s the ENT guy on tonight. He says he’ll be here in ten minutes. Wants to have the baby waiting for him in the OR, so we’ve got staff setting up now.”

His words come at me in a blizzard in this half-awake state. I have to pause for a minute to align the facts into the proper keyholes of automatic anesthesia protocols.

“When did he last eat anything?”

“You’ll love this. He drank eight ounces of formula just before he found the nut.” So now his airway will be further jeopardized by the risk of vomiting when he’s put to sleep.

“I don’t suppose he’s got an IV yet.” I reach for my stethoscope and twist my foot under the bed to rake out my shoes.

“We tried, but one cry and his breathing got worse. I was worried he might close off completely.”

It is a balance of risks. If we struggle to put an IV in the baby while he’s awake, his crying could suck the peanut farther down his tiny trachea, effectively strangling him. If he stops breathing I’ll have to push oxygen into his lungs, forcing the peanut deeper—its damage as random and unpredictable as a brick tossed by a tornado. But without the IV in place I can’t give him emergency drugs if he gets into trouble.

“Do you want me to get him over to the pre-op holding area?” Jim asks.

“No. If he’s at all unstable just keep him there and I’ll come talk to his parents and transport him.”

I am awake enough now to move into my professional zone, generating a list of emergency equipment and personnel I’ll need. As I pass the mirror in the call room I see my hair splaying in every direction. Mascara smudges look like matching bruises. Not exactly a reassuring face for distraught parents to relinquish their child to. I twist my hair up into an operating room hat and scrub away the black smudges with a paper towel. I’m shivering in the dark, chilly room, as if I’ve run out of the basic energy it takes to keep my body warm.

The emergency room smells of ethanol and body odor, bleach and ammonia. The hallways bristle with damaged bodies. My pager goes off again. The six-digit code swimming in the luminous green LED like some tropical aquarium specimen is for an outside call. It’s Noonan.

“Who?” he asks when I say my name. “Oh right. Anesthesia. I’ll be there in five minutes, so go ahead and take the foreign-body kid into the operating room. I also just got word of a tonsillar bleed on the way in, so we’ll have to do him right after this one. Hey, and make sure they have my peds tracheostomy tray there—they totally fucked that up last time and gave me the standard tray.” A change in the static on the line tells me he’s hung up.

The baby, Toby Earle, is in the cubicle nearest the admissions desk, where he can be observed more closely than the migraines or vague belly pains that stack up for hours behind more threatening emergencies. He is sitting up in a padded metal crib clutching one of the stuffed animals handed out by the staff to disconsolate children. Sam, a respiratory therapist, holds a misting oxygen mask near his face.

Toby is still pink, but his right chest wall contracts slightly with each breath, so the peanut has probably slipped past the trachea into the right lung. That could be good—it means his left lung should be clear. But any coughing might jolt the nut back up into the main airway and then both lungs could be blocked. His mother is leaning across the lowered crib rail, rubbing his back and singing softly to him. She doesn’t look more than twenty to me, but she’s keeping the panic in her eyes from infecting her voice. The child’s father appears less in control. He stands behind the pair of them, rigidly rocking from side to side in paint-splattered work boots, his hands leashed under tightly crossed arms.

Toby is a round, wide-eyed child with a scant sheen of blond hair and prominent ears. He has an incongruously mature face, like a Renaissance image of the Christ child. From several feet away I can hear the work of his breathing. He is assessing me, slotting me into the jumbled mix of alarming sights and noises that surround him, deciding whether I represent a safe zone or another threat.

“I’m Dr. Heaton. I’ll be Toby’s anesthesiologist this morning.” I make my voice sound reassuringly rested and secure. In this next minute I must become, for these terrified parents, the healer whose authoritative hand will lead them off the ledge of despair. His mother stares at me as if what she reads in my face will define the rest of her life. Her son’s survival is not up to God, or fate, or the unconfessable parental lapse that left a peanut lying like a bullet in their baby’s reach. I am the determiner of her child’s fate. It feels like the clutch of a drowning swimmer.

Toby sways with the currents of his breath, which push and pull against the blockage. I want to race with him through the labyrinth of empty hallways to the operating room, to cross magically into the moment when Noonan will lift the peanut, clasped like a diamond between the tines of his fiber-optically guided grasper, and drop it ringing into a metal bowl. We’ll laugh with the relief of tension, wonder at the way children harm themselves—that any survive the risks of childhood. I’ll wake him up and carry him, pink and vital into the recovery room.

I ask his mother about his medical history as quickly as I can. Does he have any drug allergies? Any heart or lung problems? Was he born prematurely? Has he ever been hospitalized or under anesthesia before?

Then I hold her eyes, looking into a well of maternal fear I’ve never experienced. “I need to take Toby to the operating room now. I’ll be there with him every moment. I will do everything possible to keep him safe.”

She stares at me, struggling, hoping this foreign medical world holds all the power it promises. “Take care of him. Take care of my son.”

Elaine, the circulating nurse, helps me roll the metal crib down the hall. Toby has begun whimpering at the separation from his mother. Sam walks with us, holding the oxygen-enriched mist just below Toby’s face, and the two of us are supporting him so he can sit forward, hopefully keeping the peanut from shifting position. I grab a warm blanket from the heating unit and enfold him. Holding him so close, I hear his faint, quick wheezing as the peanut wafts and rubs deep inside his airway, hovering like a menacing bird on his shallow breaths. The finest vibration passes through to me with each exhalation, the smallest contraction of his upper body with each inhalation. His hair is so smooth and warm I have to press my lips to it; he smells of baby shampoo and the moist, inviting scent of new unblemished skin—a sensation as much as an odor.

He is calmer now, soothed in the soft folds of this blanket and my arms. He is safe for this dangling moment, balanced between breath and suffocation. His risks loom when I begin to put him to sleep, when I enclose his nose and mouth in the cold blue plastic of the anesthetic mask and turn the dial on the gas canister, flooding his lungs with the sweet-scented cloud of chemicals that will suffuse from lung to blood to brain. During that infinite instant of time any mistake I make could be fatal.

Sam slips the oxygen monitor onto Toby’s toe. It’s beeping high and fast with the pulse of oxygenated blood pumped from a frightened heart. We are taut and still, waiting for Noonan to arrive—a stage set waiting for the curtain cue. I look over my shoulder to see if he is here and spot the room number above the doorway.

Three months ago I was in this room with Jolene Jansen. I was standing at the head of this operating room table and Jolene was slipping from life into death while I tried to pull her back across to this side of consciousness. Her heart was pulsing on this same monitor. I can still hear the high tone of the monitor’s beep, then the steady drop in pitch as her airways closed and her oxygen level fell.

It’s hot and sweat collects under my arms. My head throbs with the rush of my own blood. The carefully planned sequence of actions I have mapped out to put Toby to sleep doesn’t make sense anymore. In the next five minutes whatever I do, or forget to do, or do incompetently may kill this child. In half an hour I could be standing in front of Toby’s mother telling her that Toby died. That I let him die. That I made the wrong choice at the wrong moment and he died because I was his anesthesiologist instead of the doctor who may have worked last night or who might work tomorrow.

I look up and see Elaine watching me, waiting for my signal to begin Toby’s anesthetic.

“Elaine.” My mouth is so dry I have trouble forming the words. “Page Dr. Hanover. Page him stat and tell him to get here as soon as he can.”

Noonan comes banging in through the operating room doors and sweeps his eyes over the collection of nurses, technicians and me, ready to spring into action at his dictatorial order. “OK, let’s get this on the road.” He pulls on latex gloves and checks the fiber-optic scope, looks over the instruments fanned across the surgical table. He glances up and scans the faces of the crew, stopping at mine. He is waiting for me, staring at me standing motionless behind Toby, my hands wrapped around the baby’s panting torso. Heat rises into my cheeks. Noonan drops his gloved hands to his sides, the flexible scope swinging like a snake between them.

“I’ve called for backup,” I say, looking away from him. There is a tight knot just below my vocal cords that makes me gasp for enough air to speak. “We have to wait. The baby’s stable right now and my backup is on the way.”

Noonan looks as baffled as if I had spoken in tongues. “You’re kidding. It’s five in the morning, this kid’s got a frickin’ peanut stuck in his lung, and you’re gonna wait for backup to drive in?”

I look directly at Noonan with my last fragment of control. “We’re waiting for backup. I’m not putting him to sleep until Dr. Hanover gets here.”

Five interminable minutes later Will Hanover arrives, sweating and red, banging the OR doors open so they slam against the tile walls. He must have run all the way from the parking garage. “Marie,” Will says, breathing hard from his sprint. “What’s the story?” He is looking at Noonan, Toby, me, trying to piece together the medical emergency I have called him in for.

“Toby is a ten-month-old who aspirated a peanut about an hour ago. He’s got a full stomach, no IV yet. He’s otherwise healthy, no allergies or medical problems.”

“Right,” Will says, catching up on his breath and stepping in to take the oxygen mask from Sam. “How can I help?” I hear the deeper question in his voice—why have I delayed this procedure to call him into the hospital? Why can’t I, an experienced anesthesiologist, handle this case by myself? But I can’t answer him. I can’t explain to him why I have to leave this room right now, before Toby goes to sleep, before I might hear his oxygen monitor go down, before I hear any strained and frantic commands of an anesthetic emergency.