DEPENDING on the specialty I was rotating through, I spent every third night, sometimes every other, in the hospital, on call. Those nights pulled me away from my family, but I was getting to do things that other people only watch on TV. I delivered babies, treated septic shock, and pulled dislocated shoulders back into place—I was acquiring the skills I’d be using for the rest of my career. And although it was a stressful period, I knew it would be temporary: once I finished the three years of residency training, our growing young family would be happier. We were already doing okay—John, our newborn, had arrived without any health problems, and we were able to afford for Sally to stay home with the children, something she’d always wanted to do. All we had to do was stick it out until I finished residency training.
Occasionally I’d remember Kyle, the intern I’d met when I was a nursing assistant. I hoped to acquire his sheen of competence without taking on his apparent indifference to the suffering he saw. On most rotations, I could steal a couple of hours of sleep each night, which made it easier to care about patients, or at least fake it. But on the trauma service, the relentless grind eventually peeled away my defenses, and showed me a part of myself I would have liked to deny.
One Saturday night, Fast Eddie, the chief resident, sent Jonsie McClendon and me down to the ER to check out a drunk who’d flipped his car. The paramedics had bandaged his scalp laceration, put him in a neck collar, and strapped him to a spine board before bringing him in.
The ER had asked for a trauma consult because the guy’s mental status was hard to evaluate: he could just be a drunk, or he could have a closed head injury. In a car crash, the brain can get bounced around inside the skull, shearing connections. And if a vein or an artery gets torn, a blood clot grows and grows, compressing the brain until it no longer functions.
Jonsie and I walked down to begin the process of evaluating him for admission. We knew that if the guy was severely injured, the ER would have called a “trauma code,” and the whole team would’ve rushed down to take the guy immediately to the operating room. When they called for a routine consult, the injuries were usually minor. In those cases, we usually got a bunch of CT scans, and admitted the patient overnight, just to make sure we had not missed anything.
We went to the dry-erase board in the center of the ER and found our guy’s room number. Sighing, Jonsie grabbed a packet of admission paperwork and handed it to me. When we walked into the trauma bay, the ER resident gave us a quick verbal report, then ducked out of the room. The drunk guy was snoring loudly, filling the room with the smell of beer and vomit. Blood had splashed down the guy’s face and onto his flannel shirt. Thick strings of partly digested food and saliva had soaked into his beard. He was a large man, his shoulders extending far past the plywood board the paramedics had strapped him to.
“Sir,” Jonsie said in a loud voice, pulling on a pair of latex exam gloves he’d gotten from the box on the counter, between the contaminated needles box and IV supply box. He prodded the man’s shoulder. “Are you okay?”
The guy mumbled something, and pushed Jonsie’s hand away.
“He’s drunk.” Jonsie wiped his gloved hand on the sheet. “Ought to chew his food better, too.”
“Gonna scan his head?” I started writing routine admission orders.
“Well, yeah.” Jonsie snorted. “But we both know it’s going to be normal.”
We did a quick physical exam, looked at the X-rays the ER had made, and put in an order for a head CT. When the scan tech called and said they’d do our patient, we pushed the gurney downstairs. Even with the routine cases, Jonsie and I didn’t like to wait for transporters—the sooner we got this guy tucked in, the sooner we could get back to our other work.
Down in the CT suite, we helped the tech slide our guy over to the scanner’s table. Jonsie and I sat in the chilly outer area, finishing our chartwork at a desk that allowed us to observe our patient through a small glass window.
The table slowly glided into the large, open ring of the scanner. Just as his head slid in, the man woke up, started screaming, and tore off the collar the paramedics had placed around his neck. Big guy.
Jonsie yelled to the CT tech, “Call the ER, get someone to come tube this guy!” We scrambled in to hold the man down, keeping him on the scanner table until someone could come down, sedate, and intubate him before he hurt himself.
It was slippery work because he was sweaty, strong, and determined, but we kept him pinned to the table.
Years ago, if a trauma patient was too drunk to cooperate, he was left in a corner to “sleep it off” until he was sober enough to cooperate with his evaluation. Some of these patients had brain hemorrhages that were masked by the intoxication. The right way to evaluate a combative major trauma patient is to give him Vecuronium, a medication that will pharmacologically paralyze him. It’s a derivative of curare, the stuff South American native people put on the tips of blowdarts to paralyze their prey. You inject the medicine, and the patient loses all motor strength. Of course when you do this, the patient can no longer breathe, so you have to insert a tube into his trachea to breathe for him.
One of my attendings from the ER came in, paralyzed the guy, and intubated him right on the scanner table.
Jonsie and I relaxed our grips as the guy went flaccid. I looked at my hands, smeared with blood and vomit because I hadn’t had time to put on gloves. Jonsie looked at his, which were smeared red, too. He shook his head.
We went to wash our hands. “He’d better fucking hope he doesn’t have AIDS,” Jonsie said as he scrubbed. He rinsed his hands, and scrubbed again.
We both knew that the trauma attendings and Fast Eddie were going to give us a hard time about a crash tube, down in the CT scanner. “Control,” they were going to say. “You had no control of the patient, his airway, or the situation.” They’d cross their arms and shake their heads, as if hoping we’d learned our lesson. As soon as the attending left, Fast Eddie would say, “You get down to Scan Land with a patient without securing an airway, you’re fucked.”
When we got back to the scanner from washing our hands, the ER attending physician left. The drunk guy’s head CT was normal. He was just drunk.
Jonsie leaned over the guy’s face, immobile because he was still paralyzed from the medication. “You couldn’t be a happy drunk, could you?” Jonsie yelled, bits of spit flicking out onto the guy’s face. “Noooooooo. You had to be an asshole.” His voice scaled upward and the veins on the side of his neck popped out. “Now you’re fucking paralyzed.”
I understood Jonsie’s frustration. And I knew the drunk probably wouldn’t remember Jonsie yelling at him in the morning. But damn—I knew I’d never yell at a patient like that. Still, I envied Jonsie’s catharsis.
Jonsie, the CT technician, and I put on gloves and pulled the drunk over to our ER stretcher. Jonsie and I wheeled the guy up to the trauma intensive care unit, where we moved him onto a bed.
Many of our patients are intoxicated when they come in. Sometimes, a sober guy will show up. A tree trimmer who’s fallen thirty feet, or a sober driver who’s wrecked his car. They are easier to take care of, because they know they’ve been injured and want to do anything they can to help us take care of them. Even some of the patients who are intoxicated are easy to work with. “Whatever,” they’ll say, with a benign wave of the hand. But others will argue with the cops, with the nurses, with the docs, anyone who has to talk to them. And it gets tiresome. Real, real tiresome. Especially for the residents who plan to go into general surgery, or plastics, where they won’t have to interact with drunks. As an ER resident, I knew drunks would be a significant part of my working life, so I wanted to get good at dealing with them. I thought it was possible. I couldn’t know that later in my trauma rotation, a drunk would cause me serious problems.
During my first month on the trauma service I went with Jim Spangler, one of the other surgery residents, to babysit a drunk in the ER. Three thirty in the morning, on our tenth admission. We’d been up all night. I felt a buzzing need to sleep.
Jim and I walked into the X-ray room. Melinda, an ER intern I didn’t know that well, leaned against the wall next to the patient’s gurney. “Lay flat, sir,” she said in a bored monotone. “Don’t lift your head, sir. Your neck might be broken.”
The drunk struggled to lift his head. “My neck isn’t broke,” he slurred.
The intern gently pressed down on his forehead. “You’re intoxicated, sir,” Melinda said. “You could have a fracture and not know it.” She was, of course, right. Intoxication is one of the documented risk factors for having an undiagnosed cervical spine fracture.
“I’m not that fucking drunk,” he said, lifting his head again.
When Melinda saw us, she stripped off her latex gloves. She motioned to the guy with her head. “Unrestrained driver, not ejected, steering wheel bent, windshield starred. Stable vital signs. He’s been like this since he got here.” She paused, to see if we had any questions.
We didn’t. I was impressed that she had the rap down so tight within the first months of internship. Of course, she’d already had lots of practice.
She left.
The drunk raised his head and tried to look at us, but his collar limited his motion. “Put your head down, sir,” Jim said, as he leafed through the paperwork on the clipboard. I started writing his admission orders.
The drunk continued to try to look at us.
“Put your head down, sir,” Jim repeated, a sharper edge to his voice.
“My neck isn’t broke,” the drunk said again.
“Put your head down, sir.”
“Fuck you.” The drunk tried to spit at us.
Jim grabbed the guy’s hair and snapped his head back onto the plywood backboard, his face inches from the drunk’s. “Listen, dickhead. You fuck yourself up on my watch, and my ass is in trouble.” He thumped the guy’s head against the board again. “Got that?”
The drunk nodded his head, in the small arc the collar permitted.
“Stop moving your fucking head.” Jim went back to the chartwork.
I wished there was a way I could’ve warned the man: “Buddy, it’s way past midnight and you’ve fallen among savages. Do what we say, you won’t get hurt.” Of course, I’d already discovered the futility of reasoning or pleading with drunks. Jim’s method had the advantage of simplicity, clarity, and honesty. It just wouldn’t sound good to anyone who hadn’t been in our position. “Sir,” I said, “wiggle your toes and fingers.”
He did.
The guy had on a neck collar, and I knew Jim thumping the guy’s head against the board wasn’t that likely to exacerbate whatever injury he might have, but I wanted to establish that he was still in as good a shape as when we’d taken over.
“He’s fine,” Jim said. “Fucking indestructible.”
Some drunks are like Otis, the bumbling, amiable guy on The Andy Griffith Show. Others are like the ones you remember from college, playing drinking games—laughing, carefree souls. And some can be snappy, sharp-tongued, saying outrageous things that challenge the pomposity of docs and nurses. By and large, the worst they may do would be to try to flirt with the nurses, or grab at a nurse’s ass as she walks by.
But other drunks, the ones who’ve gotten in fights or wrecks trying to outrun the cops, are combative, angry, dangerous people. And we all know that the same guy who spits at you through bloody lips and calls you motherfucker will be sober when he sues you if there’s a bad outcome in his care. In court, his face will be freshly shaved, his hair carefully combed. He’ll be contrite for having been intoxicated. His lawyer will be baffled by the way doctors let him injure himself while he was incapacitated.
To let hostility show is a failure. A failure of boundaries, a failure of self-control. If you counted on human compassion to keep you from smacking one of these guys, you’d be in trouble by the third day on the job. And if you let them get to you to the point where it shows, you have no business being an ER doc.
On one level, taking care of drunk patients became just another aspect of the trauma service I had to get used to—part of the price I had to pay to get the training I needed. Like the cold, drab weather in Pittsburgh, complaining about it wouldn’t change a thing, so I tried not to talk about it too much at home. I had so little time off, I hated to waste it thinking about the hospital.
Sally and I had now been married six years. She had worked part time, as a nurse, in a different hospital, until John, our second child, was born. We didn’t have a cradle when John arrived, so we pulled a drawer from a maple dresser, padded it, and placed it next to our bed. Sally could lean over, pick him up, nurse him, and put him back in his drawer without getting up.
Sarah, four years old, went to a day care with special education teachers and occupational therapists. She’d been labeled as “high functioning,” and when they tested her IQ, it was only a few points away from low-normal.
Sally and I, like all couples, had things we had to deal with: Sarah’s Down syndrome, a new infant, moving to a new city, the chronic exhaustion of residency training.
So, if I had a weekend when I wasn’t on call, I didn’t want to think or talk about work. I’d rather build a sandbox in the backyard for Sarah, or take a walk with Sally, pushing Sarah in the stroller or carrying John in one of those baby backpacks, up and down the hills of the working-class Pittsburgh neighborhood in which we lived.
In the second month on the trauma service, I was at home, eating supper with Sally and Sarah. John was upstairs, sleeping in his drawer. The phone rang—my dad. When they’d divorced years earlier, Dad had remarried; Mom hadn’t. As one would expect, they’d both wanted me to take their side. Both had told me things about their relationship I didn’t want to know, and both had leaned on me too frequently. I’d finally gotten a cushion of time and distance between me and my parents’ divorce, but I still felt a wariness when either one called.
“Paul,” he said, his voice shaking, “I’ve got lung cancer.” He paused, and continued, “I’m scheduled to have it taken out in two days.”
“Oh, Dad.” Fucking lung cancer? I felt myself retreat from the news.
“I feel guilty,” he said, “for calling you like this.”
“Guilty?” I asked. For having lung cancer?
“It’s my own fault.” He coughed. “The smoking all these years.” He coughed again and cleared his throat. “I feel like I brought this on myself.” His voice rasped. I couldn’t tell if something was hung in his throat, or if it was from the emotional pressure of what he was trying to say. “So I’m sorry.”
“Don’t worry about any of that,” I said. “The only thing that matters is you getting well.” I stared down at the black-and-red-square pattern of the linoleum in our kitchen.
The line was silent. I looked up at Sally, who quietly put her fork down on her plate. Sarah stared at me as she slowly gnawed on the string bean she clutched in her fist.
“So.” Dad cleared his throat. “I’m going to have it removed in a couple of days.”
“Where?”
“At the hospital here.”
“Let me talk to someone at UNC.” My hometown hospital was reputable, but I wanted Dad to have the best.
“No,” Dad said. “I trust the surgeon here. You’d like him. A real straight shooter.”
“Chapel Hill’s only a couple of hours away.”
“Paul, the decision’s been made.”
“Okay. I’ll come down tomorrow,” I said, wondering how I’d work it out with the trauma team.
“You don’t have to do that,” he said. “The surgeon said it should be quick and simple.”
Quick and simple—lung cancer? “Dad, I want to be there. I’ll call tomorrow.” We hung up.
“Is he okay?” Sally asked. She reached for my hand.
“Has a lung mass.” I took Sally’s hand, our fingers interlaced. “Local surgeon’s going to resect it in two days.”
“Are you going down?”
“I’ll try to.” I hoped Fast Eddie would let me go. I didn’t want to take it up the chain of command, but if I had to, I would.
There’s a macho culture in surgery, and trauma surgery offers its ultimate manifestation. It’s like the boys’ locker room in junior high. Lots of bullying and joking. The overriding culture is: “Don’t complain, don’t explain.” I’d first experienced such a culture in Catholic high school. I’d grown up Quaker and had been in public school all through elementary and junior high school, but when I was in tenth grade, my parents put me in Bishop McGuinness Memorial High School. I’d never heard a Hail Mary or seen a nun, except on TV. I learned quickly that the most efficient way to navigate a problem with a nun was to say, “Yes, Sister,” “No, Sister,” or, “It won’t happen again, Sister.” Same thing in the fire department. If a piece of equipment was missing or broken or misplaced, the only sane response a firefighter could give was, “No excuse, sir. It won’t happen again.” I was luckier than some of my fellow residents who’d been the best and the brightest all the way through school. They seemed to think an attending surgeon would give a rat’s ass about why they’d made a mistake, or how it really wasn’t their fault.
On the trauma service, I felt like I was finally learning how to get along with surgeons. It isn’t an easy thing to do. There’s a whole mystique, a whole catechism you must learn, to go into an operating room. It involves sterility and etiquette. Both aspects of the endeavor have value. Sterility must be scrupulously maintained. And if a medical student is in the way, a surgeon could make a mistake. A scrub nurse teaches the medical students how to scrub in. You wash your hands carefully, scrubbing each finger ten strokes on the front, back, and each side. Then you scrub the palm ten times, then the back ten times, then the forearm ten times. The water cuts on and off with foot pedals. When you’re done washing and rinsing, you hold your forearms up in the air, like a supplicant, so the water drips down from your fingers, to your elbow, then to the floor. If you held your hands down, dirty water from your elbow would sluice down over your clean hands.
I enjoyed the ritual, the calming time of scrubbing, getting fastidiously clean. As you back into the OR, butt-first to open the door, a scrub nurse hands you a sterile towel that you use to dry off. Hands first, then wrists, then forearms, always going from sterile to non-sterile. Then you toss the towel into a hamper, and the scrub nurse helps you into a sterile gown. I felt like a prince, or a rich man having help from a tailor, as I reached in with my left arm then my right, twirling around, so the scrub nurse could sterilely hand me the tie at my waist.
Then the nurse holds out a sterile glove and you push your hand down into it, trying not to get two fingers into one slot. You feel a lot like a clumsy kid whose mom’s helping you get ready to go outside in the snow. If your fingers get crossed up, you can undo them when you get your other glove on. Then you stand, waiting to be motioned toward the patient. Like getting on a boat, you wait for permission. You do not speak. You put both hands on the sterile patient and leave them there, to make sure you don’t let them stray to a non-sterile place.
I enjoyed the OR. If it was an abdominal case, the surgeon often needed someone to hold a retractor, the stainless steel curved strap the surgeon would use to pull the intestines—a glistening, pale blue-white mass of squishiness—out of the way. And you’d hold the retractor, and get to watch, or daydream.
We also scrubbed in on cardiac cases. A bypass graft is a big operation that involves splitting the sternum in half and opening the chest like a clamshell. On the case I scrubbed in on, a physician’s assistant harvested vein from the patient’s leg for the surgeon to use when he made the bypass around the clogged portion of the coronary artery. I was allowed to sew up the leg, a low-skill endeavor. When I was done, I could watch the surgeon operate on the naked human heart.
Once, while scrubbed in on a coronary artery bypass surgery, the attending accidentally smacked me on the head with an elbow.
“Sleeve,” he then called out, turning from the table.
My head, non-sterile, had contaminated the sleeve of his gown. “Sorry, sir,” I said.
“It’s okay,” he said, although he’d been the one to elbow me.
An OR nurse hustled over with a sterile paper sleeve with elastic at both ends. She held one end open for him.
“Just don’t let it happen again,” he said, as he plunged his hand down into the paper tube. He turned back to the patient’s chest and held out his hand. “Scalpel.”
I moved away.
He didn’t notice me for the rest of the surgery. That suited me fine. On one level, he seemed like an asshole. On the other, if I had my hands in someone’s chest, I wouldn’t want a medical student crowding me. Of course, I think I’d ask them to give me a little room, rather than just smack them with an elbow.
Most of the surgery attendings and residents were good guys—and they were guys. There was only one woman in the general surgery program when I was there, and she bailed out. Surgeons reminded me of jocks—optimistic, not very introspective, quintessentially American: “Let’s fix it.” I liked that attitude, but their training didn’t seem to allow for much human weakness. And family leave was just as weak as maternity leave, so I was afraid they’d give me a lot of shit about wanting to get off work.
The next morning, I told Fast Eddie I needed to leave that night. “My dad’s going in for a partial pneumonectomy tomorrow,” I said. “I’d like to be there.”
He looked up from the chart he was working on. “Where’s he getting it done?”
“My hometown hospital.”
“Ouch,” he said, wincing. “Can’t you get him up here? Stone would do him.” Dr. Stone was one of the cardiothoracic surgeons who was regionally famous. Did experimental heart surgery. They’d named a wing of the hospital after him.
“Dad likes the guy down there.”
“When is it?”
“Tomorrow,” I said. “I’d like to leave tonight.”
“You on call?”
“I am tomorrow night.”
Eddie winced again, then said, “Don’t worry. Jonsie can cover for you.”
“Thanks.”
“But you can tell him.”
“Okay.” I went to the nurses’ station, called home, and asked Sally to get me a plane ticket for that night. After I’d graduated from medical school, our mailbox had been flooded with offers for credit cards and unsecured loans, so I wasn’t worried about how I would pay for the plane fare.
I paged Jonsie, and when he called back, told him about my dad. He said he’d take my call for me. If you worked hard and didn’t complain, even if you were an ER resident rotating through trauma surgery, the team would take care of you. I thanked him and promised to pay him back.
That afternoon, Sally paged me. My flight was at seven o’clock. If I left the hospital at five thirty, I’d get home by six, grab a suitcase, leave, and get to the airport by six thirty. I could shower at Dad’s house. If I could leave the hospital half an hour earlier, which was early for the trauma service, I’d have a little more leeway. I asked Eddie if I could get out by five.
“What?” He frowned, his eyes screwed up into a squint.
“I’d like to get out a little early. I gotta be at the airport by six thirty.”
“Airport?” He looked over at me. “Oh yeah, your dad.” He nodded, and slapped me on the shoulder. “Don’t worry,” he said. “We’ll get you out.”
At 4:30 P.M., I got a page, and returned it. “Paul,” Eddie said. “Go down to the ER, babysit some drunk that just came in. Unrestrained driver, ejected, never hypotensive. I know you gotta catch a plane, I’ll get Jonsie to relieve you in plenty of time.” He hung up before I could say anything. Must’ve had a problem upstairs.
I got on the elevator and jabbed the first-floor button. Some asshole had wrecked his car, and was going to moan and bitch. He’d pull at the chin of his cervical collar, and wiggle his toes. “See? I don’t need no fucking X-rays.” Yeah, yeah, yeah. But when you move your neck and paralyze yourself from the shoulders down, in a year or two you’ll get all dressed up in a nice dark suit and sit in a wheelchair in the front of the courtroom, staring straight at me.
I walked into the ER. “Where’s the trauma?” I asked one of my classmates.
“X-ray,” she replied. “You okay?”
No. I am not okay. I’m babysitting some drunk instead of going to see my dad. I kept on walking without replying.
In the X-ray room a guy was lying on a plywood backboard, and the X-ray technician was taping a film cassette beside his neck.
“Fuck you people,” the drunk shouted. “I told you, I don’t need no X-rays.” He fumbled with the Velcro tabs securing his neck collar. “Get me off this fucking board!” He tried to sit up.
I rushed to the stretcher, jammed my face into his, and shouted, “Shut up!”
He blinked as my spit hit his eyes.
“My name is Dr. Austin, A-U-S-T-I-N, and you’re going to shut up and lay down.” I ached to vent more of my pent-up anger but knew that I couldn’t. I was afraid that my father’s cancer could kill him, I was mad that I’d been delayed in getting to the airport, and furious that I had to babysit yet another drunk in the ER. My rage and restraint were perfectly balanced—but if the guy spit on me, or cursed me, I’d bust his face.
That must’ve registered, because he put his head down quietly.
His breath had the sweetly rotten smell of alcohol. I straightened, and took a deep breath. The two X-ray technicians and the nurse stared at me, their mouths open.
“What?” I demanded, looking around the room.
They glanced at each other, then back at me again.
“Well,” I asked, “you-all gonna make the X-rays, or not?”
The X-ray techs started moving again, talking quietly among themselves while adjusting the dials on their machines.
While one X-ray tech put the film in the processor, the nurse told the patient, “Sir, I’m going to put in a Foley catheter.”
“What?” he asked, trying to lift his head off the stretcher.
I rushed over and put my face into his again. “All you’re going to do is shut up and hold still.”
He let his head fall back on the board.
As the nurse pushed the thin rubber tube up into the guy’s penis, he hummed loudly.
I let him hum.
The X-ray techs took the last film, and the nurse and I wheeled the drunk back to his bay in the ER.
Leaning over a stainless steel stand, I started writing out the history and physical. I wanted to stay busy, so I wouldn’t worry about missing my plane. Jonsie hurried in. “Sorry I’m late,” he said. “Had a little problem upstairs.”
“It’s okay,” I said, as I handed him the paperwork. “I got the H and P done, but haven’t finished the orders.” I turned to go, then stopped. “Thanks, Jonsie,” I said. “I owe you one.”
“It’s your dad,” he said, looking up from the chart. “Forget this fucking place.”
“Thanks.” I rode the elevator to the lower level of the hospital. The doors slid open. I walked down the underground hallway toward the parking deck. I was glad no one was there, because I felt tears coming and wasn’t sure I could control them. Jonsie’s words, “It’s your dad. Forget this fucking place,” seemed like the wisest, kindest words I’d ever heard, and they threatened to open up feelings that I feared would overwhelm me. At the end of the hallway, I took a deep breath and let it out as I waited for the elevator. The doors slid open, and I rode to the third level, where I’d parked that morning, and stepped out into the pale gray evening.
I glanced at my watch: 6:05. We lived about twelve minutes from the hospital and twenty minutes from the airport, so if I skipped a shower, I’d make my flight in time.
At home, I stripped off my scrubs: 6:20. I jumped into a pair of jeans and a T-shirt. I stuffed some clothes into a suitcase, kissed Sally, and drove to the airport, drumming the steering wheel with my fingers. I parked in the expensive lot, right next to the terminal, and jogged to the check-in counter. I glanced at my watch: 6:45.
“You’ll have to hurry, sir,” the lady said, as she hefted my suitcase onto the conveyor belt behind her counter. “They’re boarding now. Gate Twenty-Two.”
I ran.
The flight attendants were checking the overhead compartments as I slipped into my seat and buckled the belt. I took slow, deep breaths and closed my eyes. I didn’t want to talk to the person sitting next to me, and I didn’t want to read the magazine in the pouch in front of me. I just wanted to sit, and feel the jet accelerate forward and upward, toward my father.