Chapter Twenty

November

I was the junior resident on call at St. Mary’s when they brought Ben in. There wasn’t much anyone could have done for him. He was probably dead before they loaded him in the back of the pickup. At least that’s what I kept telling myself.

And I kept thinking foolish things. I kept feeling guilty that while his arm was getting torn off I was lying on a couch in the residents’ lounge reading Louis L’Amour. Why? What possible reason did I have to feel guilty?

I don’t know, maybe it wasn’t guilt. Maybe it was frustration that we couldn’t help him, that our best wasn’t good enough. Or maybe it was resentment that life isn’t all smiles, and surgeons aren’t always successful, and sometimes the bad guys win.

He was only sixteen. I learned later that he and his three brothers had been bringing in the corn on their father’s farm near Kasson when the sleeve of Ben’s blue jean jacket got caught in the power take-off. He must have turned and brushed against it. One second he was fine, the next he was yanked sideways, flipped over the power take-off, and slammed headfirst to the ground. His body wedged under the wheels of the tractor, and as the power take-off kept spinning, his left arm was tensioned terribly, then torn from its socket with a sucking, popping sound. Blood began spurting from the gaping wound at his shoulder.

The other boys stared, first at their brother’s body and then at his arm, caught in the power take-off, spinning round and round, spraying blood everywhere, making a rapid phlap-phlap-phlap-phlap noise as it hit the ground with each revolution.

Evan, the youngest, was the first to reach Ben. He stopped short of the body, as though afraid to approach it. “Ben?” he said tentatively. His two older brothers pushed Evan aside and knelt down next to Ben.

Norman turned him over. “Oh, Jesus, Ben,” he said, leaning forward to touch his cheek. Ben’s eyes were closed. The top of his head was swollen. He wasn’t moving.

Donald scrambled to his feet, leaned over, and shut down the tractor. Ben’s arm made one last phlap sound as it hit the ground. Then it dangled obscenely from the greasy metal coupling. Blood was pumping steadily from the gaping hole in Ben’s shoulder. Norman tried to smother it with his hand, but the blood leaked through his fingers.

“Shit,” Donald said, watching the blood pour from Ben’s arm socket. “He’s gonna bleed to death if we don’t get him to a hospital.”

He and Norman lifted Ben and carried him to the pickup. They set him down in the dirt while they dropped the tailgate, clambered onto the bed, and heaved the four bales of hay over the side. In the distance the boys could see their father’s tractor moving silently up and back through the north field a half mile away.

“Evan!” Donald shouted. “Go tell Dad what happened. Tell him we’re going to take Ben to St. Mary’s.”

Evan was still standing next to the spot where Ben had been thrown. He was staring at the dark spot in the dirt at his feet. He looked first at one brother, then the other. He seemed not to have heard.

“Evan, goddamn it, go tell Dad!”

Evan jerked suddenly and began running toward the north field. “Dad! Dad!” He was screaming and waving his arms as he ran. Norman and Donald lifted the body of their brother into the back of the pickup.

“You stay with Ben.” Donald said. “I’ll drive.” He vaulted over the side and sprinted back to the power take-off. He pulled tentatively on the mangled arm entwined around the dirty shaft. It wouldn’t come free. He pulled again, more forcefully this time, but it still wouldn’t come loose. Finally, he took his jackknife and cut away the sleeve. He carried the arm back to the pickup and laid it on the seat next to him. Norman meanwhile had hooked his right arm over the side of the truck. With his left arm he lifted Ben’s head and cradled it in his lap.

“Oh, Jesus, Ben,” he kept repeating.

Donald rammed the truck into gear and it lurched forward, spraying gravel and manure from the rear wheels. Norman was flung first backward, then forward as the truck shot out of the farmyard.

The ER had no clue they were coming. Donald pulled right up to the ambulance entrance. He ran in, holding Ben’s bloody arm in his left hand, and started yelling that he needed help, that his brother was “hurt bad.”

John Stevenson, who was on ortho trauma call, Joe Stradlack from the ERSS, and Jeannie Popp, the head ER nurse, saw him waving the bloody arm. They ran out to the truck where Norman, tears running silently down his cheeks, was still sitting in the back of the pickup, stroking Ben’s hair. They loaded Ben onto a gurney and wheeled him into Trauma One.

I was up in the call room when my beeper went off. “Dr. Collins, please call the ER, 5591, 5591, 5591. Please call the ER, STAT, 5591.”

They don’t say stat in the ER unless they mean it, so I immediately picked up the phone. “Code in Trauma One,” I was told. “Kid with a power take-off injury.”

I threw my book aside and sprinted down the stairs. I got there just as Joe finished putting in the subclavian line. I glanced at the monitor over the bed and saw the patient had no rhythm. Then I saw he had no arm.

The nurses were squeezing O-negative blood into him as fast as they could. John Stevenson was fishing around in the bloody stump of the axilla with a hemostat looking for something to clamp, but by then the kid didn’t have much blood left anyway.

We went to work. We pumped him full of blood, shot him full of drugs, flailed away with CPR, clamped and cauterized various unrecognizable strands of vessels in the stump. All the while his skin kept growing colder, and doughier, and bluer. John and I kept looking at Joe out of the corner of our eyes, wondering, waiting, thanking God it was his call, not ours. Finally, when we had done everything we could think of, twice, Joe slowly straightened up and tossed a bloody wad of 4×4s on the kid’s chest.

“That’s it,” he said.

The code nurse asked, “Are you calling the code, Doctor?”

I wanted to shout, “What the hell do you think he’s doing?” but Joe just said quietly, “Yes, I’m calling the code.”

 

As usual, I had no time to think about what had just happened. For the next eight hours there were lacerations to sew up, consults to see, fractures to set. At 4:00 A.M. I wrapped the last bit of plaster around the leg of the seventeen-year-old girl in the car crash, wrote out her prescription, and dutifully recited the fracture care instructions to her parents.

I took the elevator to the sixth floor and walked down the silent corridor to the call room. I shouldered the door open. It banged against the opposite wall and slowly swung shut behind me. The wooden chair scraped across the marble floor as I pulled it from under the desk. I dropped into the chair and closed my eyes. It was quiet up here, away from the patients and machines. It was nice to sit with my mind turned off for a while. I slumped back in the chair, thankful for the silence. Somewhere down the hall, a door opened and closed. I heard the steady click of footsteps approaching and then gradually fading in the distance.

My shaving kit was sitting on the desk where I had left it twenty-one hours before. The room was immaculate. The cleaning ladies had come around in the morning after everyone left for surgery or rounds. At that time of day, the rooms were always a mess. Newspapers, call schedules, notes, and lists littered the floor. Wet towels lay in a heap in the corner of the bathroom, or hung limply from the back of a chair. The rooms often were dirtier than they had to be, almost as though the residents, tired of feeling abused, tired of cleaning up other people’s messes, had decided to abuse someone else, to create a mess for someone else to clean up.

I had never seen the cleaning ladies. I had never been in the call room when they were around. There was just too much to do. While we stitched up wounds, assisted at surgery, or set fractures, the cleaning ladies swept floors, changed sheets, and washed the sink and shower. They scooped up the disordered pile of books and arranged them tidily with Charnley’s Closed Treatment of Common Fractures, two old anatomy books, and the aged copy of Campbell’s Operative Orthopedics neatly stacked on their sides propping up a long row of well-worn Louis L’Amour paperbacks.

The sheets and gray woolen blanket were tucked tight and crisp under the mattress. The doors, the walls, the desk, the square metal ends of the bed, all rose and intersected at their perfect right angles. Everything was so symmetric, so defined. Sometimes, coming back to this room late at night, the cleanliness, the order, and the symmetry would comfort me. But not tonight. Tonight the incongruity of it all overwhelmed me.

Everything inside me seemed to have been beaten away. I wasn’t tired. I wasn’t depressed. I wasn’t sad, or outraged, or horrified. I was just empty. I kept seeing the gaping hole where Ben’s shoulder should have been. I kept feeling guilty that Ben’s death was another step on my learning curve, another item on my résumé. I needed things like that to become a surgeon. They brought me a step closer to my goal.

The whole thing made me sick. I wondered if any goal could be worth all this. It wasn’t that I minded the work. In some ways the mind-numbing drudgery was my salvation. It was a crutch, a shield. I got tied up in it and it insulated me, protected me. It used me, but I used it, too; and I had drifted into a comfortable marriage with it. I immersed myself in work in order to distort and disguise what I did.

That was not a human being my scalpel was slicing through. It was a knee. No, not a knee but a meniscus. No, not a meniscus but a target, a single unit of focus upon which my attention could be riveted. It was like one of those sequences of pictures from outer space where first we saw the North American continent wedged between two vast oceans, then we zoomed down to New England, then to Vermont, then finally to the little town of Mapleton where, in the backyard of that Victorian house on Elmwood Avenue there was a dark red picnic table upon which a baked potato lay steaming. The larger context was irrelevant. The locus of the potato was inconsequential. At that precise moment there was nothing outside the framework of the lens.

A young boy slipped and got his arm caught in a power take-off. He came to the ER with a gaping hole where his arm used to be. How much easier it was to focus on some specific thing: his hypovolemia, his lytes, where we would take the vein graft, what kind of ex-fix to use. We are not meant to see sixteen-year-old kids die. We are not meant to see arms ripped out of sockets.

My bloody hand, removing the last shred of Ben’s brachial plexus, was neither bloody nor mine. The plexus was neither severed nor brachial. It was merely a white target in a red-black hole. I could avoid the implications of my actions by ignoring the context in which they took place. They were isolated acts, devoid of meaning or greater significance. But I couldn’t deceive myself forever. The hand that emerged from that gaping wound was not the hand that had entered it, and the eyes that finally turned away from that mangled corpse were not the eyes that first registered the gory scene.

I picked up my shaving kit and walked into the bathroom where I brushed my teeth and splashed some water on my face. As I dried myself I held the towel against my eyes for a few seconds, then draped it over the sink. I had no interest in seeing the face in the mirror.

Why couldn’t I just take things as they came? Why was I continually looking for reasons and meaning? Reasons and meaning are not pragmatic. They are not the stuff of residencies. BJ Burke was not interested in what I thought or understood. He was interested in what I did.

“If you want to learn to be sensitive and introspective,” he would say, “do it on your own time.”

I imagined myself being called into his office. As I enter the room he is seated at his desk, reading the report in front of him. He makes certain I know I am being ignored.

At length he looks at me over the top of his glasses.

“Dr. Collins, what is your job?”

“My job, sir?”

“You have a job, don’t you? You get a paycheck, don’t you?”

“Yes, sir.”

“Well, what do you do?”

“I’m a second-year orthopedic resident at the Mayo Clinic.”

“Do you want to be a third-year resident someday, Dr. Collins?”

“Yes, sir.”

“What is an orthopedic resident supposed to do?”

Where was this going? “Follow orders?” I venture.

“An orthopedic resident is supposed to practice orthopedics, Doctor. He is not supposed to go around asking patients if they have ever considered the ontological implications of their fragile, mortal state.”

“I didn’t exactly—”

He jumps to his feet and points his finger at me. “We fix things. Do you understand that? We don’t analyze things. We don’t discuss things. We don’t wring our hands and cry about things. We fix them! If somebody wants to be analyzed they can see a shrink. When they come to the Department of Orthopedics at the Mayo Clinic they want only one thing: they want to be fixed.

“Now get the hell out of here and go fix things. And I better not get any more reports of touchy-wouchy, hand-holding sessions in this department.”

 

I wondered how my colleagues dealt with this issue. I suspected they did as I did: they tried to ignore everything but “the fixing.” But isn’t even the least perceptive of us eventually bound to question what he is doing?

What we were attempting to fix was, as BJ said, “our fragile, mortal state.” But mortality can’t be fixed. We can rod a femur or plate a radius, but sooner or later we have to confront the absurdity of what we do.

But, of course, BJ was right when he said what we understand doesn’t matter. All that matters is what we do. No one cares how philosophically perceptive their surgeon is. They just want someone to fix them. There would be time for “all that philosophical crap” later. But that philosophical crap doesn’t go away. It’s still waiting for you when you get back to your call room late at night.

I discussed this once with Jack Manning. Jack never seemed interested in delving into the deeper meaning of his work. He was content to fix what he could, and let it go at that. When I told him what was bothering me, he very accurately articulated the problem surgeons face, and then succinctly enunciated the appropriate response to it.

“Shit happens,” he said with a shrug. And then, looking up, “Fuck shit.”

It was 4:30 I had to make rounds in an hour and a half. I didn’t even bother to kick off my shoes. I lay down, shifted the stethoscope in my hip pocket so it wouldn’t dig into my side, and pulled up the blanket from the foot of the bed.

“Fuck shit,” I said, and closed my eyes.