Chapter Twenty-Four

May

At five to seven on a warm spring evening I swung the old Ponch into the parking lot of St. Joe’s hospital and shut off the engine. The car lurched twice, gave several consumptive coughs, and was still.

The ER was empty, thank God. I had been doing an awful lot of moonlighting while I was on Basic Science, and was praying for a quiet night for a change. I said hello to the nurses who were sitting at the desk listening to the radio. Mary was folding towels and Jenny was doing a crossword puzzle. No, I didn’t know a seven-letter word for a wet-nurse. And, no, they didn’t know what the cafeteria was serving for dinner.

I tossed my shaving kit on the bed in the call room and sprinted down the hall. I had two minutes before the cafeteria closed. A guy in a white apron was just closing the door as I got there. I squeezed by him, grabbed a tray, and glanced at the chalkboard at the start of the serving line.

“What the heck is Cheese Florentine?” I asked the woman behind the counter.

She shrugged and pointed her serving spoon at a steaming tray of amorphous green material. “Cheese Florentine,” she said.

I still had no idea what it was, but my only other choice was lutefisk, so I took the Cheese Florentine. I ate the salad, the roll, the cherry pie, and the lemon square first. I was about to begin a cautious dissection of the warm pile of biochemicals on my plate, deciding where to make the first incision, when I heard the call for a code in the emergency room.

I dropped my fork and ran to the ER. A crowd of nurses, technicians, and red-jacketed ambulance attendants were gathered around a cart in the back corner of the ER, the spot reserved for critically injured patients. I pushed my way through the crowd and saw the motionless body of a little boy of about five lying on the cart. My crew of three ER nurses was doing all the right things: getting an IV in, starting oxygen, taking vitals.

“What have you got?” I asked Jenny as I scanned the child for injuries.

“Five-year-old boy, riding his bike. Hit by a drunk. He’s been here about a minute. Mary’s getting his pressure.”

The kid’s head was swollen to twice its normal size. The jagged shaft of the radius was sticking through the skin of the left forearm. He had a partially caved-in chest. I couldn’t feel a pulse. The boy was bleeding from his mouth, his chest, his leg, his arm, and his ear.

Mary pulled off her stethoscope and shook her head. “No pressure,” she said.

I opened one of his eyes and looked at his pupils. Fixed and dilated. For a moment all activity ceased. Everyone—Mary, Jenny, even the EMT doing CPR—stopped and looked at me. It was my call. Every bit of my medical training told me I should quit right there. It was hopeless. I looked at the others. They all waited, poised in mid-task.

Perhaps it was hopeless, but some things are just too terrible to accept. I pointed at the EMT. “Resume CPR,” I told him. I would not let this child be taken from us without a fight.

Jenny had started an IV. I ordered steroids and mannitol for the head injury. Being careful not to extend his neck, I slipped in an ET tube. I moved around the cart, barking orders. I did a cut-down and put in a CVP. I stimulated his heart with epinephrine. I put in a chest tube. I drew blood gases from the femoral artery.

I tried to focus on my job. I tried not to listen to the drunk who was crying and slobbering in self-pity two cubicles away from us. “All of a sudden he was juss there,” the man moaned. “He wasn’t, and then he was, and I couldn’t stop. I tried but I couldn’t. Oh, Jesus, I couldn’t. I juss wanna never happen…”

I kept feeling for a pulse, kept glancing at the cardiac monitor looking for a rhythm. Mary, doing the chest compressions, was starting to breathe heavier, gasping a little, as she counted out each compression: “One and, two and, three and, four and, one and…”

Still nothing. The IVs were running wide open. I couldn’t think of any more meds to give. I started wondering what the hell I was doing. Why was I poking and pushing and pumping and cutting and jabbing this innocent little boy’s body? Whom was I helping?

I kept telling myself that as long as we kept trying, there was hope. The little boy was not officially dead until we, until I, stopped coding him. I couldn’t stop. He was just a poor kid riding his bike. He didn’t deserve to die. I could not accept what was happening.

“One and, two and, three and…” He is not going to die.

He is already dead.

“Another amp of epi.” I will keep going until I have tried everything.

You already have.

“Why aren’t those gases back yet?” The family is depending on me.

What you’re doing isn’t helping the family or anyone else.

After almost an hour, when the nurses could hardly keep up with the chest compressions, when all the drugs that could be used had been used, when I could no longer pretend there was hope, I told them to stop.

The paramedics and the techs sighed and turned away. Even the janitors and the secretaries who had been standing in the background silently drifted away. The nurses stopped for a moment to catch their breath, then methodically began the cleanup.

We tried not to look at each other. We began to pay particular attention to the minute details of our job: Mary was carefully wiping down the side rails of the cart. Jenny, a clipboard in her hand, was doing inventory on the drugs we had used. I picked out a bloodstain on my lab coat and devoted ten minutes to scrubbing that one stain (while ignoring the other twenty).

We became very delicate about handling the child’s body. We, who had been cutting and sticking and jabbing him for the last hour, were now careful, almost reverential with him. I lifted a hand that had been dangling from the side of the cart and placed it over his little crushed chest. Jenny took a wet washcloth and wiped the trickle of blood from the corner of his mouth, then carefully brushed the hair from his forehead. Mary gently tugged the bloody sheet from under him and replaced it with a fresh one. We did what we could to prepare him. His parents who had been clinging to each other, terror-stricken, in the waiting room, would want to see him.

There is a rule in most hospitals that forbids anyone from removing the tubes or lines that have been inserted during resuscitative attempts. They are supposed to be removed only by the pathologist or the coroner or God-knows-who. It is a rule I have always despised, and I was not going to obey it now. I was not going to let the parents see their little boy with all those things sticking out of him.

I pulled the ET tube, the subclavian line, and the chest tube. I asked Jenny to pull the IV. His skin was cooling, thickening. He wasn’t bleeding much anymore. He was quickly changing from a little boy to a dead body. The end of the radius was still sticking through the skin of his left forearm. I tucked the arm under the sheet.

The nurses were wiping blood off the instruments, the cart, the floor. They whisked away the bloody debris overflowing from the garbage, all the while taking surreptitious glances at me, wondering. They knew what came next. They knew I couldn’t in all mercy delay any longer.

I kept twisting the lap sponge in my hands. Those parents had entrusted their child to me. They were farmers or drugstore clerks or factory workers, and I was the fair-haired boy from Mayo, the one who was supposed to save their son. Instead I was about to tell them I hadn’t saved a goddamn thing. Their son was dead.

I still have a job to do, I told myself. I will not give in. My responsibility to the dead is over, but I still have responsibilities to the living. I will not give in. I turned away from the nurses and looked up at the ceiling.

Oh, God, I thought. Oh, God.

I longed to let go, but I didn’t have that luxury. I didn’t get paid to let go. The others could vent their emotions, but not me. I was supposed to be there for others, not for myself. I needed to shut up and do what I could for those who were left behind.

I don’t know what I said to the parents. I scarcely remember the conversation. I believe they took it well, whatever that means. I remained quite composed. I wonder if they thought I was a cold fish.

I spent the next two hours treating the patients who had been waiting with their earaches, stomach pains, and wrist fractures. It was a small emergency room so everyone knew what had happened. They were apologetic, as if recognizing that their problems paled in comparison to what they had just witnessed.

They had been listening through the drawn curtain as the drama unfolded. They heard us wage our frantic, and ultimately futile, fight; and doubtless they, too, suffered when they heard the log nurse declare flatly, “8:27 P.M. Resuscitation halted.”

I must have looked more distraught than I realized. All the patients tried to encourage me. I can’t recall if I was embarrassed by their efforts or if I welcomed them. Perhaps I resented them.

I left the drunk, the one who had killed the little boy, until last. He had gashed his cheek when he fell getting out of his car. Two stern-faced Mankato policemen were standing next to his cart, waiting to take him away as soon as I finished. As I stood over him, preparing to suture his laceration, I tried hard to hate him. I wanted an object at which I could direct my wrath.

“Oh, Doctor, what have I done?” he said to me. “I’m sorry. I’m so sorry.”

He was so remorseful, so devastated, that I couldn’t find it in me to hate him. The two Mankato cops, however, didn’t have that problem. “Thanks, Doc,” one of them said when I put in the last stitch. “Now this bastard is going to jail and I hope he rots there.” The prospect of his rotting in jail seemed to please them. It did nothing for me. Why do we always think our pain will be less if we can make others suffer more?

At length I caught up with the rest of the work in the ER. Then I started to fill out the ER record and the accident report. I was about halfway through when I realized I couldn’t remember all his injuries. Was his facial laceration four inches or six? Was it his third finger or his fourth that was dislocated?

The body was in the hospital morgue awaiting transport to the coroner’s office. I had never been to the morgue before. Jenny had to tell me where it was. I went down to the basement, to the end of a long corridor. I pushed open the door and startled an owlish-looking man who must have been a pathologist. He wore thick, dark-rimmed glasses that made his eyes look huge.

“106.8 centimeters,” he was saying.

The little boy’s body was lying naked on a metallic table in the center of the room. The man was obviously performing the postmortem. He held a Dictaphone in his left hand, a tape measure in his right.

I introduced myself. We said a few words and then went about our business. I examined the boy and scribbled a few notes on the index card I carried in my shirt pocket. Lying pale and naked on that table, he didn’t look like a little boy anymore. He looked like a dead body.

The pathologist adjusted his glasses and went on with his dictation. “Severe cranial contusion involving the right temporoparietal region…”

This was too much for me. Yeah, life had to go on, and, yeah, autopsy reports had to be dictated—but right there? Right then? Did we have to be in such a hurry to reduce him from a child to a report? It was hideous.

I wanted to scream at the pathologist: Is that all you have to say? That he was 106.8 centimeters long and had cranial contusions? That’s a summing up? He was trying to reduce this little child to impersonal facts dribbled dispassionately into a Dictaphone. I wanted to choke him. What the hell do you know? This little boy cannot be summed up so tidily. His height and the summation of his injuries don’t begin to describe him.

I was approaching the end of my Basic Science rotation, the end of my junior residency, and I was beginning to understand that there was more to that little boy, more to all of us, than can be measured with a ruler or weighed with a scale—a lot more.

If not, I thought, everything I do is pointless.