home » Son and Foe Magazine » Issue Three » Genesis (The G.I. Bleed) part 1 of 2

 

Genesis (The G.I. Bleed) part 1 of 2

“Genesis (The G.I. Bleed)” has been divided into two parts for its online publication due to its length. This division is artificial and is not a part of the story itself.

You haven’t missed much; the blood itself (beginning), the flashing lights, the sound: the drone, the hesitation, the burps, the counterpoint, and other electronic silliness that passes for a siren nowadays. The ambulance has just arrived at the dock. In a moment, the stretcher will be bumping through the doors. We are aware of what we are about to receive, though there may be some doubt as to whether or not we are truly grateful. Fortunately, we are not busy. There is not even one other patient in all of the green-tiled rooms of our emergency department. We have twelve beds, every one of them empty. This is a rare event, extraordinary even. Such profound quietness in an emergency room late at night is odd, spooky and any reference to it essentially blasphemous. (E.R. personnel are as reverent as gamblers.)

The stretcher enters now with two EMTs, male and female, pushing it. The stretcher itself is tubular, spindly, with ridiculously small wheels. The tallest of the EMTs is already talking: “Mr. R… (I didn’t catch his first name) Collan, forty-three year old male, vomiting blood since nine o’clock this evening. Pressure 78 over palp. Pulse 138. Respirations thirty-five. History of pancreatitis, history of chronic E-T-O-H abuse. No diabetes. No hypertension.

(The other EMT is looking along the side of the stretcher.)

I listen, but do not move. This is my third eight-hour shift in a row and I had not slept before the first one. I am exhausted and worn out. I am quite unreasonably tired. My brain feels bloody with fatigue. Were it not for this patient’s arrival, I could be heading for bed. It could take hours now, depending on the exact scenario, to deal with him. What I should do is kill this patient.

I find myself watching the tight blue pants of the female EMT, the black plastic handles of the scissors in her back pocket, her cellular phone, the firm curve of her buttocks. I have already seen the patient’s face, though. His face is classic. I don’t mean the pallor, sweating, or diaphoresis, but the overall aspect. The faces are strangely interchangeable in these chronic alcoholics who have at last come down to their G.I. bleed; what we see in them is the spirit of exsanguination. The patient is anxious and embarrassed, like a dog that has just urinated on the rug or a man that can’t stop farting in public. He is breathing rapidly, shallowly, carefully, trying not to jiggle his body. For once, he is paying some attention to his life.

There is a commotion now, a problem with the stretcher to which he is being transferred.

–Damn!

(We all hate these stretchers.)

–Mr. Collan! Let loose of the rail! Mr.Collan! Let loose of the rail!

–Grab him!

(Mr. Collan is jittering allover, flapping, like a large bird. He is saying something like, Ehhh, ehhh, ehhhhh, fu-ha fu-ha. Son of a bitch!)

–Mr. Collan!

At the sound of his name, Mr. Collan convulses twice. Suddenly, there is a black stream oozing from his mouth. Three nurses, wearing pale rubber gloves, are pulling at sheets, folding and manipulating him. Mr. Collan has grabbed the rail again. There is something stuck and dangling now in the crushed stubble of his beard. A monkey could not have grabbed the rail of this stretcher tighter. (A monkey!) In the pause, I see a bowel movement, black as tar, spewing out of his rectum. Then Mr. Collan’s flabby buttocks are in the air. He vomits, then vomits again, though wretches is probably the better term, the vomitus twisting out of his body.

The EMTs are still talking. The pulse is 138. The bed at the scene was covered with black blood and coffee grounds. He is not known to have varices. They couldn’t get a line.

(Only the fact that he may not have varices is good news.)

I move over and sit on an adjacent stretcher. This Mr. Collan is rather interesting. He is bald-headed with a blue snake tattooed to his forehead; there is an earring in his left earlobe. His face is pierced in three places. How old, did they say he was? Forty-three? A bit old for this particular appearance, a bit young for such a bleed. G.I. bleeds are rather common things. In fact, a bleed in and of itself is nothing; we may see two a night; it is the extent of a bleed that is of importance. A truly major bleed is somewhat rare, surprisingly so, actually. (Palp, though, they said; 78 over palp) which means there is no bottom number to the blood pressure. The patient is suspended over a void.

This is going to be a major G.I. bleed.

At the moment, everyone is touching the patient but me. The nurses are slapping up and down his arms, searching with large-bore Angiocaths, the needles and catheters which will be used for the infusion of IV fluids and blood. The nurses are working as fast as is humanly possible. They are collectively impatient. They, I say. I myself am merely sitting on a stretcher. A vulture has less patience than I. The truth is, there is something extra going on with me tonight. As I’ve said, I am quite unreasonably tired; I am in a speculative and dangerous mood. I have. been in this mood before, and strange and puzzling, not altogether understandable, things have evolved from it. Visions, I think, visions.

To the clerk, who has come in and is standing for no good reason–curiosity perhaps–beside me, I say call G.I. and let them know what we have. G.I. (gastroenterology, G.I. we abbreviate it for some reason) will have to come in and scope the patient to find the exact source of the bleeding. Not just tonight, but immediately, I say, or think I say. I’ll talk to them if they like, I say. (Or think I say.) Something like that. Something like that is what I say.

 

The clerk leaves and I use the opportunity to look at the blood in the basin. In truth, it is important to look at the blood. Despite my dangerous mood, I am pondering; and my pondering adds an extra ingredient to the mix. I feel something like an Indian scout of old, paying attention to the animal tracks, to the broken grass and twigs, to the leaves and puddles on the ground. The great majority of the blood is dark and watery. There is something that looks like tar and black jelly. There are some large clots. All of this is of no particular interest. There is something else, though, something that looks red in a crescent near the perimeter of the bowl. In certain oriental soups you find a similar something. This red something is to be paid attention to.

I hear a prolonged low hissing noise and soon thereafter a quick beep. The beep is from the automatic cuff of the blood-pressure monitor. 79/22 it says. (Pronounced 79 over 22.) The machine thinks there is a bottom number now to the blood pressure. Not much of a bottom number, mind you; the void has a floor of glass.

(Then too, it is the machine that is thinking.)

The nurses are finding nothing in his arms. Finally, the head nurse looks up at me. She is a blonde, currently wearing her hair in a loose ponytail held together by a pink bow. Her husband is an orthopedist with a huge practice in the suburbs. When this blonde is not torturing males with large-bore catheters she tools around in a convertible BMW with the top down.

 

–Guess what? she says.

I guess, reply, in fact:

–Wonderful.

This reply (my reply) the nurse interprets, of course, as sarcasm. I am still sitting on the stretcher. I am somewhat intimidated by her prolonged stare. Her eyes are as green as emeralds, perhaps as unlucky. I cannot believe any amount of schooling can get such a woman to listen to me. Her interpretation normally would be correct. Normally, I say. But I am not quite normal tonight. What I mean tonight is different, more literal. What I mean tonight is great.

(What I mean is perfect.)

–You want a syringe?

I shake my head, no.

In passing the head of the stretcher, I cannot resist touching the blue snake that is tattooed on the patient’s forehead. (It is damp, cold with sweat: diaphoretic, as is the patient.) The patient, of course, is in shock; a tough guy, no doubt, in other circumstances; it’s a good thing the women are handling him. Suddenly, I find that I have fallen asleep standing beside the stretcher. Then I am awake, or seem to be.

I put on a pair of gloves and sweep Mr. Collan’s damp testicles aside.

What the head nurse has told me with the words “Guess what?” is that this patient is a drug addict. We are not going to be able to get blood from his peripheral veins. We are going to have to go elsewhere, where he normally doesn’t think or dream of going. We are going to his groin now where, despite the low pressure, I can already feel the femoral artery. The artery is not bounding, but then again, not so thready either. I feel it very distinctly. I then go slightly medially to where I feel absolutely nothing at all. The patient’s skin is raw-looking, pale and hairy. This is where the femoral vein is…or is supposed to be. (Is, in this case; a thin jet-like fountain begins spattering into the Vacutainers.) I hand the glass tubes, like test tubes, with rubber stoppers, to the head nurse. She rocks them back and forth to keep them from clotting. I find myself watching a silver bracelet on her left wrist, her wedding rings under the rubber glove.

I wait, looking down at the patient, holding pressure on his femoral vein.

God knows how much he has lost.

–I’m going to need a triple-lumen, I say.

Actually, I’m going to need a number of other things, too, all of which will take a minute or so to find and set up. In the meantime, I hold pressure on Mr. Collan’s vein, trying not to make it too obvious that I am leaning against him, propping my exhausted body up with my fingers. I have discovered through the years that I very much like holding pressure on large blood vessels; it is something to do, something essential, something no one is going to make you stop doing. But those are not the only reasons, or even the main one:

It’s like being in the eye of a hurricane.

 

I remember, years ago, as a medical student having been up all night while on-call. It was one of my very first clinical rotations and I was under the impression I was seriously tired. We were in an antique hospital with fire hoses in glass cases in the corridors, with tall green oxygen tanks chained to the walls. We were walking down an upstairs hall, the intern and myself, turning left then right, then left again, going through hall after hall, through endless corridors, with two-toned walls. Finally, we arrived at a small room on the fifth floor. We poked “our” head inside and saw the senior resident on another service.

He wanted to know what was in the E.R. that might be coming his way.

There was an addict with cellulitis and another man with a left-lower-lobe pneumonia.

(A cellulitis is a skin infection which–in addicts–tends to come from dirty needles).

A pneumonia is a pneumonia.

The resident was unshaven. He had a grey voice. His feet were propped on a desk. I saw the scruffy side of his face. He did not turn around. He did not flip a page in his journal. What he did was say:

–I love an addict.

That was that. We left. I never saw him again.

In retrospect, I wish I had paid more attention to his face. At this distance, there is something slightly hallucinogenic about the entire episode: the fire hoses seem suspiciously dusty in my mind. I have a feeling that the resident’s face may have been my own. But if it was, my face, my voice, it was some time before I learned what I meant.

Veins are not just the medium for an addict’s salvation but the medium through which a physician must fight what that salvation has done to him. The serious infections that an addict gets can last for weeks and are both deadly and recurrent; which means, for practical purposes, you are never free of your patient. For six weeks, day and night, you will be called repeatedly, paged, beeped: His I.V. has infiltrated; he has a cellulitis; he has pulled out his central line. There will come a time when you know every inch of his body. An intravenous line normally takes a few minutes to start. Normally. Not for an addict. Always sleepy, always behind, you will have to search for thirty minutes, for forty minutes, for an hour, for an hour and a half, for one more rush at life. If the problem is endocarditis, a bacterial infection of the heart (which it frequently will be), the course of antibiotics must go for four, five or six weeks and cannot be allowed to stop. As the intern or resident you must keep an access in that body, that wreck of a body for six weeks. (Six weeks.) When you destroy the veins, you destroy access, for blood, for fluids, for antibiotics, for everything. Finally, you become little more than a spectator, and death the only player that can get on the field.

 
 

I remember also (perhaps the same year) a woman in the room with another one of my addicts. She stood aside. His wife? Girlfriend? Frightening what is left of her beauty. How much, I mean. Is she trading sex for drugs? Such a trade, no? If she would, I would…might anyway. But I am going to collapse right here in front of both of them. It is three in the morning. I am asleep. No I’m not. We wrap his arms in warm towels. I pump up a blood pressure cuff, search for those veins he can’t normally reach. For some reason, I saw part of one of the medical student’s pharmacology tests today. At what rate must you resume the I. V. to attain an identical blood level of penicillin G if the infusion has stopped for two hours? Was that a joke? I need simpler questions at this time of day. What is my name? How old am I?

Sheepishly, my patient looks at me. Whence this dew of sweat? Why is the woman still standing aside? They are looking at one another. She injected him with something, I know. With a heavy object I could break out the sockets of her eyes. Do whatever you like, but leave my veins alone.

Why do you take care of me, my addict says, does not say, with his eyes. Why do you put up with me? He is sweaty. I am not. I say nothing; there is nothing to say. I don’t care for you; the system cares for you; I am trapped by the system. I have been up thirty-eight hours. Only in medicine and the military does one deal with such levels of exhaustion. I care nothing for you, do you hear me? I wish you were dead.

 

The truth is, Mr. Collan, in the worst of such cases it is difficult to remember when you start pulling against the patient.

–Aren’t you going to put on gloves?

We are back in the E.R. now. (Actually, less than forty seconds have passed.) A noise now, an absence of noise seems to have distracted me. I am indeed going to put on gloves. For now, with Mr. Collan our G.I. bleeder I must insert a central line.

Ah, here is the tray.

Without epinephrine?

–Yes.

The blue bottle.

(We are referring to the Lidocaine. Did I say that out loud?)

Mr. Collan, if you have a moment, I will show you how to put in a central line. Despite the ham-handed mess people can make of it, it is not that difficult. What is tough, for everyone concerned, are the possible complications.

We need to lay you flat. Almost flat. If we lay you perfectly flat, you can vomit into your lungs. As much as I might like to see you vomit into your lungs, that would be too careless… But wait… Ah…

–Restrain him!

–Get him!

–Mr. Collan!

–Son of a bitch!

Mr. Collan is struggling now. He is at least partially in the DT’s. Still, I can’t sedate him at this pressure. The nurse will have to hold his head down and to one side. She will have to insert her hands underneath the sterile drapes. I noticed they did not specify a race in the ambulance report and now I see why. You seem to be of no race; your skin is not black, not white; not yellow, not red. Your blue snake is all I am truly certain of. Though, come to see more carefully, there is perhaps a tinge of yellow in your skin. It may not be real; a mere saffron echo in the light. If it is real, I hope this tinge derives from ancestors from some meridian of the tropics, not from bilirubin. I will double-glove for this; if I get AIDS or hepatitis, I want to get it in a more exciting fashion than in your neck. (I find myself looking at the pink bow in the hair of the head nurse.)

What else am I doing, though?

I am feeling the sternal notch in Mr. Collan’s neck, and, on either side, the belly of a muscle, the sternocleido-mastoid, a belly forking like a claw; in the crux of that claw, I am going with the point of my needle aiming for the ipsilateral nipple. Good word: ipsi, means same. Ipsi-lateral: same side. Opposite is contra. Aiming, aiming. Too far to the left, hit the carotid artery; too far to the right, puncture (drop, we call it) the lung. Therefore, I am aiming for the nipple on the same side of the body as the side of the neck I am puncturing. The procedure is slightly easier with males. The nipple stays more put with age.

You ask, isn’t there anything more accurate? Or fool-proof?

No.

Have you ever hit the carotid? Or the lung?

Have I?

I have no comment on that.

(You hear me, Mr. Collan, I have no comment.)

If I do it tonight, you are dead.

Relax. You may have sensed, and it is true, Mr. Collan, that the thought of killing you has crossed my mind. But I have no intention of killing you through incompetence.

Interesting, as it turns out, the head nurse is holding the head. Should have made a joke about that. Seems a bit late. We are back in the E.R. now.

–Hold still Mr. Collan!

–Tie his feet too.

–He’s pinching me, dammit!

–Break his fingers.

A warm smile from the nurse that I address this to. Not the head nurse. Mr. Collan smiles too; a gold tooth is revealed. There is a moment of lucidity between us all.

 

–Mr. Collan we are trying to help you! Would you please be still!

(Indeed. We may help you more than you dream.)

Observe now, Mr. Collan, I begin with a very narrow needle, a twenty-two gauge, to make sure of my landmarks. If I make a hole in the wrong place, I want it to be a small one. You might as well trust me for the moment, Mr. Collan; I repeat, I am thinking about killing you, but I have no intention of killing you through incompetence. I insert the needle slowly…slowly…but see nothing. I advance some more, pull on the plunger. You are squirming, Mr. Collan; you are making this all the more difficult. Still…nothing…nothing. Then, suddenly, a perfect explosion of blood: turbulent, raw, rosy. I find it impossible to watch it without generating a little sound in my mind, a sort of explosion: ploosh, like a child might make while playing army. Ploosh! I suspect it would be impossible for you to watch, Mr. Collan, without a cold chill running down your spine. You and your junkie friends might perhaps try this sometime on a folded blanket in a hallway. Now we go with a much larger needle, a needle with a catheter around it, and do the same thing. There is the blood again. (I look up momentarily and see, midway the table, those tiny testicles of yours. Do you know how that happened? I must tell you later. You must be no slouch of a drinker.) I don’t inject the blood back. One of the greatest joys of being a physician is that messes are cleaned up for you. A quarter turn of the syringe unlocks it. What is that, Mr. Collan? No one cleans up messes for you? Except me. I clean up messes for you. You are a mess. I toss the syringe onto a stand. Now the needle comes out. I attach another syringe; recheck, then again. Because the catheter can slip. You really don’t want it to slip, Mr. Collan. The blood must shoot– Hold still Mr. Collan! The blood must scream out of there. Any trace of a doubt, and I must pull it all out and start over. I must absolutely make myself start over. Am I satisfied? Yes. Yes. You are struggling– Goddamit! Mr. Collan! (The head nurse is holding the head.)

The sterile drape is sliding off, falling onto the green tile floor. No matter. Now a guide wire will be placed into the catheter, a wire which will enter your heart. It’s OK for the wire to enter your heart, Mr. Collan, it is just not OK for it to go anywhere else. What will be guided by that wire is a sharp plastic sheath, as long as an ice pick and three times the diameter. The sheath will be inserted blindly with only the memory of that plooshing blood of old to guide me. If I am wrong, that sheath is capable of ripping through anything in your body. Now the guide wire is out; the introducer out; the tray a bloody, sharp, dangerous mess. Everything out except one huge catheter with three tubes, called a triple lumen, inside it. Check all of them. Fine, fine. I am not wrong. Everything is fine. OK. Yes.

–I need some two-oh silk…

–It’s already on your tray.

Oh.

I pause. Relax. Have time to think. I seem to be more awake. I am sewing a double, then triple throw in the first knot. Now watching big satisfying drops in the clear IV tubing. One each, one liter, of Ringer’s lactate and normal saline, running furiously, slowing momentarily, becoming little hurrying globules of light. The wound in your skin is like a tiny mouth where the catheter goes in. The two-oh silk is in my hands. Big silk is such a joy to tie. I pull on your skin like a mattress. Does that hurt, Mr. Collan?

–Did G.I. ever answer?! (I yell, now, to the clerk in her booth while tying another knot).

There is no response. The clerk is behind a fiberglass partition and cannot hear me.

–Ask her if G.I. answered!

–Yes! She says, yes!

–And?

–They’re coming!

–Coming?!

(My God.) I seem to be more awake.

–I told them you were busy and couldn’t come to the phone!

(My God. My God.)

–Call surgery too! They need to know! If it’s arterial it is going to go to them!

(There is no response to this. A silence as I make, complete, the third stitch.)

Why did I say that? Everyone in the room knows it. The truth is, I prefer at all times to say as little medical as possible; it is redundant, silly, flinging jargon and strategies around among nurses and physicians. It is akin to chatting away on a CB Radio (something else I won’t do).

–Who’s on for surgery?

–Ssss…en gar!

–Who?

–Slazenger!

Ah, the beautiful one. Sleek. Slinky. Very competent too, knows it. Obnoxious as hell. Occasionally wears black stockings and crosses her beautiful ballerina legs while writing orders. My, my. This will be my competition. I am definitely more awake.

Suddenly Mr. Collan vomits. He vomits blood, raw blood. Nothing but blood. He is bleeding again. This is the first bright red blood we have seen from him. There is blood on his chest, his pillow, in his ears. Now filling an emesis basin. He sputters and sputters. There are red bubbles everywhere. He is bleeding again. (Though, in truth, we tend not to phrase it that way. What we tend to say is that he has broken open.) You’re going to love what comes next, Mr. Collan, I might have refrained. Oh boy.

Without waiting for an order, the nurse begins to tear open a large plastic bag with a clear plastic tube inside. From the yellow container I begin spraying Cetacaine in the back of Mr. Collan’s throat to numb it slightly.

Sorry, Mr. Collan, we have to lavage you. (Mr. Collan is gagging now.) Does that hurt? I’m afraid the pain is very specifically your problem. You are bleeding because of your endless years of drinking. How many times have you been told to cut the drinking out? How many times have you sneered at us? You and your cohorts have beat us to death, day and night, with your sclerosed and collapsed veins, with your overdoses, your DT’s and episodes of pancreatitis. You are not completely disoriented at the moment; you are beginning to see what we have seen from the very first, that you may die right here, right now. This recognition on your part indeed gives some satisfaction. The terror in your eyes gives some satisfaction. You are the little bully, the tow-headed unmanageable brat who has at last stuck his finger in the fan. The first emotion we must all deal with is a sort of glee.

 
 

There is blood everywhere now. This is not good. I attach a fifty c.c. catheter-tipped syringe full of water to the Ewald and inject it into your stomach.

Your mouth is around the clear, plastic Ewald tube, something like a fish on a stringer.

What I pull back is raw blood. (And more blood. And more blood.)

In a movie or on TV the sound track would get louder at this moment to indicate anxiety. But any anxiety we feel is, in fact, very superficial; the truth is the blood has a calming effect; there is no longer the slightest doubt of what needs to be done. Indeed, for my part, Mr. Collan, I suspect I could watch you die as dispassionately as I could watch water boil. It is a paradox, really; if I stay in this mood, I will do a better job. There is no chance of my fumbling or dropping anything, no chance of my missing a vein. You may benefit enormously if I stay in this mood.

I become like the gambler who cannot lose.

Again and again, filling the syringe with water, clear, cold, not sterile, but nevertheless pure; again and again, injecting it down the Ewald into Mr. Collan’s stomach; again and again pulling back the same water once more, newly full of swirling blood and clots. Then discarding that water.

Mr. Collan may wonder why we aren’t doing anything else. (I am not at all certain I am as awake as I think I am.) What Mr. Collan is looking for is a little plastic bag of blood for us to hang up and run into him. In truth we are looking for a bag of blood, but know it can’t arrive yet. Still, we have done something in addition to the fluid and lavage. We have started a clock in our minds. Mr. Collan thinks he is one big skein, one limitless bladder of blood. He is not. He is only about six quarts, only some five thousand five hundred tiny little cubic centimeters of blood. He is a not so big a bladder of blood. He is a bladder it is not so difficult to empty.

With the onset of the bleeding, we have a moment to ourselves. Another paradox, perhaps. Mr. Collan seems to be watching me now. Perhaps he is wondering how I plan to kill him, especially in such a small room, with so many witnesses. Patience, my friend. You won’t see. More correctly, you won’t understand. For that matter, no one in this room is going to see or understand.

Allow me to give you an analogy:

Imagine, please, a chess master who has decided always to make only the most obvious move. He would be defeated and quickly, but his defeat would have little or nothing to do with his opponent. He would be defeated by the nature of the game.

I want to defeat you by the nature of the game.

 

(With each syringe, we are adding, counting: pink, red, pink, pink, pink, pink.)

The housekeeper is in the room now. The housekeeper with his mop is mopping. The housekeeper with his mop is adding as well. He is not adding quite the same way we are. (So difficult to remember when my mind was not encumbered with anatomy.) But even the housekeeper knows, what he sees on the sheets, on the floor, on our yellow gloves and smeared onto the chrome of the stretcher, is a lot. This…is a lot. So much in. So much out. Anyone will begin to add, to start a little clock running in their minds. Mr. Collan too, no doubt, is adding. Mr. Collan is not adding quite the same way we are. Mr. Collan has grown accustomed to being alive.

What I see this time in the barrel of the syringe is not nearly so red. Only pink. The next time, too, only pink. A deeper pink. What we are really dealing with here is time, not necessarily hours. Add for pink. Subtract for red.

Beep. (Blood pressure.) Sixty-eight over twenty: 68/20. Oh boy:

A nurse has the computer printout of his history.

–Do you want to hear it?

(Did I answer? I don’t think I did.)

–There are three admissions for DT’s. One…two…three for pancreatitis, one for pancreatic pseudocyst, two for cellulitis…alcoholic cardiomyopathy. Three for reactive depression. One for cocaine abuse. Three for overdoses. One for substance abuse, unspecified. One for rule-out endocarditis…

–Did it rule out?

(I am liking the idea of killing you more and more, Mr. Collan.)

–No… Yes! Yes it did!

–How about hepatitis?

–No.

–AIDS?!

–No.

–Do you see any problem that is not drug or alcohol related?

–No… Correction! One! Merely a problem, though, not an admission: an ingrown toenail.

–Ah.

My complete abuser. I love you. Please don’t die on me before I can rip your soul out. I can imagine your saying, years ago, in a bar somewhere, while raising a heavy glass, how you would rather die than do without this stuff. Excellent! I hope you remember that. This is the room for forgotten promises. (We also answer rhetorical questions.) But there are larger things.

Goddamit!

(I look up and see a nursing assistant shaking her hand vigorously.)

–He pinched the hell out of me!

–Did he break the skin?

–No.

–Good.

(No paperwork.)

Sorry, Mr. Collan. As I said, larger things: concerning the drugs, not the ones you took but the one you injected in your veins. Something happened there, didn’t it? Something you did not expect, something you were never able to forget. You woke them up. You became like a puppet grown aware of its strings; hung-up, gazing, mouth not quite awry. Your veins started feeling empty. You became aware of the interior of your vasculature. It became vaguely itchy, alternately thin and congested, sometimes like a golden chain dangling in the hollow of the your body, sometimes like the clapper for a bell. Your veins were asleep and you woke them up and now they won’t lie dormant again. Your veins were asleep! (I tell you) and you woke them up forever.

How do I know this?

Don’t ask how I know it.

 

–Surgery wants to know if you can come to the phone!

(A voice, suddenly, from the clerk, from behind the screen.)

Can I come to the phone?

The clerk cannot see me. It makes little sense, really, what I say next:

–Does it look like I can come to the phone!

This is an arterial bleed. Must be. (But one truly cannot tell.)

The clerk enters the room. More quietly she relays the message: The surgeon says to stabilize him and she will be here in a few minutes.

Tell the beautiful, competent but obnoxious surgeon that this man is not going to stabilize.

(This is what I think. But I say nothing, merely nod. The surgeon will be down soon.)

Wonderful. Actually, I very much like the sound of what the clerk has just said. Surgery says she. Surgery is feminine tonight. Like the fates, the muses. Like what else? Like Eve. Like ships at sea. But this man. If you call this a man. Look at him. I wonder whether junkies are made in the image of God. No? Yes? Perhaps?

It’s an image I do not like, evidently.

end of part one