I remember one addict, a nice guy, truly. He was taking a correspondence course in air-conditioner repair. Very proud of how well he was doing. I wanted very much for him never to be embarrassed at his pride. I made an attempt to hide my fairly considerable education while in the room with him. I left it at the door, hid it at the end of the hall, sat on the opposite bed and talked with him. We talked of three-phase motors and rotary compressors. (What do I know of three-phase motors and rotary compressors? Plenty, actually.) He had kicked, was more or less cured, was even losing that anxious and faraway look of a man not making it in life. But I made it clear:
You do the drugs again, you die.
Yes, yes.
Big problem though: girlfriend junkie.
He was back two weeks later. Temperature 102. Pulse 128. (Pressure 96/50.)
Why you do this?
Love.
It was love that devastated his heart. Very soon thereafter, bacteria like tiny claws began snagging out his valves. We knew he might stroke any second. (He did stroke, later.) Despite enormous, mega doses we call them, of antibiotics, despite preparations for immediate surgery, the bacteria and fibrin and antibodies got ahead of us, began ripping out the valves of his heart, sludging vegetations and plaques. Tricuspid going. Mitral, going. Aortic going, going, going, going… Bits and pieces of bacteria and platelets and heart drifting off into blood stream. Love will be triumphant! The emboli can go anywhere now, like sparks from a fire. Exactly like sparks. A showering of emboli. Little sparks, perhaps no problem. (At least maybe no problem.) Big sparks. Fire! Always fire! Fire in kidneys! Fire in brain! Brain like a dandelion. Paralyzed perhaps. Can hit anywhere! Suddenly. Completely unpredictable. Can no longer use little finger; can no longer use left foot; can no longer see. Entire left side of body gone. From second-to-second and minute-to-minute it keeps happening and may not stop. Love will be triumphant! The devastation is not over soon like in regular stroke. It keeps happening. Thirty-six years old. Sure could have used left side of body a little longer. With these air conditioners and heavy rotary compressors, had real use for left side of body.
–Doctor!
Well. Well. In truth, we are seldom so formal. (Doctor, indeed.) Was I asleep? No. But according to the cardiac monitor, Mr. Collan is now in V tach. This is an inherently formal rhythm. Ventricular tachycardia. It looks like a sine wave. The heart is galloping too fast to fill with blood. V tach is a very elegant-appearing rhythm if one can get over what it means. (One can never quite get over what it means.) It means the patient has minutes, sometimes seconds to live. Most humans cannot pump blood at this rate. Some can. Most cannot. Mr. Collan cannot. I know very well he cannot. Mr. Collan’s eyes are rolling back in his head. We get very formal now. Now is not the time to kill him. Everyone knows exactly what needs to be done. Aesthetically, I very much like the look of V tach. Though, in truth, it’s not my favorite waveform. Torsades-de-pointes is my favorite. It shows what complex forces are driving the world. Torsades is equally deadly. More so.
A commotion sure enough now. Open the crash cart. Go for the defibrillator. Cables too short. Unlock the stretcher. I am wide, wide awake, of a sudden. Unlock the stretcher and pull it out. We are going to have a forty-five second delay. I’m going to try to tube him while he’s down. Seconds. Seconds, we have.
What has happened here? It is the old tale of muscle and nerve, embryologically elaborate variations on a theme. Vectors and impedances. Buddies. Sometimes look out for one another, sometimes argue. Buddies, I say, brothers too, especially in the heart, fight, though, on occasion, especially in moments of great stress. When the fight gets out of hand, a third party may yell Doctor! and point out a beautiful sine wave on a monitor.
–I need a laryngoscope and a number eight tube! And the Yankauer suction!
(I would not do this first if I could get to the defibrillator immediately. Can’t. So.)
When I finish putting in the tube, what we are going to have to do is stop the heart. When we do this, especially in this situation, it may not start again. Possible. Happens. Sometimes yes. Sometimes no. If it does not start again, we (I) will pronounce the patient dead. I am completely dispassionate. I am also the gambler who cannot lose. I look at the monitor. V tach, still. What will be next? V fib. Then asystole.
Yes. Next will be asystole.
Would you like to know a little more about it?
Imagine a cemetery. Sunny day. Imagine exhuming a body buried for ten years. Pry open the casket. Spill the body out onto the warm close-cut cemetery grass. Undress the body. Ignore any mold. Ignore any changes in features. Ignore the heavily sutured and unhealed cuts from the embalming trochars. Ignore anything and everything that would suggest that it has not been exactly pleasant to have been dead for ten years. Attach an EKG machine. Turn the machine on. The rhythm displayed on the screen will be asystole. It is a rhythm for all time.
But now. Yankauer suction. 10 cc syringe. Copper stylet. I am rather good at this. Thank God I am good at this; this would be a terrible thing to be bad at. Laryngoscope, tongue, throat, blood everywhere. Suction, suction. A feeling of literally tunneling into the body. The narrow, grey, corrugated look of the trachea. There! Easy. Good. Clear. Clot like a leech, dangling from the tip of the suction.
Nothing to be too proud of here, intubation easy, very easy in this guy. (I stand up. Memories of loose skin, tucked like an upholsterer into the forbidden orifices of the body.)
Am I pulling against myself? No. This man must not die naturally.
On the monitor I see Mr. Collan has slipped into V fib. Formal name: ventricular fibrillation. A certain species of lay person who is always cruising at the limits of his knowledge will use that name, too. (Is she in ventricular fibrillation, doctor?) Otherwise, it would never be said. Vee Tach, Vee Fib, we would say. Then we would say: asystole. The head nurse has the paddles ready, is passing them over, setting the controls.
–How much?
–Two hundred.
Joules, I mean.
Named after James Prescott Joule who discovered the mechanical equivalent of heat. There is an electrical equivalent, too. We shall fire it like a lightning bolt through this man’s body. It is enough to weld small pieces of metal together. Joules equals work: power integrated over time; 20,000 volts over a small fraction of a second. With this we will depolarize each and every cell of the heart simultaneously, in a way they have never been depolarized. This will stop the heart. There will be a moment of pure and utter silence that has not been present in Mr. Collan’s body since many months before birth. One can imagine the heart saying to itself, “What?”
Then, hopefully, starting again in a better-behaved fashion.
It doesn’t have to start again. Ever. Regardless of chest compression, epinephrine, atropine. If it doesn’t, we (I) shall fill out a death certificate. We (I) shall use black ink.
–Synchronized?
She knows the answer to this, but must ask.
(Evidently I answered. I don’t remember answering, actually.) Everyone away from the stretcher now.
Ka BAM!
In truth there can’t be such a noise. Why does there always seem to be such a noise? What is there to make a noise? What there mainly is is a lot of motion. The patient is liable to buck vertically off the bed. It’s an opisthotonic sort of bucking. In Michelangelo’s Sistine-Chapel portrait of the damned-in-hell, he shows an opisthotonic sort of writhing. It’s the same here. It always seems to occur in slow motion, too, a slow curling motion, a gyrating spasm with slow release. Orgasm?
Eyes on monitor. Eyes… glued to monitor. Nothing nothing. There. Oops. No: Vee Fib. The defibrillation did not work. Vee fib again.
(Mr. Collan’s conjunctiva are beginning to look like the fairy wings on the surface of milk.)
This is it.
Everyone must get away from the stretcher. Plenty of energy in this little machine. Plenty of energy to stop more than one heart forever. Like a gigantic orgasm? Possibly. Doesn’t feel like an orgasm, evidently. This is not going to work.
–360 joules!
[I have a collection, a small one, very small (two patients) of what people have said after being resurrected from this quiver of the heart. Eyes rolled back, essentially dead. Then Ka BAM! Most say nothing, too knocked out. But two did, immediately. A small series, the words of the dead. What do dead men say?]
One said:
–Son of a bitch!
The other said:
–You do that again and I’ll kill you!
But Mr. Collan is going to say nothing. Mr. Collan has a tube down his throat.
–Three-sixty! (I say again.)
We are set at three hundred and sixty. Prescott Joule would be proud.
–Now! Clear! Go. Clear!
Ka BAM!
Eyes glued on the monitor. Nothing. Nothing. Then: a pulse. Another. A sinus pulse. (Good P wave.) Sinus brady. Full sinus. My God! Well, well, well. Sinus rhythm. Going faster now. Sinus tach. Sinus anyway. Good enough. Feel a pulse with it too. Good pulse. A successful defibrillation.
Must move quickly now.
Now that he is intubated, we shall place him in Trendelenburg: feet high, head low to improve his blood pressure. Good. Good… Suction. Good. A miracle. Nothing down there. Afraid he might have vomited into the lungs. He didn’t. But he is exhausted. He will collapse for a while. We are breathing for him externally now, fluid and blood are external too. Tubes, tubes everywhere, even in his bladder. Aspects of his body are becoming peripheral.
The clerk is approaching the stretcher. She evidently has a message for me. What is going on?
–It’s surgery again: She wants to know…
–What do you mean she wants to know? Where is she?
(She is the one who was supposed to save him. Not I.)
The clerk seems as fascinated as we are by this blue tattooed snake.
–The surgeon wants to know if you can come to the phone.
–Does it look like I can come to the phone? Tell her to get her ass down here!
I simply cannot believe that it converted.
A bit of giggling now, among my team.
(We are in Trendelenburg and sinus rhythm after all.)
I look at what is coming out of the Ewald. It is pink. But only slightly. Almost clear. Incredible. I wonder if shocking him had any effect? Vaguely possible perhaps; platelet aggregation is at least partially electrical, something like that, very interesting. Can’t be, though, probably just a coincidence or the Pitressin may be having an effect. Merely light pink. Pure coincidence, I am sure.
Completely out of it now, curled up, Mr. Collan has begun trying to bite me. But he can’t because of the Ewald and ET tubes. From a creature of need, he has become a bundle of reflexes. Where is the blood?
You’re exhausting me, Mr. Collan.
I am now breathing for you, squeezing the Ambu bag. I have taken over the most primitive of reflexes. So here, you see, Mr. Collan, I have made the most menial task my own. I could easily delegate this. But I can run things from here as well as anywhere. In fact, I enjoy breathing for you.
The conventional wisdom is that drugs are an escape from reality. In truth, I do not see them that way. Take you, Mr. Collan; you are largely with us. You are largely intact. Only your veins are gone. Things can and probably will get much worse. I see the apocryphal addict: now a diabetic because his pancreas has been destroyed; now a dialysis patient because his kidneys have been fried; now breathless because his heart has failed. Finally there is only one thing left: Or is there? The apocryphal addict, elbowing his way across the desert of his physiology, has no will whatsoever. He is a creature of needs alone. In fact, he has become a most primitive animal.
(Very early, the young physician learns about drug-seeking patients. They talk only and always of the pain, the pain, the pain! Then one day he understands.)
They are talking about something outside of their bodies.
Beep:
94 over 48.
A much better bottom number on the blood pressure…
Where is the blood? My, my, how slow it can be. Five, ten, fifteen or twenty minutes. Twenty minutes is a long time to ignore eyes that are dying. Still, Mr. Collan is doing better. Spoke too soon. Spoke too soon.
(Didn’t speak at all, actually.) He is vomiting raw blood again.
This man is going to die.
No, I do not, cannot, see drugs as an escape, but as moving toward something very central and primitive: a beginning, if you like, a primordial swamp or Garden of Eden. One can define reality variously, and repeatedly because it is repeatedly various. Reality is peripheral, an accident. But for the abusers there is a center, a common ground.
Mr. Collan, we intersect you in your progress toward that common ground.
There are more people in the room now. A domino effect. As a bleed proceeds, through a process I have never quite understood, there is a gathering of unfamiliar faces. I am nominally in charge and yet this happens. Even in a hospital, a G.I. bleed is something that happens where it happens and tends to be treated where it happens. There is not a lot of moving the patient about. Such a bleed is very often the terminal event. Any place seems good enough to die.
Case in point. Observe: medical students. We seldom see medical students in the E.R. They are not required to be here, so they don’t come. Medical students can hide in a hole a rat couldn’t crawl into. They have heard a rumor, perhaps. One of the students is watching as the blood is swabbed and smeared with a thick mop on the floor. There is a faint water-color wash being left on the tiles. Medical students have begun to see what they are in for, what this profession is all about that they have entered. They become desperate to protect their last years of freedom. Two students here now: one male, one female. No three: two males, one female. Where did they come from? Who are they? Where are they going? Poor little happy things.
–What’s his pressure?
What?
(Suddenly, here, at last, we have a new voice.)
At last, here, suddenly, we have the surgeon, somewhat breathless, in fact. (My God what a doll.) Truly, I thought I remembered her face, but it seems I had forgotten the details. I can scarcely look directly at her. I can’t look directly at her. One should not look so fine in scrubs. Her face and hands appear raw they are so freshly scrubbed. Her ears are set close to her head like a model. Every one of my crew, rather striking women themselves, notices her. This surgeon looks like an advertisement for something.
Life on earth, perhaps.
–What’s his pressure? she repeats.
(A physician after my own heart.)
But I wonder myself, now.
103/56.
(My God.)
–Is G.I. coming?
–They’re here. He’s here. I saw him pass.
I wonder what the clerk said. I repeat the story to the surgeon: I tell her I think it may be arterial. It may be arterial. Still, I wonder what the clerk said.
My nurses are almost glaring at her. The head nurse is retaping a recently established IV site. The head nurse establishes eye contact with me, a look I cannot begin to interpret. My God, how complex this is becoming. The beautiful female surgeon as dominatrix. We should dwell on this at some later time.
Mr. Collan is still vomiting but the vomitus is less red now. Sometimes even severe bleeds suddenly stop. (This one is not going to stop.) Of course, you can never know. But this one is not going to stop. Blue pads on the floor now to keep us from slipping.
Running fluid into his veins, his own blood slushed with it though his heart, then out through stomach and Ewald; onto the bed, in bedpans, in cracks in the stretcher, in the joints of the stretcher, in bloody feces and on the floor and walls. I see some blood on a Mayo stand. In great explosive eruptions, the blood may go so far as to hit the ceiling. We have had one or two such eruptions already. I look up, curiously, then see it, fresh, it seems; two or three drops, no more: a duality, trinity, of sorts.
I look very shallowly into his eyes.
Beep. Pressure is… Never mind what the pressure is. But good. Good. OK, at least.
Do you know how long ten or fifteen minutes are in this situation?
Wait. Wait. Wait.
How slow it all is: Wait, wait, wait, wait, wait, wait wait, wait wait…
(The surgeon is reading through the chart.)
I glance back at Mr. Collan. Funny: his eyes are very alert now. He knows he is dying. He sees a lot of work going on around him. He is the focus for a lot of work, perfectly meaningless to him: instruments, tubes, monitors. He is wondering, waiting, fearing perhaps. What is it going to be like to die? There is a pleasure, truly, in observing this.
I look up at the cardiac monitor, the green tracings on the scope. Good P wave. Good QRS. (Pronounced as individual letters: Q…R…S…) Rate of 120. OK… What can I say? OK.
Mr. Collan seems to be watching me now, watching my hands on the Ambu bag, watching other things, wondering what I am thinking. In truth I wonder what you are thinking, Mr. Collan. I sense you are accusing me of being coarse, or blasphemous. Blasphemous! Please, my friend! Do be civil… Blasphemous! Don’t make me laugh.
Don’t you see what the real problem is, at this moment, between God and myself?
We both want to kill you, Mr. Collan.
Maybe this woman can stop us. This woman indeed. Would you please look at this woman. I seem to love all the orifices of the female body, especially the one I almost can’t get to: the cervix, the little entrance to the womb, like the nose of a puppy on a rubbery fruit. The Bible got it wrong, if one can say such a thing meaningfully: women, knowledge, sin, life, death, good and evil; the symbol should not be an apple; it should be a pear. The womb does not feel like an apple; it feels like a pear, like a rubbery fruit.
I glance now at the surgeon still reading through Mr. Collan’s chart, her ballerina legs crossed, a golden chain with golden links dangling from her left wrist.
Now, here, at last, the bags of blood arrive. Two at once, in fact. We shall hang one bag, wait a few minutes, then hang the other. (I think, but say nothing.)
Meanwhile the nurse has already snagged the first bag on the IV pole. Without asking me, I mean. Am I in charge here or not? Probably not. What would she have done had I said no?
But you have a prayer now, Mr. Collan.
I squeeze the Ambu to give you oxygen and air. The large plastic bag resembles a huge olive. The bag is red with blood. The blood doesn’t stick to the plastic, doesn’t coat it, I mean. Very interesting. Blood soaks into cotton and wool, drifts into water, doesn’t quite seem to know what to do in the face of plastic.
I am coasting at the moment, rambling perhaps; a physician is fundamentally about decisions and there are no decisions to be made just now. Activity has become a blur in the room around me. I am responsible for you, Mr. Collan, not the activity. G.I. is here now. I see the gastroscope being assembled. When the gastroenterologist arrived, we looked at each other and laughed. My crew looks like a bunch of kids who have had a blood fight. I suppose there is no such thing as a blood fight, but if there is, we have had it.
(I see the fiber-optic scope, black, snake-like. I pull the Ewald out to allow room for the scope.)
The surgeon is now on the phone, now looking at the lab slips. I am still pumping the Ambu. Why? Because there is no room for a ventilator anymore. And because I find it mindless and relaxing.
But the surgeon I cannot ignore. Would you please look at this woman. I saw her once at a party for the residents in fishnet stockings and a short skirt. I really could not quite believe what I saw. Why don’t we step over here, mademoiselle, my dear and glorious physician? This is what women are for, you know, for starting over. With your aid, in one bed, merely a stretcher if you like, we could start a new set of veins, a new liver, new fresh skin, fresh clear eyes, something very like or called hope. This man has some fundamental problems now. With the aid of your body we could start anew. You are cocky about your brilliance and dexterity, but everything in your brain or mine is as nothing compared to what your uterus knows. We could expand that rubbery fruit of yours, cause it to grow. Your body is wise, no doubt; I would like to feel its wisdom. No, actually, I would not. It is late; I am tired, tired past exhaustion, rambling now, virtually incoherent. I want nothing quite so esoteric.
I want to crawl into your vagina and let my ankles dangle out.
We are a crowd now: a horde. There is a problem with the light for the scope. No, it’s OK. The fuse was blown. Can’t believe there was another fuse. The surgeon with her perfect hands is palpating Mr. Collan’s abdomen. Mr. Collan seems to be bleeding more now. I watch G.I. with his scope peering, like a voyeur, deep into the depths of the body, twisting, turning. It is all in the wrist. Then:
–It’s arterial, he says, definitely arterial. Near the duodenum.
Do I want to look?
No.
Actually, I want to continue looking at the hands of the surgeon.
Am I losing track? Part of me seems to be alone in this room. I have withdrawn mentally. My presence is not particularly needed anymore. I see G.I., the fiber-optic scope being removed, the brilliant tip like a blue-white star. Perhaps we can have a little less of the vasopressors. Where are we on the Dopamine? 15 mikes. We could go to ten, maybe. No, maybe not. Maybe we should hold what we’ve got. Fifteen is OK.
Mr. Collan has opened up more now. He has opened up significantly more. He will never last till everyone arrives.
I feel the stretcher being unlocked. I feel the stretcher actually moving. What’s happening? Did I miss something? Did I fall asleep?
I look at the head nurse:
–They are moving him now? I say.
–They are thinking about a Swan.
–Let them think about it in the SICU.
–They’re not going to the SICU. They are going directly to the O.R.
–What about the team?
–The team is already here.
What!??
(A silence in my mind. Let me count, one, two, three, all the meaningless seconds of silence in my mind. How? Why? It’s past midnight.)
–There’s a perfed cecum in room seven, she says.
Oh.
Ah, so. A perforated cecum; a patient’s abdomen is full of feces. As a consequence, the team is here; the entire operating team is here; now, upstairs, as we speak, cutting, cleansing, resecting, wearing their pale gloves, using their shiny silver forceps like chopsticks. The scrub nurses, the anesthesiologist, the chief surgical resident, a staff attending, all are here, now, ready for you next, Mr. Collan.
(One man’s feces is another man’s luck.)
My God! Look at you, eyes awake, so alert again. I had not noticed that. Something else I had not noticed. But we won’t speak of that.
Despite all effort, it is still going to be a coin toss for you.
Beep: Pressure is holding, too. 94/48.
They need to untangle some IV tubing to get the stretcher out. We have one final moment, you and I. You look so alert. But your eyes are scared, wondering, looking around. The stretcher is moving. Where are you now? Where are you going? Let me explain:
You are in the valley of the shadow of death.
I wonder whether it is wise for you to leave it. Bleeds are very messy to look at, but a good death otherwise, and rather painless. You were already delirious; the worst was over for you. You may have been heading toward a golden sunrise (a vision I saw, I think). At least you were until we got in your way. It is not my fault, you know; I had other plans, or think I did. Maybe I did. Who knows? I’ve had other plans innumerable times before and never acted on them.
It’s a means of staying awake.
An hour and a half later, the calm has returned. Everyone is gone. The E.R. has been completely cleaned, except for a few dots of blood which are drying still on the ceiling. There is a vague hum of machinery. One might imagine the Titanic having missed the iceberg. Then suddenly, unexpectedly, a messenger arrives, very literally, a man from a messenger service. He is carrying a little Styrofoam cooler of B-negative blood which is being relayed from another hospital. I can imagine the messenger himself an hour previously, in a room with a telephone, a TV, a toaster, some Pop-Tarts. Blood is needed immediately! Carry this blood! The voyeur in him thinks there might be some excitement at the other end. He arrives, like an embarrassed guest, apologetic with his gift. But sees nothing, Nothing, only our empty stretchers, our green and spotless tiles. Nothing happening here either; the party is elsewhere now. He is disappointed, has disappointment in his eyes. World everywhere the same.
We direct the messenger appropriately, then talk among ourselves.
–You think he’s still alive?
–Maybe.
(Not only do we not know, we cannot even guess.)
When the messenger returns and is on his way out, we ask him:
–Is he still alive?
–They didn’t say anything. They took the blood, though.
–They would take it either way, I say. I glance at my watch. It’s too early to call upstairs. We will call later. I am not sure I want to know at this moment. The truth is (as you perhaps have realized by now) Mr. Collan’s face, like that of my resident of long ago, was not totally unfamiliar to me.
Soon afterward, an aide asks.
–Whose nail file is this?
–Nail file?
–The fingernail file here on the desk.
(The aide picks it up and we pause, all of us, to look at it.)
–Maybe the medical student left it as a plant, the head nurse says.
–As a plant? I say.
–As a plant. As an excuse to come back and talk to you later.
–Why would she want to do that? I say.
–Why indeed? the head nurse says.
–She had a nail file.
–Who?
–The surgeon.
–Did she?
–I think so.
–A nail file?
–Yes.
–Maybe.
Well, well, well.
Like a rubbery fruit.
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