All she said was, “Doctor, he's turning blue.” She spoke the words softly, quickly into my ear. I turned to look, expecting a grin. All I got, though, was backside, hurrying away to the exam bay, like a game of tag.
I’ve relived it a million times. It wasn’t a game, it was a play. A stage whisper blurted by a vanishing actress. She knew her audience. She told me the patient was cyanotic – cyan-colored, like ice – but the delivery had its own message: ‘I may be new here, but I'm not panicked. I've done this before; I'll do it again.’ On TV she would have stood up straight and tall in the center of the ER and ceremonially announced just short of a shout, ‘Doctor! The patient is acro-cyanotic. Come STAT!’ Writers love the word STAT. Clinicians only use it when they're pissed off. ‘STAT' is Latin for 'hurry the fuck up'.
Anyway, that's how it started. Henry: Day One.
She got exactly the response she wanted. On cue, I thought ‘Bullshit.’ I probably snorted. Robin Benoit was a nurse. I knew well the common doctorly chauvinisms about nurses as diagnosticians.
In all the retelling, the reliving of the opening, for the other doctors, the family, my closest friends, my parents, the police, the lawyers and over and over for myself, I have always admitted that I hesitated, though only for a few seconds.
Don’t misunderstand me. I would never let a patient lie there starving for oxygen for even a millisecond, no matter whose ego is on the line. But I did not believe thirteen-year-old Henry Rojelio really could have been blue. Not ten minutes earlier he and I had had been talking about baseball and his crooked penis. He was not that physically sick.
Nor did my hesitation make one whit of difference. The record will support that. Five seconds was not long enough to have mattered. But the issue has never laid down and died.
Professional machismo looks lousy in the hindsight of self-recrimination.
I was on the phone. I ended the call, abruptly, then sat there with a vacuum-tube stare long enough to show that I wasn't impressed and certainly wasn't panicked either. This according to the rules I had learned early on: Never run. For punctuation I took a last gulp from my can of Squirt and made a point of finding my stethoscope. ‘Where's my fucking stethoscope?’ I remember saying out loud. I was annoyed. Whether the patient’s cyanosisis real or imaginary it’s a pain in the ass for all concerned. I patted all my pockets, then found it looped over my shoulders. All this may have added five seconds to the down time. That could not have been critical. I sauntered after Robin. I didn't – I wouldn't – believe her. Five seconds.
Though new to me, Henry had been a regular in the Glory ER. His chart – which I had dutifully read over – was into its fourth volume. At his worst he was only a moderately bad asthmatic. When I listened to his chest on admission he was not all that tight, and he was getting over-aggressive treatment as it was. True ‘blue’ was not possible.
I pushed open the door, smiling, stupidly optimistic that a doctorly presence would right the misdiagnosis and end the scurrilous rumors. It had worked before.
He was, however, lying oddly flat and straight, unconscious and limp, and by-god blue all right. And starting to turn a mottled gray, which is worse than blue, because it's what comes next.
I thought to turn around, not to run away, but to find the Resident-Who-Knew-What-To-Do. For almost all of my time tending patients there had been somebody at least one year further along in training, standing behind me, sheltering both the patient and me. Certainly I'd signed on in little Glory to be The Doctor, but I had hoped to avoid conflagration at least until the locals had come to trust me. I knew I was a good doctor despite anything they might have heard. They'd told me it was a quiet little ER in a quiet little town, and no one would bother me. Turns out, though, sickness is pervasive.
I was, I confess, paralyzed. Though not as long as they tried to imply. A second can seem so long. Panic, however ephemeral, looks bad. All my brain parts were going off at once, chattering and bickering. "Hurry, think, hurry, think, hurry, think." Robin, bless her heart, spoke, coaching me. "Is he breathing?"
I put the back of my hand an inch under the boy's nose, hoping for a tiny current or hint of warmth. Nothing was moving. Of course he wasn't breathing; that's why he was so goddamn blue. He was, though, a known malingerer. It said so in his chart. Maybe he was holding his breath. I'd heard mothers swear their children would hold their breath long enough to turn blue, but I’d never seen it. I didn't really believe it possible, but at that moment I was willing to believe in the Tooth Fairy if she could help. I dug a knuckle into his sternum, hard, and twisted it. It's one of the accepted bits of medical sadism we use to weed out fakers and wake up drunks. Henry, however, lay still.
He was dying or maybe already dead. He needed me to breathe for him. I looked for the bag. Every ER room in the world is supposed to have a breathing bag and mask in plain sight, ready to go, no glass to break in case of emergency. It’s usually hanging on the wall by the oxygen outlet. In Henry’s room there was only a stripe of yellowed adhesive tape, loose at one end, no bag. The breathing bag had not been replaced from the last disaster which, in this backwater, may have been years earlier.
I imagine there are times in every profession when you feel as though you are the last fledgling hawk or hawklet high up the rock wall in a canyon and it's time to see if your upper extremities are functional or merely decorative. You sit on your ledge and look down and all around for as long as you can. Then you jump.
Just as I'd done on vinyl dummies, only faintly fearful I'd ever have to do it on flesh and mucus, I tilted his head back, pinched his nostrils, sealed my mouth over his, and blew in. I think his chest rose like it was supposed to, but it wasn't as if I knew what a good chest rise looked like. This was my first time. I muttered an inanity, "Holy shit," then the obvious: "Get the crash cart."
"It's here," Robin said.
I gave Henry another breath. I did indeed know what to do.
Henry’s chest rose, I was sure, but only a little, then fell. A gurgling sound came from his lips. I stuck my thumb into his mouth, under the tongue. I wrapped my other four fingers over the chin, closing a circle around the jaw, and pulled up. I held it there with my other hand and tried a third breath. It moved a bit more air.
The next step seems odd. It’s peaceful. You check for a pulse. You lay two fingers on the throat, just to the side of the trachea, and try to dig them gently under the muscles and feel the carotid artery. Even with only a very weak pulse, say a blood pressure of 40, they say you can feel it there. It's peaceful because you stand perfectly still. You can’t have anybody jerking the patient’s clothes off, sticking in IVs, or doing CPR. In fact, you really want it quiet. You get a glazed-over stare. Your eyes aren't focusing on anything. All your focus is in your fingertips.
Until you've done it, you think it’s an easy call. That's what they blithely teach in CPR: "check for pulse." Either there's a pulse or there isn't. But in a real live or maybe dead person, when there isn't, you keep thinking it's your fault. You're missing it. ‘It's weak but it's there.’ ‘Try a little farther over that way; no back the other way.’ ‘Surely there's a pulse.’ There ought to be a pulse there.
Robin was rummaging in the crash cart. She was hurrying to uncoil a length of green plastic oxygen tubing. She jerked on it violently to straighten a tangle, then slammed the cart drawer shut. I said, "Could you be quiet for just a second?"
Immediately she was as still as the other two of us, staring at me. Her I’m-not-panicked bit was gone: She looked terrified.
As much as I wanted there to be a pulse in that boy's neck, I couldn't find it.
I had already waited too long in Fantasyland. That's always how it is. Time slips by as you try to find a way around admitting that the heart really isn't beating and by god you need to do chest compressions, and by god, now that you think of it, you should have been doing them for some time now. You don't want to admit, on the hospital overhead speakers, The Reaper is winning. But you have no choice: I called a Code.
‘Launch’ is probably the better verb. It's a rocket with a very short fuse. You strike the match and make sure you can get the hell out of the way because a million things are about to happen and the process, unless you and someone from Hospital Security physically block the door, will run its course. "Get help," is all I said. That's all it takes. I closed my eyes for half a second and when I opened them Robin was gone. I heard her shout just outside the door, then someone running, then another voice shouting.
I felt Henry’s breastbone and walked my fingers down to its end. I backtracked an inch and squared the heel of my left hand in the center of his chest. I put my right hand on top of my left, locked the fingers together, then rose up on the balls of my feet, directly over him. The gurnery was too high for me to lock my elbows, but I could still bear my weight into his chest, feeling for what I guessed was just enough "give" to squeeze the heart between the spine and the ribcage and pump blood downstream.
I wondered what a small-town code team would look like. I don't often pray but I remember thinking of God, and for a couple of milliseconds I might have asked for mercy for Henry, and just as much for me.
Even alone and scared I was thankful to be doing something physical. Just like everyone else doing CPR for the first time, I didn't know if I was doing it right. I imagined his heart being squeezed under my palms, then passively refilling. Once as a med student I watched an intern do chest compressions on a pulmonary cripple who had a line in the artery in his wrist. We could see on the monitor the blood pressure waves she was generating and she adjusted her stroke to the best wave. In him at least, the best flow came with a sharp and frighteningly deep squeeze. His ribs cracked. The intern winced. The resident said, ‘It’s better than staying dead.’ He did that also.
I bore into Henry's chest, trying to do the same kind of stroke. I counted to fifteen, because that's what I'd learned in CPR class. I gave him two more breaths, then started over. The eternity of pumping and breathing alone probably measured less than 90 seconds by the clock.
He was an awful color. I stopped once and again laid my fingers on his throat. Some patients bounce right back. If my desire counted, his carotid would have been booming. I tried to invoke all my years of study and training and a fiercely wrought want and strength of will. As if it might help.
The exam room door jumped open, shattering our silent supplication. It hit the wall behind it and shook with a deep bass vibrato. Patty Kucera, RN, one of the ER regulars and a sizeable woman of around 6 feet and 280 pounds, was first of the motley cavalry of backwater medicine to charge in. On her heels were two other women, a tall man in hospital scrubs, and Robin.
I had run codes as an intern, but when you're the intern giving orders to an experienced code team, it's like being a little kid telling Mom what goes next in the cookie dough. She'll do what you say as long as you say the right thing. If you say the wrong thing Mom will do the right thing and smile at you. You'll learn. I knew the approved protocols for a standard Code, but sometimes that’s not enough.
The best spot at a code is the one standing over the patient's heart, bobbing up and down. The job is at once the most mindless and the most critical. You can look around, talk to people, smile sometimes. It is like sex: You can do it with empathy and passion or you can do it with your head in the next county – if your mechanics are adequate the immediate outcome likely will be identical. It is not, however, the place for the person who's supposed to be making decisions, so I tagged Patty to take over the chest compressions.
It’s a sea change to go from the physical simplicity of one-rescuer CPR to the role of the Guy-in-Charge-of-the-Code. I stood there for a second knowing I was forgetting something. I mouthed to myself; "ABC. Airway, breathing, circulation." I asked, "Where's Respiratory?"
"Right here, doc." It was the lone male in the crew, a respiratory therapist – ‘RT’ – named Roger. He had somehow materialized a breathing bag and mask and was jamming the mask into the boy's face, squeezing in oxygen. He gave me a little sideways grin. He was straining to hold the mask tight to Henry's face with one hand. The mask was too big and half the oxygen was being expelled over the eye sockets with a farting noise. Even so, the chest was definitely moving.
Vickie Rhoades, the evening shift charge nurse out on the wards, slit Henry's sleeves and pant legs with long gliding scissors strokes. In seconds he was naked but for stained briefs. She threw flimsy wires around his neck and connected pasties to his chest for the EKG. She tucked the free parts of the wires under his shoulders so they wouldn't flop around and get pulled off, which they always do anyway.
Vickie wrapped a wide floppy yellow rubber tube around the boy's left biceps area and slip-knotted it. She snapped her finger on the big vein over the elbow, wiped it furiously with alcohol and slid in an IV. She finessed the catheter off the needle and up the vein, pressed hard on the vein with the other thumb to plug it off, snap-released the tourniquet, connected the line and opened the roller valve, all without spilling a drop of blood. The whole thing took maybe 30 seconds.
"Got an IV," she said. "D-5. Runs like a racehorse. TKO for now. Atropine and Epi going in. An amp of D-50, doc?"
I was blank. There was no reason to give sugar. I mumbled, "No. Hypoglycemia this isn't.”
“It’s protocol,” she said.
“Well, okay, I guess it won't hurt. We'll try everything."
"Narcan?" Vickie asked.
Again a blank. Narcotic reversal? "He a user?" I asked.
I said, "Sure. Wouldn’t want to buck protocol." She smiled and nodded.
Patty was breaking a sweat over Henry’s chest. “You need a break?” I asked her.
“Naw, I’m fine.”
Two more women had come in, but there was nothing immediate for them to do. They stood waiting for a job, adding their worry. One said “Oh my god, it’s Henry.”
Half the hospital's evening personnel were in the room. "Who's tending shop?" I asked.
“Beulah,” Patty answered with a grunt.
“Ward secretary. She’ll call us if somebody needs something important.” In a 30-bed hospital even the secretary will know who’s in trouble.
Robin was bent over the EKG, staring, running out foot after foot of printout and bunching it up in one hand like toilet paper. With a small mastodon bouncing on the kid's chest the print needle was all over the strip and none of it meant a thing. You could have seen that from Flagstaff. "What's the rhythm?" I asked, making conversation. She looked up with the pained expression of someone awaiting her executioner.
"Lots of artifact but there's nothing underneath it," she said.
"Hold your compressions a sec," I said. Nurse Kucera wiped her brow. Robin stopped bunching up the EKG printout and slowly stretched out her left arm as the strip got longer and longer. The needle lazily drifted back and forth like it was dreaming about something pleasant, then spiked an irregular plateau wave. Maybe somebody was popping popcorn in a microwave in the next building. "Looks pretty flat," she said.
"Resume compressions," I said. "Let's draw up another round of epinephrine and atropine and get an intubation tray ready. Can somebody get a blood gas?" I felt better giving real orders, even if they were obvious. "I'd say he 's about 40 kilos. Give another half milligram of epi and o-point-five of the atropine."
Once the drugs are emptied into the IV port and chased into the vein with a flush of IV fluid, you stand there hoping somehow something will change. It’s a lull in the action.
"What happened to Henry?" Vickie asked Robin.
Robin jerked more upright like a puppet coming to life. She was pretty, slim, stylish and in her mid-20’s, all of which set her apart in Glory’s hospital. She jerked her head a bit, swinging brown hair over her mouth. "How well do you all know him?" she said.
"We all know Henry,” Patty said. “Frequent flyer. Asthma. Seizures. Well, real seizures maybe – fake seizures for sure. Big-time loser."
We stared at Robin. "I wish I knew what happened," she said. "He told us his asthma was bad. Pollen or something. Wanted his epi shot." She shrugged. "We gave it to him," she said, nodding toward me.
They looked at me. There was a moment of silence, either sympathetic or accusatory, I wasn’t sure. "He didn't bounce around on the stretcher for you?" Patty asked, screwing up one side of her face and jerking her arms like fishhooks.
"No," I said.
"Did he insist on showing you his crooked penis?"
“Well, yeah, that did come up.”
"Did you feel honored?"
"I had a feeling I wasn't the first."
"His asthma must have been way worse than we thought," Robin said.
"Maybe," Vickie said. "Maybe he was so tight he couldn’t even wheeze. I’ve heard that happens."
"He’s never been even close to that bad before," Patty said.
"Did Daniel come in with him?" Vickie asked.
"Daniel? His dad? Is Daniel his dad?" Robin asked.
"Yeah. Pompous little grease ball. Dark goatee," Patty said. “Bigger loser.”
"Yes. But he kind of disappeared," Robin said. “I thought it was weird.”
“He’s like that,” Patty said.
Roger, the RT, interrupted. "Doc, I don't think I'm ventilating him too good. What do you think about maybe intubating him?"
"Stop compressions. Check for a rhythm," I said.
Patty stepped straight back and slowly raised her locked hands and elbows over her head. The room was silent. Vickie poked in the neck for a pulse. The EKG was still flat.
I mumbled, "Resume compressions," and looked at Roger. I said, “Sure, Roger.” We both knew he probably had done a hundred more intubations than I had.
I ripped open the plastic wrap around the intubation tray and unfolded the sterile wraps to check the equipment. The blade fit the handle and the light worked. I slid the fat soft aluminum wire stylet inside the tube and bent it into a banana curve, just as the anesthesiologists always did.
I stepped under the IV line, over the EKG cable, under the oxygen tubing and slithered up to the head end of the gurney. I would need leverage. I leaned into the gurney. It began to roll away. "Lock the fucking gurney, please," I said. Patty stepped back from the CPR. She kicked down the wheel-lock lever then leaned back into Henry’s chest.
I said quietly to Roger, “Okay.” He looked at me. I repeated it, making a small waving motion with the laryngoscope in my left hand, staring at the boy's mouth. Roger moved the mask aside and stepped back.
Henry’s mouth was full of regurgitated food. "Oh shit. We got chunks. Suction." I was nearly yelling now, which of course adds nothing of use. Vickie handed me the suction tubing. Attached was a tip the size and stiffness of wet spaghetti. I wrenched it off and flung it backward against the wall behind me, cutting the back of my hand on a metal bracket. "Fuck. Who put this sucker on here?" I asked – shouted. I tried to scour out Henry's mouth with the open end of the main tubing. "Those are for getting secretions out of bronchi, not for getting peas and carrots out of the trachea."
"I'm sorry, Doctor," Robin blurted. Though she had spoken to me she was staring straight ahead, apparently focused on Henry’s spirit leaving the room. I was surprised anybody had answered my rhetorical question. It reminded me, though, whose ER it was. The staff was not here to be subversive. They were here to help sick people and I was a guest on a reluctant invitation. I'd best not bite at them.
The stream of what had been stomach contents looked like vegetable beef soup. Once I got the mouth cleared I said to Roger, "Let's give him some of the good air." After eight or ten breaths of oxygen I again said only, "Okay," cueing Roger to step back. I guided the tip of the laryngoscope blade down the boy's tongue and lifted.
I prayed for the anatomy to be clear, just this once. It wasn't. All I could see was a muddle of mucus secretions and pink, puffy soft tissues shaking in jerky synchrony with the chest compressions. The only thing I recognized with certainty was a single pea stuck to a tonsil. "It never looks like the goddamn pictures," I said. "Stop compressions a second." I used the suction tip to clear the secretions and then as a probe to gently part the tissues. Suddenly the cavity seemed to pop open and there lay the target, the inside of Henry’s voice box. Then, just as suddenly, the tongue flopped around the blade and all I could see was a fat gray wad of blubber covered with taste buds. "Fuck," I mumbled. I pulled out and motioned Roger to give Henry some breaths.
While the oxygen went in I sighed and looked around at the nurses. Robin spelled Patty at the chest compressions, diving into Henry’s chest like she was pushing the Devil himself back to hell. After a dozen breaths Roger stepped away again. I put the blade down Henry’s throat again, concentrating on keeping the tongue to the left where it belonged. The view opened up again. The target was clear. I passed the endotracheal tube to what I was certain was the trachea.
"In," I said.
A flurry of concerted activity began, like a string quartet, all moving in different ways but creating a single result: I inflated the cuff at the tip of the tube, Roger connected the breathing bag, Patty laid her stethoscope into the boy's right armpit and Robin resumed bouncing on Henry's sternum. Roger squeezed the bag. The stomach rose. A gurgle came from the mouth. I groaned. Patty listened to both sides of the chest, then the stomach, as Roger repeatedly squeezed the bag. She told me, practically shouting because her ears were full of stethoscope, what I already knew: "It's in the esophagus."
Angry with myself I jerked the tube out too fast. "Ventilate, please," I said. Roger re-attached the mask and pumped oxygen, probably pushing chunks of dinner farther down the respiratory tree.
I grabbed at the laryngoscope and knocked it to the floor where the blade and handle separated with a mocking clang. "Keep breathing please," I said, bending to get my tools off the floor. I reunited blade and handle and looked at the ceiling, biting my lip.
I sucked out Henry’s mouth one more time and slid the blade in so deep I knew my first view would be esophagus. I slowly backed out the blade until the voice box suddenly fell into view. I finessed it open with the tip of the blade and saw the by-god vocal cords. They're distinct when they show up. "Well hot damn," I mumbled. I slid in the tracheal tube. Again the string quartet routine. This time the chest rose instead of the stomach.
Though Patty was listening to the chest again, the Doctor’s Rule is to disbelieve until you hear it yourself. "Where's my stethoscope?" I asked, scanning the growing clutter of syringes and wrappers and alcohol pads surrounding the boy.
"Around your neck, doc," Roger smiled. "That's always where they are."
Henry had definite wheezes and new gurgling noises that made the picture ominous. Roger taped the tube to Henry’s face while Patty did the breathing.
"More epi, please," I said.
"Do you want another dose of atropine?" someone asked.
“No. He’s blocked out for the next four hours at least.”
I asked Vickie to stick the big artery in his groin for a blood gas. Shock plays hell with acid-base balance. She managed to find a vessel on the first pass. It was darker than spoiled claret, but at least it wasn't black.
An elfen blonde making notes on a clipboard, leaning back on the counter, blurted: "It's been 23 minutes." It's about now in a code when the team begins to back down, hoping the Guy-in-Charge isn't one of those who thinks he can cheat death if he works everyone to exhaustion. I'm usually one of the first to pronounce the dead dead, but they usually hit the door dead, not sassy like Henry had been.
"You want to try shocking him?" Patty asked.
Vickie said, "Live better electrically."
"He's in asystole," I said. "No point."
"Maybe it's fine v-fib," Patty said. That's the excuse for getting out the electricity when there's nothing else to do.
"Well, if you want to, we can," I said.
"I just thought it was the only thing we hadn't tried." Subtext: ‘Nothing's working means he's dead. We got work to do elsewhere.’
I checked his pupils with a light – both were dilated open and paralyzed. In this setting it didn't mean anything definite, but it looked bad. Robin paused her chest compressions two beats worth and looked at me with what I took to be a plea. Like everyone else, she and I were exasperated, but we had, by virtue of Henry having shown up on our watch with an apparently functional heart, the most at stake in his resuscitation. Our eyes locked for a second before she went back to staring into the ether.
I said, "There's no reason for this kid to be dying."
I knew they were all thinking, 'Even if heart starts, brain still dead.' The books say even the best chest compressions achieve only 20 percent of normal blood flow. However, I had seen a patient open his eyes and look at me during CPR. He nodded to a question. Ten minutes later he died. You don’t forget that.
"Anybody got any ideas?" I said. "Am I missing anything?" Before you let go it's always best to be sure no one on your team is silently thinking you’ve forgotten something. "Anyone object to stopping?" There was verbal silence.
Robin spoke. "Maybe one more round of drugs."
"Sure," I said. "Epi. And give some bicarb." I nodded at Vickie and Patty.
One of the gallery spoke: “American Heart Association doesn’t recommend bicarb.”
I nodded. “Yeah, I know. And I know why. And I want it anyway.”
"Want to try high dose epi?" Patty asked.
“High dose?” I said, obviously seeking guidance.
“It’s kind of new. One of the other docs told me about it. I guess it’s still controversial, but apparently sometimes it works when nothing else does.”
"Okay," I said. "How much?"
"Well, like six or eight milligrams at a time in an adult."
"Okay. Give him four," I said. "And two amps of the bicarb. Sometimes it helps the epi work."
The nurses injected the drugs. The chest was bellowed up with the breathing bag and compressed down by Robin's weight in alternating synchrony. We all stared silently at the EKG monitor. At first nothing happened. In fact, it probably took a full minute, but the needle made a sudden jump up in the middle of its regular CPR-induced bounces. We all saw it, but all knew it could as likely have been from sunspots at Henry’s heart. Then it did it again. And again. “Hold compressions,” I said.
Robin wiped the hair from her eyes and leaned over to join us watching the EKG. The needle jerked upward, then retreated back to midline with a lazy floating motion. In the next 15 seconds, the jerks upward began to come more rapidly and the floaty motions downward began to sharpen, to look more like the inverse of the twitches upward, and these 'beats' sped up to about one per second.
"Jesus Christ I think it's beating," I said quietly. Louder: "Stop compressions a sec."
The waveforms, at first only an evil approximation of an EKG, lost, beat by beat, their aberrant slopes and plateaus. An army of upright and familiar-looking spikes marched across the screen like soldiers to the rescue. Just as slowly I began to smile. In the next few minutes the stagnant venous blood, with its overload of epinephrine, was accelerated back into action. Henry's pulse hit 180, and he developed a real blood pressure.
The faces of the staff showed a mix of relief and surprise. While they set up drug infusions Patty made a speech out of a medical cliché: "Geez, it's good to have the heart of a 13-year-old."
Vickie said, “Yeah, but Henry will find a way to make us pay for this. You know he will,” she laughed.
Sometimes after a full arrest you get a honeymoon recovery; the heart will beat like crazy for 20 minutes, then rapidly degenerate and finally quit forever – the last cardiac gasp. I hovered over Henry’s monitor, expecting the worst.
Watching the hypnotic march of the EKG, I mentally replayed the first half of my encounter with Henry, looking for clues. When he’d been checked into the ER, Robin had written on his clipboard only “asthma” in big quotes. She’d found normal temperature and blood pressure, though his heart rate and breathing were both a little fast.
When I’d gone in to talk to him, he was alone, sitting on a gurney, bare to the waist. "Hi Henry, I’m Dr. Malcolm.” I squatted a bit to get to his eye level.
He squinted at me. “You’re new here,” he said.
“Well, I’ve been here off and on for a couple of months,” I said. “How’s your breathing?”
“Like always.” His voice was low and croaking – frog-like.
“Like always when you come in here you mean?”
“Uh-huh. I don’t come in unless it’s bad. Or I’m having a seizure.”
“No, of course you wouldn’t.” I warmed the business end of my stethoscope between my palms. “Who’s your favorite Diamondback?” I gently laid it on his back.
“Your favorite baseball player. The D-Backs? You don’t like baseball?”
“No. It’s boring.”
His heart was fast, and he was wheezing and struggling a bit to move air. The rest of the exam – the belly, the throat, and reflexes – was all normal. “What sports do you like?”
He said, “None.”
“Okay, Henry, let me see about getting you some medicine.”
“Wanna see my penis? He asked, reaching for his pants. I am not often speechless, but that did it. “It’s crooked.”
A good doctor would never ignore a symptom. Though I figured I would probably regret it, I went along. “Is it bothering you?” I said. Maybe it was infected or something. Infections can set off asthmatics.
“Here,” he grunted, pushing his pants and briefs off his bony little hips. “Look at it.”
I was indeed regretting this. I found some gloves and began an orderly genital exam. He had very scant early pubic hair. His testicles were normal, but there was a mildly contracted surgical scar on the underside of the shaft.
“Looks like you had a hypospadias repair,” I said, suddenly remembering I should have had a nurse ‘chaperone’ present for any genital exam.
“Is that where – that thing you said – does that mean the piss comes out the bottom?” He was pointing to his scar.
“Yes, if you mean the bottom-side of the penis,” I said. “The opening of the urethra – the hole the pee comes out – is on the underside of your penis when you’re born. It was probably fixed when you were a baby.”
“It was,” he said. “Now it’s crooked.”
“Well, not too much,” I said, straightening it and letting it fall back. Time to change the subject. “It looks like you’re working pretty hard to breathe, Henry. I think we better get you a respiratory treatment.”
“Yes, Henry, a ‘neb.’”
“I don’t like those,” he said.
“Well, I’m sorry about that, but the alternative is a shot, and my guess is you’d like that less.”
He grunted “I get those all the time.”
“Let’s try the easier thing first, shall we?”
He grunted again.
Awaiting me at the doctor’s desk were the three and a half volumes of old charts from his dozens of prior visits and admissions. I ordered his inhalation treatment and began reading the highlights from The Book of Henry.
In addition to his hypospadias repair and asthma, he now clearly had ‘pseudo-seizures.’ More of his prior ER visits were for feigned seizures than for asthma. Most of the seizures had been easily debunked by the usual bedside tests. Someone having a generalized seizure – a real one – is incapable of doing anything purposeful, yet Henry would routinely make small movements to help the nurses get him into a protected position. One time, on hearing that he needed a bite block between his teeth, he opened his mouth.
‘Pseudo-seizures syndrome’ is a diagnosis both ugly and complex. I pulled a text. What I remember now are things like ‘complex disorder of behavior,’ and ‘commonly dead of suicide before age 30.’ These patients learn to use fake seizures to get maximal attention. The psychiatric progression is both predictable and extremely refractory to treatment. A few cases had responded to the most intensive psychotherapy – on the order of two to four hours with a therapist every day. No health insurance in the world would pay for that, nor would the State of Arizona or Maricopa County.
His prior caretakers believed he had been abused as an toddler by his biologic father. I mentally laid the psychiatric disorder to an abusive father, despite the lack of any evidence of a connection between the two pathologies. I went to the hallway vending machines for a can of Squirt. When the neb was finished I listened again. His wheezing was better but not much. Robin told me he asked her for his shot. He told her that was what he always got. I checked his chart. As he said, he had been given sub-Q epi at each of his last two visits for asthma and responded well. I wrote the order. Minutes later the dam broke.
Henry’s cardiac honeymoon was holding up without any more heroics from us. He stayed pink. His pupils stayed big, though, and he wasn’t waking up. Brain in limbo.
Convinced he was going to live at least the next half hour, I decided I could afford to attend to the mundane. I sat at the desk to write my report, but the cut on the back of my hand was bleeding on the page. I found two sterile cotton balls and taped them over the gash. Thus made safe for paperwork, I wrote a two-page chart note headed “Code – MD Report.” I put down every clinical detail I could remember from the moment Henry first arrived in the ER until we declared our standoff with death. It lacked only an explanation of the cause.
Henry needed to be in a pediatric ICU. From our faux-oasis outside Phoenix I had two choices. St. Elizabeth’s was closer, more pleasant, more "moneyed.” But like any fledgling doctor I chose what I knew, the one on my old turf, University of Arizona, Maricopa Branch. “The ‘Copa.” While Patty called an ambulance for transport I phoned the Maricopa operator and asked for the Pediatric ICU.
"Who's the resident 'on'?" I asked the charge nurse.
"Intern is Michelle Rosenbaum," she said. "Senior is Mary Ellen Montgomery." Dr. Montgomery was my housemate and closest friend.
"Is either one there?"
She found Dr. Rosenbaum. The intern said ‘Sure’ as formal acceptance of transfer. I told her everything I knew about Henry and asked her to have Dr. Montgomery call me back.
My next job was one of the particularly hellish moments of doctoring, facing the family. I would need to tell people I had not previously met that their son had nearly died at my hands and might yet finish the job. Despite my natural desire to hurry through any such discussion I have learned it is best to go slowly and give information by implication, nursing along the aggrieved until they get it. I leaned on my elbows at the desk for a good three minutes of silence, rubbing my face and rehearsing my words. I remembered the troubled boy I had spoken to – their son. I stood up straight enough to make my mother proud and marched into the waiting room as if I did this every day.
All for naught: the waiting room was empty.
I asked Patty to call Henry’s home. She left a vague message.
So we entered the many stages of waiting. Waiting for the ambulance, waiting for a callback from the family, waiting for Henry to wake up, waiting for an answer. The hardest part of medicine.
Wandering about the ER, I passed in front of the motion detectors over the ambulance doors. They slid open, offering an automated invitation outside. I stepped into the sun, warm and pleasant in the late-winter afternoon, for a time to think. The view across the parking lot was a golf course. I heard a ‘thwack’ and a curse. Beyond the artificial greenery were low red mountains shielding Glory golfers from the snarl of Phoenix.
Had I known what caused Henry’s arrest I would have written it down in big letters. When you don’t know you enter the many stages of analysis and reconstruction, an unscientific process of untestable theorizing and conjecture by dozens of doctors and nurses who were not involved.
This I knew: His arrest made no sense. Though I could not have claimed great experience with the nuances of asthma, I certainly knew how to treat it, a disease so common it’s boring to most pediatricians. Nor was I an expert in pseudo-seizures, but there was no link in patho-physiology connecting pseudo-seizures to cardiac arrest.
I went back in. If there was going to be reconstructing done, I wanted to have copies of whatever data there were. Even scanty evidence might be useful. I made photocopies of the code sheet, the nurses’ notes and my own chart notes, then went back to Henry's room to see if I could think of anything else.
But for the tubes and wires he would have looked pink and healthy, just asleep. Roger had brought in a ventilator to breathe for him. One of the nurses had wrapped him in a thick cotton blanket to keep him warm on his ride into town.
The room was cluttered with torn paper and plastic wrappings, a few bloody gauzes, partly emptied syringes and long strands of EKG printout. On the counter by the sink was a scattering of syringes and needles. I gingerly poked through them and found the one Robin had used for the sub-Q injection just before the code. It was the smallest; the only one-CC tuberculin syringe in the detritus, still full to the eight-tenths mark, with a brown glass ampule, minus its top and its contents, taped to the side of the syringe. The ampule said, "EPINEPHRINE (Adrenaline) 1 mg/cc."
As I was reading it Robin came in. I thought she saw me staring at the syringe. I looked up at her, but she had turned to fuss with Henry’s IV drips.
The ambulance people came in. "We're ready to go, aren’t we Doc?" Roger said from the head of the bed.
“Sure,” I said. I smiled wanly to the paramedics.
I didn’t really think about why I was doing it, but I went around the corner and out of sight to the med room, found a small baggie marked "Specimen" and put the syringe in it. At the desk I found a big brown inter-departmental envelope, put the baggie in it, rolled it up, taped it, wrote my name on it, and put the package in the drug refrigerator back in the med room. It was pure reflex.
As the gurney was being wheeled past – Vickie steering it from the foot end, Roger squeezing the breathing bag – Robin set on top of Henry's legs a big plastic bag, like a discount store shopping bag. Ithad in it the shreds of Henry's clothes. It said on it, “Thank you for choosing Providence of Glory Medical Center, Glory, Arizona.”
That was almost seven years ago.
Now I am ‘home.’ In Hooker, Nebraska, my point of origin.
I practice medicine in the Hooker ER and places like it. I work the hours the other doctors don’t want.
Hooker, population 9,858, is the only town in an 80-mile radius with a hospital. There’s a one-doctor clinic over in Othello but that’s a really tiny town, 27 miles from Hooker, and they lock down on nights and weekends. From 7 PM on any Friday until 7 AM on the following Monday the only doctor the ill or injured can see is me, or somebody like me.
My Henry Troubles in Arizona left me practicing medicine as an itinerant physician. I camp on weekends in ERs like Hooker’s, scattered across the plains, for 60 hours at a stretch, for an hourly wage, currently $43. I am, or so it says on my papers, only partly trained.
The hospital in Hooker has the kind of non-committal name they seem to like in generic small towns – “Hooker County Community Memorial Medical Center.” “HCCMMC.” A medical center, not just a hospital mind you, that commemorates the community. My guess is it had the least chance of being controversial when the Board of Trustees had to pick.
I grew up in Hooker, an age ago. It seems it is my home again. Relocation by default.
Through college in Boston and medical school in San Diego, I told friends Nebraska was a great place to be from, emphasizing the 'from'. There was mild dishonesty in participating in the clichéd bashing of a place I loved, but it helped shut off the stupid jokes from people at the edges of the continent about how backward everyone knew us Midlanders to be.
Luckily I had a Nebraska medical license before the Troubles began. Licensure requires medical school, internship and the National Board Exam, not a residency. Near the end of my internship in Arizona my father harangued me into doing the paperwork to get my Nebraska medical license. Dad was planning on me taking over his practice when I finished residency, and he was getting impatient. When he started practice thirty-odd years before my internship he was the only doctor in an eighty-mile radius. It was catching up with him.
I made it clear I had little interest in either a generalist’s practice or a life on the prairie, but for the cost of a license fee I figured I would be able to get him off my back for at least the duration of the residency.
Getting a license, however, was a happy event. Pre-Henry I was a jauntier soul; the future was boundless. While home for a week vacation I made rounds with Dad every morning. With my shiny new License to Practice the hospital was willing to give me ‘Courtesy’ privileges, and I got to scrub an appendectomy with him. He actually let me do the operation, though my deliberate manner, under the eyes of 30 years of proficiency, must have seemed plodding. It created palpable impatience at the operating table. Nonetheless I count it as a trophy memory.
Though he didn’t entirely approve of my choosing to be a full-time surgeon he did understand that no one, these days, could do it all, the way he had. He was a throwback to the days before every doctor did a residency; a living, breathing General Practitioner. He still did routine operations and delivered babies. In those days of hubris I told him he was a living fossil. I also pointed out that a fully trained surgeon, should he be so inclined for some silly reason, could take over the majority of Dad’s practice, where a fully trained internist or family practitioner could not. He nodded and smiled, believing I would still find just such a silly inclination.
My next visit – after my failed residency, after Glory, after Henry – was the antithesis of the Proud Homecoming. Tail between my legs, unable to explain in sufficient detail, Nebraska was a hideout, my sanctuary. Jauntier days looked quaint.
For gainful employment I checked on the hometown ER, hoping to pick up some hours. They said to call Western Acute Health, Inc.; they ‘had the contract.’ Western Acute was the cashflow brainchild of Mel Steele, an ER doc in Cheyenne. Mel figured out he could develop an income stream by holding contracts to supply doctors for ER coverage at tucked away little towns few doctors would otherwise find. Western gets paid by hospitals like Hooker County to keep a licensed doctor available in the ER for the entire weekend every weekend. So the local family docs don’t have to cover all the hours of the day and night. So they don’t get too fried and pack away like moths to the lights of the city.
It started out as a way to pay my bills while I waited out my appeals and applications. I would work weekends but get the uncrowded weekdays to be skiing in Colorado or fishing or hunting in Wyoming. It became a habit.
The work can be good.
The waiting can be brutal.
The hospital in Hooker is at the western edge of town. Sometimes I stare out the window of my second-floor call room – “The Penthouse” – watching, just across a gravel road, beef cattle graze. Hooker has no golf course, and no low mountains. But then, there’s nothing that needs to be hidden.
Watching the sky is the best. Clouds of hospital cotton float overhead on sunny summer days and the blackest, most malevolent thunderheads roll across grassy dunes just before sunset. The better ones kick up all kinds of flotsam with their opening salvos, then pelt it back to earth with fishing-sinker raindrops or, on a good evening, hail that sounds like glass slowly shattering.
Recreation inside a hospital is cramped. Sixty hour shifts, mostly spent in the on-call quarters, reading, watching some game-of-the-week on the tube, sleeping, eating cafeteria fried foods. Since Henry and my time in Glory, flirting with nurses has lost much of its allure. But the time is not all a waste. I do study my area of medicine. I mix literature into my often-pedestrian reading list and for at least part of every weekend I get paid $43 per hour for sleeping.
When things fell apart I told Dad the final outcome and a smattering of the details. Naturally, he was angry with all concerned. He wanted to bring legal action. Afraid the law might have something to say to me, too, I silently demurred. I told him about certain clauses in Arizona employment contracts that would make a suit pointless. These gnawed at him, too.
Two months ago I was back in Arizona. Though I am persona non grata there to the medical establishment they have not yet set up border barricades.
Mary Ellen Montgomery, my former housemate and the doctor who took Henry Rojelio off my hands that night in Glory, called, via my parents, saying she had something for me. I made it to Phoenix in 36 hours.
While there I called a criminal attorney, Gerry deLee, and made an appointment. A cop I know recommended him. His office was in a bank tower in central Phoenix. It smelled of cigarettes and sweat. The view from the lone window was of a city block across the street, sandy and completely vacant but for three broken off palm trees and an equally topless concrete foundation.
Mr. deLee’s face had redundant folds of the upper eyelids that made him look half asleep most of the time. From the questions he interposed, though, it was obvious he was listening, acutely. I retold Henry’s story. I rambled. It ran to two hours. He rendered professional judgement: The statute of limitations was running out on minor things and for major things the situation was too murky and the time too long ago for any DA with an ounce of sense to want to pursue it.
Apropos the events, there can be no certainty.
Also apropos the events, I am going to act on the knowledge I possess: I have a certain freedom to speak.
My would-be career as a surgeon was castrated so long ago it is irrecoverable, and to me, through the years, a vanishing concern. Still, these events were real. They redefined my life.
I will tell two stories: Neither means a thing without the other. They are separated in time by ten months. Though they are nearly seven years old they are clearer to me than my last weekend ER shift. Both happened in the Phoenix area. They call it “Valley of the Sun.”
Some may see crimes or insufficiencies in my manifest acts. Certain omissions trouble me more. Major parts are played by individuals believed by most to have known better. Most of the cast is still about, playing their parts, greasepaint intact.
Ergo, my story.