Trauma Room Two

by Philip Allen Green

With a sigh of resignation, I realize there is no escape. I click on his name and assign myself as the treating physician. The screen flashes to the medical record.

I log out, stand up from the computer, and walk over toward room three. I pass the nurse who checked him in. She sees where I am going and smacks herself dramatically in the forehead with her palm while rolling her eyes. I suppress a laugh, at least we are all in this together.

It all started about a year ago when he first showed up in town. Like most drifters, the first thing he did when he arrived was head straight to the emergency department. Everyone who lives on the road, it seems, always wants to know what the ER is like in a new town.

Blood pressure is eighty-three over forty now. That is too low. She already has two large-bore IVs started by the medics. Both IV machines are pumping at full speed, their electric hum and buzz audible in the quiet room. Bilateral streams of saline drip into clear plastic tubing that runs into her arms. The fluids flow into her blood vessels.

They pour in just as fast as the blood pours out. Out into her abdominal cavity from her leaking aneurysm. The aneurysm is in her aorta, the biggest blood vessel in her body. It carries the blood like a living pipeline from the heart down through the thorax and into the abdomen. Eventually, it splits into the smaller femoral arteries. Her aneurysm sits just above the split, right on one of the largest parts of the vessel.

I take the moment to reflect on my life in this place. I have been so burned out lately. It seems I am just doing the same thing over and over without really doing anything at all. Staff members have been angry. My patients have been angry. Angry parents, angry spouses, angry siblings.

This is why I became a doctor. Not because I can stitch a wound, manage a trauma, or splint an arm. No, I became a doctor to be with people when it matters the most. I did it so that I can stand at the edge of the cliff with another human being and we can gaze out together into the night beyond. I did it because I, too, am afraid. I did it because I want to find some way to lessen the fear—not just for me but for all of us.

It is sad and wonderful and terrible and beautiful to hold the hand of a dying person.

There is a ventilator with a touch screen interface, a fiber optic GlideScope, a monitor that captures every beat of her heart, her every breath, her oxygen level, and her blood pressure. There are three computers in this room alone, not including the telestroke robot used for stroke patients. It hits me that I am surrounded by nearly as much technology as a space shuttle pilot. And yet none of it does any good at moments like this.

Her blood pressure now is fifty over twenty-two. Her heart rate is twenty-eight. The lines widen on the monitor, and I see her heart skipping occasional beats.

I hold her hand a moment longer. It is still warm, but I know she is gone. I keep holding it even after the monitor line goes flat, just to be sure. I don’t want to let go first. After all, a promise is a promise.

The alarm on the monitor chimes out suddenly like church bells tolling on a distant hill. I reach up and shut it off. The room is quiet. I can hear the noise of the ER outside the room. Other patients. Other people. Other problems. I don’t want to leave, not quite yet.

“What if I know he or she is going to die? What do I do then?” At the time I had no answer. But now, thanks to my friend, Ann, I do. I guess I will tell you since I cannot tell him. First, it is OK to be afraid. That is normal. Second, introduce yourself, use your first name. Third, hold the person’s hand as he or she departs this life. That will be enough.

The ER is empty. We have not had a patient in over six hours. The storm has stopped all motion but its own. My lone nurse has disappeared somewhere upstairs into the little hospital to grab a few hours of sleep. I do not mind. For once this place feels safe from the world outside.

I needed to get away. Away from death. Away from the trauma. Away from the endless waves of suffering people. On a whim, I signed up for this three-month emergency medicine job in the remotest part of Wyoming that I could find.

I am disgusted with myself that I cannot remember. I have to remember. I need to remember. Is it not the duty of the living to remember those who are no longer with us? I take a deep breath. Do not get frustrated. Sort them through.

The parking lot feels like another world. Snow falls past the headlight beams, the flakes from the blizzard swirling and curving every direction but down. I grow dizzy just trying to stay upright. I have to slow my steps so as not to fall. I see the old man. He is standing next to the open passenger door of an ancient farm truck, the engine still running. The big diesel grows louder as I approach, the ktunk-ktunk-ktunk unmuffled by the falling snow. As I near, the man takes a step back and signals frantically for me to hurry.

A small gold necklace dangles straight down from her neck, twisting back and forth in the dashboard light. I can see it is a cross. Two gold, female angels sit on the horizontal beam of the same cross, their bare feet dangling off like children sitting on a swing, their hands clasped together across the apex. It is strangely mesmerizing with the snow falling all around me.

I sit down in the room with the woman. I feel bad abandoning her in this empty place, even if she is dead. No one should be abandoned twice in one night.

Maybe I will be OK, too, I realize. Maybe I don’t need to remember the faces of the dead. Maybe I need to remember the faces of the living. After all, they are the ones who are still here.

A tiny woman sits on the gurney next to her. Her back is arched and kyphotic with age. A few strands of thin, white hair are spun across a balding scalp. Her left eye is a solid milky white.

Her mother’s heart is in ventricular fibrillation. Inside her chest, it writhes and bucks like a fistful of living earthworms tossed into a campfire.

I look at the monitor. Still in V-fib. We shock again. And again. Check for pulse. None. Asystole now—no pulse. A tech restarts CPR. “Give her an amp of epi and draw up some Amiodarone, I say. I crack open our airway kit, grab my Mac 4 blade, snap it together, and stick it into her mouth.

We inject epinephrine, atropine, dopamine, fluids, bicarb, and ourselves into the effort. The woman’s chest is now like a pillow, collapsing impossibly inward with each compression of CPR. The rhythm changes. We shock again and again.

I step outside into the ambulance bay for a moment to clear my head and stop my hands from shaking. Some days I am ashamed of what I have to do to make a living.

Facts collect and gather on my patients like the crows that collect and gather on the power lines strung above the hospital parking lot. The more facts I collect about a patient, the more likely they will coalesce into a noisy flock and take flight together as a story.

An old man lies on his side, curled up tightly from contractures that trap his arms and legs into the permanent bends of flexion. An angry bedsore on his hip tells me he has been left somewhere curled up in a bed, unattended for a long, long time.

The tips of my fingers search and probe about until they find his radial pulse. The monitor over the patient’s bed shows his heart rate, his blood pressure, and even his oxygen level. Yet those are just numbers on a screen. My fingers ask questions the monitor cannot answer. How does his skin feel? Is it warm or cold? Clammy or dry? Flaky and sick or smooth and healthy?

I count the beat of his heart with my fingertips for thirty seconds and multiply by two. Just like the monitor, I calculate his pulse to be fifty-four beats per minute. But unlike the monitor, my fingers tell me his pulse is weak and tired. It has no snap against the volar pad of my index and middle fingers. There is no tiny hum, buzz, or bound like that of an athlete’s pulse. Instead, it is just quiet steps that plod along and bide their time.

Each new question is another crow that glides down from the sky to land on the wire with the others. A flock is forming; a story that needs telling begins to take shape. I try to ignore them, to stay on task.

man’s shoulders. The middle of his left clavicle has a big step-off, resulting in one arm hanging slightly lower than the other. Even curled in a ball I can see it. It makes him look like he is leaning to one side, falling over in place. Maybe he fell out of bed at the adult home and no one reported it. It would not be the first time. Maybe that is why he is breathing fast—because he is in pain. Or maybe it is just an old injury and nothing more. The only way to know is to check it for tenderness.

Whatever, in the course of my practice, I may see or hear (even when not invited), whatever I may happen to obtain knowledge of, if it be not proper to repeat it, I will keep sacred and secret within my own breast. —FROM THE HIPPOCRATIC OATH

He looks at me. His eyes are pale blue. They have a pleasant emptiness, a wide open sky quality about them. They are not unlike the curved dome of blue that stretches from one edge of a vast free range cattle ranch to the other.

He wears a bolo tie. It is a black braided line that matches the leather one on his Stetson. It hangs down below his neck. A sterling silver steer’s skull pulls the two lines together at the top of a fine, white long-sleeve cotton shirt. It is pressed and clean.

One by one, the memories disappeared like a herd of cows dying off from rinderpest.

How many times have promises been made by people who have no way of knowing what it is they promise? Oaths are sworn based on the abstract idea that love and discipline can win out over age and disease. Sometimes love and discipline do. But more often than not, the promises end up being ropes, the same ropes that guilt uses to lasso families into bad choices and decades of pain. Dementia is the worst of all—a disease that seems to feed on promises and guilt. When you find dementia, you find a family haunted by the impossible choices before them.

On her ring finger is a wedding ring. It is a nice, midsize, upper-middle-class diamond. The band itself looks to be white gold. They say the average man spends one month’s salary on a wedding ring. That would make her husband someone like a family doctor, a lawyer, a banker, or a somewhat successful businessman. Not a brain surgeon or a major CEO but someone successful enough to marry a pretty woman and make her feel good with just such a ring.

I shudder. I do not want to remember that right now. But the woman in that one died. I know—I just saw her again last night in a nightmare.

Her eyes jerk erratically from nystagmus while she speaks. I get the sense it is going to happen any second.

The woman on the bed writhes about, her brain short-circuiting and frying before us. My nurses attack her flailing arms with large-bore IVs while the techs go to work with the trauma shears they carry on their belts. The techs dissect, cut, and carve apart the scarf, sweater, pants, and boots, like surgeons gone mad with scalpels.

“Got it!” yells one of the nurses starting the IV. “Give her two milligrams Ativan and an amp of bicarb,” I answer. It is injected before the IV is even secured. Somehow someone arrives with a gurney. We heave her writhing half naked body onto it, throw a sheet over her, and run her through the hall to the trauma room while she seizes.

But my shift is over. I step into Trauma Room Two to check on her and finish some charting. She, too, now lies in a drug-induced coma, waiting for a bed upstairs in the ICU to open up.

White sedation and clear saline drip through tubes that hang over her head, run down into the IVs still in her arms, and disappear into her blood.

Please choose one: The three words blink in front of me on the computer screen. Please choose one: Patient is □ Male □ Female I click “Female.” I watch as the auto-template feature fills in the paragraph for me based on my choices. Patient #879302045 Patient is: thirty-eight-year-old female Status: postmotor vehicle accident. Please acknowledge you have reviewed her allergies, medications, and past medical history.

Have you counseled her about smoking cessation? I click “No.” A little animated icon of a doctor pops up on the screen. His mouth begins to move as if speaking. A speech bubble from a comic strip appears next to it. “Tip of the day: counseling for smoking cessation is important for the patient’s health and part of a complete billing record.”

Her chest rises and falls at a rapid pace. She is breathing fast, almost panting. It is a raspy sound. I bet if she spoke right now, her voice would sound raw, the kind of scratchy raw that comes after too much screaming. But she doesn’t speak. She just lies there breathing with a thousand-yard stare fixed to her face.

The patient starts moaning. I look over. She makes a guttural sound—just loud enough for me to hear—that is part wail and part cry.

She is in a hospital gown. Her clothes were cut off with the trauma shears when she came in. She still smells like gasoline, blood, and burnt plastic smoke. It burns my nose sitting this close to her, and it makes my eyes water.

I scan the ER. There are doctors and nurses everywhere down here, yet all those I see sit at computers with their eyes chained to the screens and scowls on their faces while they click and type, click and type. I bet the hospital could burn down around them, and they wouldn’t notice.

The computer dings twice now, prompting me to hurry up. I remember that my patient throughput time is monitored, reported, and compared to the national average. A timer has appeared at the bottom of the screen, letting me know that I am four minutes and twenty-eight seconds behind the average ER doctor throughput time. The numbers keep climbing. If I spend too much time on one patient, I will get a letter from administration for not meeting my throughput quota.