Gemini

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Also by Carol Cassella

Healer

Oxygen

For Lucie Rose Gendreau

Your light still shines

What are days for?

Days are where we live.

They come, they wake us

Time and time over.

They are to be happy in:

Where can we live but days?

Ah, solving that question

Brings the priest and the doctor

In their long coats

Running over the fields.

—PHILIP LARKIN, “DAYS,” FROM
COLLECTED POEMS

“There is only one law in the universe that never changes—that all things change, and that all things are impermanent.”

—BUDDHA

Part One

•
1
•

charlotte

It is natural law that
all complex systems move from a state of order to disorder. Stars decay, mountains erode, ice melts. People get off no easier. We get old or injured and inevitably slide right back into the elements we were first made from. The organized masterpiece of conception, birth, and maturation is really only two steps forward before three steps back, at least in the physical world. Sometimes when Charlotte lost a patient she thought about that and found it comforting—a reminder that she hadn’t failed in what was ultimately an unwinnable game. But if she thought about it too long, she had to wonder if her entire medical career was an interminable battle against the will of the universe.

She resisted sinking into such rhetoric the night Jane Doe was whisked across Puget Sound in a medevac helicopter to Beacon Hospital’s intensive care unit, to Charlotte. It seemed they always came in the middle of the night, the ones from the more remote hospitals on the Olympic Peninsula—West Harbor and Forks and Port Townsend. Charlotte could picture some overwhelmed doctor reaching his breaking point too many hours before the next sunrise, dreading a night of slumping blood pressure and low oxygen levels and erratic heart rhythms, finally picking up the phone to plead the case for a flight to Seattle. Not that anyone had to plead; they were never turned down.

Charlotte had her own survival plan for these long nights on call: get the critical facts over the phone, tend to the crises of her eleven current patients before the new one arrived, grab a Diet Coke and some Oreos from the vending machines, a blanket out of the warmer at the nursing station, then tuck into a ball on the love seat in the ICU’s waiting room and listen. Listen for the chop of the helicopter blades, the rising pitch of the engine as it settled onto the roof with its cargo of impending death. Listen for the buzz of an elevator being held open, the swish of the automatic doors into the ICU wing. Sometimes the next sound was a “code four” alarm—someone who’d clung to breath all the way over the peninsula, the islands, the bay, giving up just when the medical mecca was reached, as if a glimpse of heaven in flight had convinced them to move on. Most often the next sound was her pager, confirming the patient had arrived. And then Charlotte was up, the blanket dumped in the hamper and her white coat buttoned.

She made her first assessment before she was even through the patient’s doorway: weight, age, the color of the skin, the shade of the bruises, the number of tubes snaking from the body, sucking fluid away, pumping fluid in. By the time she was at the bedside she was ticking off which invasive lines would have to be removed, replaced, inserted.

Jane arrived just after 3:00 a.m. with no fewer than five tubes: one down her throat, another in her neck, two in her left arm, and one looping from her bladder. Jane’s arrival was heralded by pages and alarms and a scrambling of personnel that stopped just shy of a code four. She came with a four-inch stack of medical records, a splint on her right arm, a scaffold of hardware stabilizing her right lower leg, and so much edema that her skin was pocked with the medic’s handprints. But she did not come with a name. Not her own name, at least.

The medics rolled the orange transport gurney next to the bed and, smooth as a dance, coiled up all the lines and logrolled Jane onto her side to slip a plastic board underneath her. Charlotte stood at Jane’s head and Anne, the nurse, held Jane’s feet. On the count of three all the lines and tubes and wires and the sodden, bruised flesh of Jane Doe slid onto the clean white sheets of the bed that would become her next home. The medics talked while they moved, disconnecting the portable monitors, locking down the empty gurney. “Pressure dipped to seventy after takeoff so we upped the dopamine. Had her on a hundred percent O2 halfway across to keep her saturation above ninety.” The taller of the two handed Charlotte a clipboard to sign, looking more relaxed now that Jane Doe was hooked up to the hospital’s equipment and off his hands. They had met before, on some other transfer, though his name tag was half-covered by the bell of his stethoscope and Charlotte couldn’t recall it. He tapped the stack of chart notes he’d brought. “I wasn’t sure she was even going to make it across.”

Charlotte looked at the monitors, her new patient’s heartbeat racing across the screen. “How much fluid did she get on the flight?”

“Fifteen hundred. Pressure kept falling. Not much urine, though.” The fluid in Jane’s Foley bag was the color of rancid orange juice.

“Thanks for getting her here”—she nudged his stethoscope aside—“Harold.”

“Harry.”

Charlotte held her hand out, and he shook it. “Right. Harry. Sorry.” She flashed her own name tag. “Charlotte Reese. Now, if only Jane had worn hers, we’d know who she is.”

—

For the next two hours Charlotte’s only goal was to keep Jane Doe alive. Her blood pressure was so low the monitor’s alarm kept chiming, the numbers flashing in red. Jane’s hands and feet were dusky blue, and the largest IV line had clotted off. Charlotte tied an elastic tourniquet above Jane’s elbow and tapped the skin creases, hoping to feel a vessel.

“You want me to turn up the dopamine?” Anne asked.

Charlotte glanced at the numbers on the pump. “Call the pharmacy and get some Neosynephrine. And some fresh veins along with it. They must have forgotten to stick those in the helicopter.”

Anne hung up the phone. “Ten minutes. They’re all out of veins. You want to do a cut down?”

“Not yet. How’d we get so lucky to be working tonight?”

“No luck about it for me, baby,” Anne answered. “I’m taking every shift they offer. Got no child support check again this month.”

“Can’t you get a judge on him?”

“Judge would have to put money in the man’s pockets to do any good. Tryin’ to get blood from a turnip.”

Charlotte closed her eyes to focus every sense through her fingertips, pressing and releasing an invisible tension in Jane’s swollen tissues. “There it is. Hand me a sixteen-gauge IV.”

“Like I was saying.”

—

By the time the sky was lightening, Jane Doe was stable enough for Charlotte to dig into the records the medics had left on the desk. If time didn’t matter, if this were her only patient, she could spend the whole week sorting through what had been accumulated in four days. How many numbers and images could be spit out of centrifuged blood and spinal fluid and spinning magnets and X-rays? Hundreds. Thousands. She started by skimming the blood work completed just hours before they loaded Jane into the helicopter; her eyes caught the critically abnormal numbers as though they were in neon: Jane’s kidneys were shutting down, her liver was stressed, her lungs were stiffening and filling with fluid, her bone marrow wasn’t making enough blood, and she was infected with some unidentified bug, verging scarily near septic shock.

Anne looked over Charlotte’s shoulder. “Any surprises?”

Charlotte turned toward the woman lying immobile on the bed. Anne had dutifully pulled the metal side rails up, as if there were any chance this patient would spontaneously move. “What you see there is what I’m seeing here. Not good.” She flipped the chart open to the doctors’ progress notes and started deciphering the handwritten scripts. Charlotte hated the auto-filled phrases pumped out by her own hospital’s medical software, saw it as a shortcut around the methodical, personally described physical exam she had been trained to do. Once she had ripped a printed chart note in half because someone—she assumed a student—had clicked “normal exam” and the computer spit out exactly that for a patient with a subtle heart murmur, which had probably caused his stroke. Later she discovered the error had been made by the chief of surgery. But at least computer-generated notes were legible; her eyes blurred with fatigue reading Jane’s chart.

Charlotte translated a summary for Anne. “Hit and run. A truck driver spotted her in a ditch beside the highway and called 911. Femur fracture, shattered lower leg. Broken elbow. It looks like she was conscious when she got to the ER but too disoriented to give a clear story or her name . . . her initial head CT was OK, so maybe just hypothermia. They rushed to the OR to fix her leg. And somewhere in there things really went to hell.”

The doctor who’d called Charlotte to request the transfer four days after Jane’s accident had sounded young and exhausted. Charlotte had caught the note of regret in his voice, almost defensive, anticipating blame. She knew they were begging for doctors out on the peninsula—towns built on timber and fishing now collapsing along with those industries, three or four hours and a million cultural miles from the city. The doctors they could hire were often new graduates, and the best of them burned out within a few years. And how much of every doctor’s education happens after he leaves medical school? Half or more, Charlotte thought. More. The guy was in over his head, doing the best he could in a rural, underfunded hospital. Reading these notes, she felt almost as bad for him as she did for Jane. After they fixed her leg they’d taken her to the ICU, still unconscious, still chemically paralyzed by anesthesia drugs. A day had passed balancing her fluids, transfusing blood, and then another day weaning her off sedatives, trying to figure out why her oxygen levels were so low. But she didn’t wake up. Another head CT showed no bleed, no midline shift, nothing to explain it. And on the third day, when Jane was still unconscious, when her white blood cell count started going up and her lungs started getting stiff, a storm had blackened the coastline and flying her out was impossible.

Charlotte paged through the lab reports and radiographs, waiting for one to pop out at her. Something unifying. Something correctable. After fifteen minutes she shut the chart and cupped her palms over her eyes until the world was dark and small and calm and the thousands of bits of data settled. She was Jane Doe, lying beside the highway, cold, confused, in pain, lifted into an ambulance, rolled into an emergency room bay talking, apparently making enough sense the doctors were more worried about her bones than her brain. Then the blissful nothingness of anesthesia, the pain in her leg and arm and bruised body finally relieved. The bleeding from her open fracture stopped. Warm for the first time in hours.

Charlotte opened her eyes. “It happened in the OR.”

“What?” Anne asked.

“Whatever happened.” Charlotte flipped to the back of the chart, the tab marked Surgical Records. The operation had lasted more than five hours—two or three hours to put a rod up through the fractured bone of her femur and then another two hours working on her lower leg and arm. The surgeon’s notes were boringly unremarkable, glibly dictated from memory, Charlotte could tell. She turned to the anesthetic record—three pages of dots and checks and Xs marching across the gridlines noting blood pressure and pulse. Then, in the middle of page 2, a brief, sharp dive into scary-low numbers before they popped back to normal. So brief it might be written off as a few erratic readings from the automated machines, a kink in the tubes, a loose blood pressure cuff. But when Charlotte looked closely at the other numbers charted by the anesthesiologist, she knew it wasn’t an aberration. He or she had given repeated doses of drugs to kick Jane’s blood pressure higher. And one line below that, Charlotte saw Jane’s oxygen and carbon dioxide levels. They, too, had taken a dive, quickly corrected but blaring like alarms.

Anne looked over Charlotte’s shoulder. “What happened?”

“I bet she threw a fat embolus when they put the rod into her femur. Has to be. That’s what hit her lungs.”

“Was her oxygen level low enough to turn her into this?”

“Maybe. Or maybe not. Maybe some of the emboli got into her brain.” Charlotte closed the chart and walked to the end of Jane’s bed, watched the white sheet rise and collapse with each forced mechanical breath. She imagined the shimmering spray of pale yellow particles forced out of Jane’s marrow when the metal rod was hammered home, coursing through her blood, across her heart or through her lungs, into the fine capillary network of her brain, where they lodged with the effect of a thousand tiny, toxic bombs. “Damn. Can’t fix that one, Jane. Have to get the rest of you well and see if your brain still works.”

Not a month earlier Charlotte had had a conversation with her boyfriend Eric, who’d more than once watched her throw the weight of modern medicine along with her single-minded will against all natural forces to keep a patient alive, only to lose in the end. Eric had challenged her on it that day. “Should quantity of life always trump quality? Maybe you set your goals too high.”

She knew he was only giving voice to her own darker thoughts, but still she’d been miffed. “Maybe I’ll repeat that to your doctor when you’re lying in an intensive care unit someday.”

“Maybe I’ll get lucky and be in your ICU. I’m just saying it might not be the
number
of days that matter. Maybe it’s the
one
day they need to fix whatever’s standing between them and heaven.”

“Said the guy who doesn’t believe in heaven,” she had retorted.

—

“Stay with me, Jane. It’s going to get worse before it gets better,” Charlotte said out loud.

“The Neosynephrine’s here. What next?” Anne asked.

“Next I call the doctor in West Harbor and tell him to stop blaming himself. This one was an act of God. God and whoever slammed into her and drove away.”