Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (27 page)

“Okay,” the intern said. “Okay, okay.” He parted the fat with the scalpel, then followed behind it with his fingers, feeling for the muscle wall of the abdomen.

“Watch out,” Sudesh said.

The intern felt along the abdominal wall. “Rectus,” he hissed, “rectus, obliques.”

“Where are you going to cut?” Sudesh asked.

“There, there,” the resident said. Murray stood over him, breathing fire but saying nothing.

The intern's hands were shaking as he cut. We all leaned over, trying to see as best we could.

“Deeper,” Sudesh said. “Go deeper. We've got to see better.”

“Where's the bladder?” the intern wanted to know. “I need to go just above the bladder.”

“Is that it?” Sudesh asked.

“We need some retractors,” the intern said. “I can't see anything this way.”

Sudesh grabbed up two small shovel-like devices and attempted to wedge them into the open surgical wound.

The intern's right hand disappeared into the woman's belly. He looked like he was rummaging around in a sack, groping blindly as he searched for the uterus. Then he made another cut, it seemed, and then cut again. He must have opened up the uterus now with a little incision. “Bandage scissors,” he said, waving a bloody hand at Eileen.

She fumbled through the tray looking for them.

“Those,” he said, “those.” She handed them over. He maneuvered them into the wound and started sawing away at the uterine wall. “Shit,” he said at one point. He cut some more and then, “I've got the head. I've got the head.”

Sudesh repositioned the retractors, trying to get a better exposure of the uterus. “But can you get it out?” he said.

The intern buried his other hand deep within the patient's belly and stood for a moment, tugging like mad.

“You're not going to get it out that way,” Sudesh said. “You've got to make a bigger incision.”

The intern's face was red and his forehead glistened with sweat. He struggled, both wrists and forearms buried deep within the woman's belly.

“It wouldn't be so bad,” Murray shouted over the intern's shoulder, apropos of nothing I could see. His face was purple with rage. “It wouldn't be so bad if she wasn't so…
damn
…” —he spit the word— “
fat.
This woman is
fat.
”

He looked up at me standing a couple of feet away from him. “Move back, move back,” he told me. “Give them some room.”

I retired to the doorway. As I paused there, the two pediatric residents walked in and stood beside me, both looking sleepy. One had a Mickey Mouse tie on, the other had a pliable Goofy figure wrapped around his stethoscope. They peered around the room and visibly paled.

“What?” one of them asked me. “What happened?”

“Gunshot wound to the head.”

They looked over at the adult-sized figure on the gurney and said, “So why are we here?”

“Crash C-section. She's pregnant. If they can deliver the baby and there's anything there, you guys are on.”

“You've got to get that baby out,”
Murray screamed again. “Out,
out, out.”

“Oh my God,” the resident with the pliable Goofy doll said. They both stood there, apparently transfixed.

“The Isolette is over there,” I told them, nudging the one closest to me.

“We've still got to make the incision bigger,” Sudesh was saying. He took the scalpel away from the OB resident and extended the cut, first in the skin of the abdominal wall and then deep within the abdomen, up into the body of the uterus. He started groping around as well, elbow-deep in the woman's belly. After a moment there was a river of blood, and the OB intern suddenly hoisted up, from deep within the woman, a very dead-looking baby.

“
Cut the cord, cut the cord,”
Murray shouted.

Sudesh and the OB intern struggled to clamp the umbilical cord. Finally they succeeded. Sudesh cut between the clamps. The baby was free now, ready to live or die on its own. Her own. It was a girl.

“Give it here, give it here,” the pediatrician with the Goofy doll shouted.

“Suction, suction, suction”
Murray kept shouting over him.

I became aware of someone else standing beside me. A tall man in an immaculate white lab coat. I knew him but I couldn't place him.

“What's going on?” he demanded of me.

“Woman shot in the head,” I said. “They just did a crash C-section.” I recognized him then: Dr. Cobb, chief of OB-GYN. He was one of the big guns. Big guns don't usually cover the ER. He must have heard something was going on.

At that moment Murray hoisted the baby into the air and stepped forward to the Isolette. “Get out of the way,” he shouted.

“Holy Moses,” Dr. Cobb said. He waded into the crowd packed around the bed. As he pushed his way toward the gurney, people looked behind at him and fell away when they saw who it was.

“Gloves!” he demanded of Donna, the surgeon barking orders to the lowly nurse.

“They're over there,” she said, pointing.

One of the medical students handed him a pair of sterile gloves.

Dr. Cobb stood for a moment, contemplating the abdomen. Finally, “Who opened this belly?” he demanded.

“I did,” the OB intern said.

“What the hell do you think you were doing?” he said, pointing down into the depth of the woman's abdomen.

The room became quiet. The only person talking was Murray barking orders to the people clustered around the Isolette. The intern looked down at his gloved hands and at the scalpel he had there. He then looked deep into the belly, trying, it seemed, to figure out what Dr. Cobb was gesturing at. He didn't seem to have much more of an idea than I had, watching as I was from across the room.

“Who opened this uterus?” Dr. Cobb thundered again.

The intern shrank back.

“What do you call this? The ‘Jack the Ripper’ approach? While you were at it, why didn't you just take out the spleen as well?”

“Sir,” Sudesh said. “I extended the incision. We had to get the baby out.”

“You had to get the baby out! Well, what about the mother? How are you going to put her uterus back together?”

(Murray, over by the Isolette, was handed a 3-5 ET tube and threw it across the room. “
That's way too big,”
he shouted.)

Sudesh peered up at the chief. “Well…,” he began.

“This woman is a setup for uterine rupture. Her next pregnancy is going to be a disaster. She's be lucky if she goes to term.”

“Sir,” Sudesh said in a small voice. “She's been shot in the head.”

“That's no excuse for poor technique!”

Murray heard this somehow and turned around. “What the hell are you talking about?” he shouted.

“Are you the attending here?” Dr. Cobb shouted back. “Because this is inexcusable.”

Murray came back over to the gurney, people scrambling to get out of the way.

“What the hell are you talking about?”
he roared again.

“This woman's uterus is a disaster.”

Murray said nothing. He just stood there, eyes wide, face twitching, his nose not more than three or four inches from Cobb's. He was trembling with anger. I thought of all the times before when I watched Murray lose it, and I realized this time was different. All those other times Murray had lost his temper over little things, minor irritants. This time was something new, something I had never seen in Murray before. This was rage clearly justified. And it seemed to me as I watched Murray standing there, wild-eyed, stretched to the breaking point, that this was the definitive time, this was the end of the line. The slipping was over. Murray was now in free fall. At the time I'm not sure what I thought he was going to do, but looking back I always see Murray standing there in that crowd of onlookers, one hand raised, clenched, held up close to his face. Cobb stood before him, gazing first at the fist and then at Murray's face. The two of them just stood there for a moment, eye to eye. Cobb blinked first. He stepped back and looked around, nodding to himself. Murray then leaned over the cart and pointed emphatically toward the woman's head. “This woman was shot
in the head.
She is
brain dead.
We are trying to save the baby.”

Dr. Cobb opened his mouth, then closed it, looked around and opened it again. “Oh,” he said.

Murray bore down on him. “If this woman had another baby it would be a
medical miracle.”

Dr. Cobb stepped away from the bed and looked around. I could see him realize that he was in a strange land here. This was not some sterile operating room, all order and control. This was a place where lunacy prevailed.

I will give Dr. Cobb credit. As he stood there, I could see it dawn on him what was going on. He looked first around at all of us and then into the belly of the patient. Finally he looked up at the intern and said quietly, “What are you closing with?”

“O' chromic,” the resident said.

“Here,” Dr. Cobb told him. “Get me a needle driver and more chromic and I'll help.”

Murray brought the kid back. By the time the baby left the resuscitation room, she had a good pulse and was breathing a little on her own. It was as bad a thrash as the delivery had been. Murray did it all, though, intubated the baby in an instant, got all the lines in, treated her acidosis. The two pediatric residents stood to the side throughout, looking awestruck. They never said a word.

After it all, Murray stood in the middle of the trauma room in typical Murray mode, arms crossed, growling, as he watched them wheel the Isolette upstairs. He should have looked triumphant, but he merely looked like Murray. He was tic-ing like mad, chin up, right eye twitching as he shouted,
“Move, move, people, you gotta move, here,”
as if anybody was going to do anything else.

The mother made a comeback as well, such as it was. As soon as the baby was out, she rebounded. The first measured systolic blood pressure was over 200. But by now Murray had lost interest in what was left of her; he scarcely glanced at the patient's vital signs and shrugged when the trauma resident told him it would be an hour or more before they got the woman up to the ICU. He did stop at the door, though, on his way out, and looked back at us. “I don't want that woman to die down here, guys,” he said. “I want her to die in the ICU, where she belongs. So move it, move it.” Then he left.

I helped wheel the woman, accompanied by monitors, IV poles, ventilator, over to CT. This was the stone age of CT times. A simple CT took fifteen to twenty minutes to perform, developing the film another ten minutes. (Now it is practically a finger snap.) Finally the radiology tech hung the processed film up for us to peruse. There we all gathered in the obligatory attitude of prayer, gazing up at the lighted x-ray box, eager to see the injuries in black and white.

The first bullet went through the frontal sinus, tumbling as it went, creating a shower of bone chips. It then cavitated a swath of tissue running from the frontal sinus back through the frontal and parietal lobes before it exited though the occiput, the back side of the skull. The second bullet entered through the orbit and passed obliquely down into the brain stem. It ended its brief flight just above the medulla. There it now rested, a great metallic mass, no longer bullet-shaped, ringed by a shadow of radiographic artifact.

It wasn't necessary, really, to understand the bullets' paths. One only needed to take one look at the scan to see that the brain had been blenderized. Ours was an academic concern only.

We all stood for a moment, Monday-morning quarterbacks, arguing over the path of the bullets as they entered the patient's skull. Finally someone voiced the obvious question: “Is she brain dead?”

“Are you serious?” the trauma intern asked.

“We're gonna have to document it in some way,” the trauma resident said, nodding. “Why don't you give Neuro a call?”

And so the Neurology team came down. Three residents, all wearing immaculate white lab coats. They hemmed and hawed over the patient and examined the CT at length. Finally they all declared that she was probably brain dead
but…

“We want to do calorics,” the lead neurologist told the team.

Caloric testing involves the vestibular system, a primitive and very fundamental component of the working brain. To stimulate the vestibular system, you inject cold (or warm) water into the ear canal. The presence of the water cools the inner ear. In normal people this will produce nystagmus, a rapid twitching of the eye. An abnormal response would be deviation of the eyes without the twitching.

This woman had nothing.

The neurologists talked about this for a long time.

“I think we should do an EEG,” the senior resident told us. “You never can really tell. Her heart is still going strong.”

Donna shook her head. “Give it up, guys,” she told them. “Isn't it obvious that the wheel may be spinning but the hamster is gone?”

It was late. I had done nothing on my research project; I had spent the whole afternoon rubbernecking a code. I needed to go home and get something to eat that wasn't junk food and get some sleep in a supine position.

On the way out I stopped at the plate-glass door just beyond Security's desk and looked out at the view of the parking lot and the big steel oxygen generator that was, apart from a rhomboid of sky, all we could see from the ER. It was the dusky end of a moody, thundercloudy sort of day. The sky was a flat expanse of gunmetal gray, now nearly black. As I stood there, Murray walked up beside me and he stopped as well, not to talk to me, apparently, but to look outside, at the world out there. I could see his reflection floating in the glass. He looked totally worn out, frayed, wasted, spent. I caught a glimpse of it that day, but now I know that look cold. It's the look of someone who has spent years in a room filled with all the losers of the world, and who has become, through all this, just another loser as well, another crazy guy stalking the hallways, an addict at the end of the line, a would-be suicide more pathetic than tragic. There Murray stood, face twitching like mad, silent as the grave. I saw that face as my face in ten years, fifteen, my face superimposed on his. But would I recognize that look if I was wearing it?