“My mouth lining is sucked dry by the hormones of anxiety, and my heart is thrashing under a green scrub suit.”
Excerpt from SUIT©
first published in M.D. magazine, vol. 34, no. 11
Hey, this is the original, my brain realized after my eyes had scanned the chart. How did he get this? Well, of course, he probably subpoenaed it or something. It’s just that I thought we’d still be dealing with copies.
“Well, Doctor. Will you answer the question please? The lawyer asked. My eyes found him, greasy-haired and thick mustachioed in front of me. Hands on his hips like an inquisitional mother.
I composed my voice: “Yes. It does appear to be the chart.”
He didn’t ask me to repeat what I’d said. My quivering muscles subtly pulled at my body to keep it erect in the witness box.
“Would you please read for the court what you wrote on the emergency room sheet.”
“Patient victim of MVA, passenger side, not belted…”
“… What that means, please?”
Someone was interrupting my reading. “Huh?” my head and eyes looked up.
“Would you explain what that means, please?” said the lawyer in a tone of controlled exasperation.
“Of course,” my mouth smiled. My head accompanied with a little nod.
“ ‘MVA’ means ‘motor vehicle accident’: in this case, a car hitting a power pole. It’s important to document where this patient was sitting and whether she had on a seat belt.”
“Why is that important?” His black mustache jerked above the words as he pumped them out.
“Because it gives you important clues about the mechanism of injury. You suspect worse damage if the patient didn’t have a seat belt on, or if the speed was great, or if the patient was the driver and may have hit the steering wheel. Or if the windshield is broken.”
“Keep reading, please.”
“Auto vs. pole. Prolonged extrication due to electrical hazard…”
“… ‘lectrical hazard?”
“ ‘What electrical hazard’?” I re-asked. My brain wanted to be sure it got the question right. “Is that the question?”
“Tha-at’s the question,” the hairy black-suited lawyer sing-songed Elliot Abrams style.
“There were high tension wires knocked down by the accident. They had to be cleared before the paramedics could get to the victims. There was also some delay prying the car open to get them out. All that delay worsens the patient’s chances of survival because there’s bleeding going on which we can’t…”
“… Now, now, Doctor. We aren’t interested in your opinion. There are, indeed, some things which lessened Miss Buckley’s chances of survival, but we’ll discuss them later,” he threatened. “All I asked you to do is explain your rather incomplete notes. Please read.”
He then strolled a little toward the executioners to the left, then toward those to the right, turned to the box in which my body’d been deposited and crossed his arms.
First, my brain had to squelch the sputtering rage he’d triggered, then it allowed my mouth to begin: “The documentation is not incomplete – it’s brief. I spent my time and energy on the patient, not on…”
“Please,” yawned the judge to my right. “Just read the chart.”
“… Denies loss of consciousness, complains of pain in back and hips. Denies shortness of breath. Denies headache, neck pain, paresthesia, which, …” I plunged into this before the lawyer could do it again, “means numbness, tingling or any such clue that she may have had a spinal injury.” My eyes didn’t look up. The description of my examination flowed from the chart, into my eyes, through the brain where it took two pathways simultaneously. One led to a translation of the words into sounds which my throat droned out for the court. The other was a memory circuit, two years old but well worn with frequent playing. It hallucinated for me while my mouth responded to the Black Knight:
There’s a profound stillness in the Emergency Room while we await the ambulance. The lab tech and x-ray tech have been called in and mill around between me and the nurses, all of us drifting from E.R. to hall to radio to coffee. Nothing more to be done. Two bottles of IV fluid are hanging with lines flushed full, needing only to be plugged in. The oxygen tube is unwrapped and ready. The ambulance entrance door is open. My mouth lining is sucked dry by the hormones of anxiety and my heart is thrashing under a green scrub shirt. I make my brain rehearse yet again: ABC -- Airway, Breathing, Circulation. We know she’s in shock, but check the airway first. Then the lungs. After that, she’ll need blood and probably, surgery.
“Did the surgeon call yet?” my brain hallucinates. I asked that probably a half dozen times.
“His answering service said he’d call,” says some drifting shadow in white.
“Is Rhonda Buckley here?” a voice we don’t recognize. From the passageway to the lobby has come a middle-aged woman. Below the neck she’s tight and withdrawn, clutching herself with arms as though to hold herself in one piece. Her legs bring her toward us with spasming muscles. From neck up, everything reaches out: her sleep-twisted hair like randomly directed antennae, blood-engorged ears directed nearly straight forward, frantic eyes, and the words.
“They say she had a bad accident and they brought her here. Can I see her?”
We detail a nurse to take her off somewhere comfortable and explain what little we know and what whole lot we don’t – including the victim’s identity. By now, of course…”
“They’re at the door!”
We swarm around the ambulance gurney, then rush it down to the E.R. At the edges of the blanket I can see only an arm, into which pours fluid from a hanging plastic bag, and her face. Framed by a large plastic neck collar, sandbags at both sides and a strap holding down her forehead, is a face of chalky skin spattered with dust and glittering shards of glass. Dried blood over the left eyebrow. A dust-free rivulet from eye to sandbag reveals the path of some earlier tears.
I ask her her name.
“Rhonda. It hurts. It hurts bad,” she begins to sob.
“Tell the court what you found on examining her back and hips, please. I believe you’ve told us that’s where she said it hurt?” His black little mouth said it all in one exhalation, with the sound of tiredness which implies it’s been such a struggle to get this doctor to stick to the relevant information.
“I was getting to that.” My brain was reading it as written (as requested) and hoping to take control a little, showing how the proper sequence of examination – A, B, C – had been followed.
“Once her airway was secured and her lungs were shown to be functioning, I examined her from head to toe – quickly. I reached between the backboard and her back and felt her spine. There seemed to be some tenderness low down, but I couldn’t roll her over to look at it.”
“Because I didn’t know whether she had a fractured – a broken – back or not. It wouldn’t be safe.”
“And the hips?”
“Her hips, actually, were OK. But…”
He’d raised his woolly hand to stop me. “Please,” he blew out his mouth onto the floor where his head was then aimed. “Just read the record. We need to know what you found, not what you recall two years later.”
My memory circuit recalled quite well what I’d found. But he wasn’t interested. So my brain read on while the hallucination resumed:
“Her tummy’s a little rigid and she has rebound. Are both lines in?”
“Both in. Wide open.”
“What’s her pressure?” While I wait for the answer, I squeeze her pelvis between my hands. Rhonda sobs in pain and something crunches between my hands.
“Sixty over zip. Pulse 140.” At that news, my mouth goes dry again. Or I feel it again if, in fact, it hadn’t moistened but had merely been overshadowed by other stimuli. Not only was she still in shock in spite of all the fluid, her blood pressure had dropped from what the paramedics reported.
“Where’s the blood?”
“Right here,” the lab tech appears at the door.
“Hang two units and pressure them in. Where’s my surgeon? Did he call?”
While a nurse and I wrap pressure cuffs around the blood bags and pump them up to force the blood into her as fast as the tubing will take it, another nurse calls the surgeon’s service. She needs surgery to survive. The broken edges of her large pelvic bone are pouring out blood and marrow. Her abdomen is already a lake of blood, having filled during the time it took to get her out of the car and in here. The heart and blood vessels aren’t even half full anymore and her brain and heart aren’t getting enough oxygen, no matter how much we hose into her lungs. Either organ could stop working any time now.
“Now, Doctor. Does it say there anywhere what steps you took to save Miss Buckley’s life?”
Of course it does, you vampire.
“Of course it does…” Thank you, brain. Thank you for stopping right there.
He smirked and flourished his right arm in a motion sweeping up his chest, away from his face, and into an upturned palm. The grand gesture of introduction. “Would you read it please?”
“Two units whole blood given, oxygen at 15 liters per minutes, legs elevated, Dr. Smelsley called at 2:10, 2:20, 2:30. No answer.”
“Would you tell the court, please, who Dr. Smelsley is?”
“He’s a surgeon. The surgeon on call.”
“So it was your judgment that Miss Buckley required surgery?”
“Definitely. She was bleeding to death.”
“Would you say her condition was critical?”
“Yeah. She was bleeding to death.”
My brain squirmed at how calm and logical everything seemed. To the fifty or so people in front of my eyes it must have been so clear. Anyone, even a lawyer, could tell what was needed and how to get it in time. My eyes searched for and found Mrs. Buckley. Quiet, withdrawn. She was sitting at the lawyer’s table.
To my memory, the image of her was the same when I’d squatted directly in front of her that night to fill her in:
“She’s very badly hurt, Mrs. Buckley, and she’ll need surgery to survive…”
“And when did you first suspect she was ‘bleeding to death’, as you put it?”
“During the examination. And when her blood pressure failed to come up with IV fluids.”
“Not before that?”
“No… No… Not before I could examine her.”
“You didn’t have any hint that she was bleeding before the ambulance arrived?”
“Well, of course, I knew her blood pressure was low in the field, but I didn’t know from what.”
“You didn’t know it was from bleeding? In an auto accident?”
“Well, yes, I suspected it was bleeding. But I didn’t know how much. Or where. Sometimes it’s just a little bleeding from the face or scalp. You can’t tell until you do the exam.”
“I see. And now, Doctor. Please tell us whether, anticipating that the late Miss Buckley would require immediate surgery for her severe injuries, you called the surgeon on call and told him that he would be needed?”
“Yes. We did call. Before the ambulance arrived. But all we got was the answering service.”
“Of course. Isn’t that normal, Doctor? To get the answering service at one thirty at night?”
My brain spasmed:
“Then do it,” Mrs. Buckley answers quite logically through the dense fog of emotional shock she’s generating.
“I’m trying to reach the surgeon now. If I can’t get him, I’ll need to send her to the next town where there’s a surgeon available.”
“Why can’t you get him?” She’s truly bewildered.
“Well, he hasn’t called us back and I really can’t say…”
“Just do what you think is right, Doctor,” she slices through her shock to my eyes. “Just do whatever you have to do to save her. She’s my only baby…” The antennae are wilting and her eyes turn inward again behind welling pools of tears. “… Just save her. Please save her…”
I leave Mrs. Buckley with the nurse and go back to the E.R.
“Sixty over zip with both units in. She’s not as responsive,” someone says.
“Smelsley call? Is Smelsley coming?” I’m almost shouting in frustration and early panic.
“He hasn’t called in but they paged him. They don’t know where he is.”
I order two more units of blood hung and try to get Rhonda to talk to me. I realize that I’m just stalling. We’re not even keeping up with the bleeding, certainly not making headway.
Smelsley could call any minute and I’d turn her over to him. I’d deliver her still alive, my job finished. Or, he might not call until too late, and I’d wish I’d sent her off to the hospital and surgeon in the next town. A risky 25-minute ride, but her only chance if Smelsley never shows.
I look at her face – pale and sweaty. Sleeping Beauty. Seventeen years old. Do the right thing and she gets, maybe, sixty years. We hang more blood.
“Call Smelsley again,” I scream.
Then I realize I’m just thrashing around. I’ve got to make a decision. The clock says 2:29.
“Get the ambulance crew in here. If we don’t hear from Smelsley by two thirty-five, she’s going to Coverton.
Moisture returns to my mouth. Things relax a little. I call Coverton and let them know she may be coming – to get surgery set up. We spend the next six minutes getting her set up for transfer.
“And isn’t it true, Doctor, that after calling Dr. Smelsley you waited one hour with Miss Buckley in critical, unstable condition before transferring her to Coverton?”
It was a question with which my brain was very familiar. It led through my synapses to several other questions I’d explored frequently and rather expected to hear from Vlad the Impaler before the witness box was finally opened to spill what was left of me out onto the floor.
“I didn’t wait one hour. I tried to stabilize her. We were working all that time.”
“And isn’t it true that you only waited 5 minutes after calling Dr. Smelsley at two-thirty until placing her back on the ambulance with her blood pressure lower than it was when she came in to you?”
Like I didn’t care? Like all I wanted was to shove her out the door still alive and go home to bed?
“After we failed to hear from Dr. Smelsley the fourth time, I didn’t feel we could wait any longer…”
“And what, Doctor, in your medical judgment, made you think she had any chance of reaching Coverton alive?”
The synapses that made up that pathway had been well worn over the past two years and could be depended upon to trigger various brain chemicals. These mixed into a soup of neurotransmitters in which I began to drown. Eleven months of practicing for this day had failed to protect me. Slipping into the soup I see her loaded into the ambulance with the brave paramedic who gives me the thumbs-up sign and a frightened nurse whose eyes question mine. My gut tightens because she’s still my responsibility until she gets there. But I can’t even touch her now.
I try to explain it to her mother with words that stick to my flypaper mouth:
“… A calculated risk … she’s young and strong … anything can happen … they’ll be waiting at the door for her…”
Doubts thrash in our brains as we mechanically clean up the E.R. and rationalize out loud, when Smelsley strolls in.
“Why did you send her?”
“Why didn’t you call?”
“How far away is she?”
“Where the hell were you, anyway?”
And many more such phrases are all in the neurotransmitter alphabet soup, swirling around my drowning soul.
I call the paramedic on the radio. Now another decision is needed.
“She’s crashing fast, Doc. B.P. inaudible – about 40 by palpation. Pulse has dropped to 100.”
“What’s your ETA to Coverton?”
“About 10 maybe 12.”
“What’s your ETA back here?”
“What’s your ETA if you turn around and come back?”
“Why would we do that?”
“Never mind why. What’s your Goddamned ETA?”
There’s a ward clerk down the bench apiece from the radio. “Doctor, you can’t use profanity on the radio. It’s against the law.”
“ETA back to you – about 15.”
“I’m ready,” says Smelsley with uncharacteristic generosity born of freedom from all this.
The radio conversation itself has taken three minutes or so.
“Where we going, Doc?” asks the radio.
The clock is electric, but I can hear it ticking by the radio, within the soup.
“Doctor. Doctor. Will you please answer the question. Doctor!”
Up, dripping, from the soup, with puddles of it caught between my eyes and lower lids, I pushed my voice to request he repeat the question.
“What made you think she’d survive the trip? Considering the condition she was in when you put her back on the ambulance?”
“I didn’t see any alternative at the time. It was either that, or she dies in my E.R.”
“But Dr. Smelsley arrived to perform the surgery you, yourself, have told us was necessary. What would have happened if you’d just waited for Dr. Smelsley, then turned the case over to him?”
You think I haven’t asked myself that question before? Haven’t asked a half dozen other E.R. docs what they’d have done? Haven’t lost 15 pounds ‘cause I can’t eat over this? Haven’t decided to quit medicine and do something else, far away? Haven’t thought about what it feels like to be in Mrs. Buckley’s brain? In her empty house?
“I don’t know. No one knows. All we can do is guess.”
“Is that what you did, Doctor?” asked the form in front of my blurred eyes as he turned slowly to face the firing squad. “Guess?”
No, my neurotransmitters said. No guess. No guilt. No energy left to fight.
Just get it over with, my brain told my body. Go home to bed.
“No. I didn’t … ‘guess’.”
He must have been expecting more.
“Well? What did you do?”
Oh God. This questioning goes on forever. I should know. I’ve asked them all backward, forward. I’ve played it many different ways in my head:
Don’t stop here, go straight to Coverton;
Keep her here until Smelsley shows and document the calls;
Start another IV line and give blood faster;
Call a helicopter to move her after 15 minutes in the E.R.
I’ve learned something from it and nothing that gets said here today will change things for Rhonda. And wishing I could do it over again is just self-destructive. What do you want from me, Mrs. Buckley and lawyer? Harakiri?
“I did what the chart says I did. It was the best I could do under the circumstances.”
They opened the witness box and I poured out, sloshed across the room and spent the next two days in neurotransmitter soup.
I forget how much they got.
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