July 23rd, 2003

Nescafe rabbit

Requisat in Pacem, M.

Tonight, O Best Beloved, I saw murder done. Murder without malice, without intention, without reason or purpose. Murder by omission. Murder of a little boy who should have survived. I can't decide how I feel - I'm torn between impotent fury and ravening grief, and something or somethings unnameable.
It was one of those nights in the ER - not too busy, quite a few things I was going to tell you about, O Best Beloved, interesting things I saw. They all went flying out of my mind the moment the call came in. "We've got the [helicopter] coming in, paediatrics trauma." Nobody knew any more than the paramedics had radioed in - that we had, incoming, a two-year-old boy who had been ejected 30 feet from a car, that his heart rate was 90 (too low) and his blood pressure 90/60 (also too low), and that they would be there in 13 minutes.
So we pulled together the peds trauma team, and we sent the onsite EMT's to meet the helicopter, and they brought him in, bagged and on oxygen, and we saw some neurological responses, coughing and a little bit of a gag reflex, and I stood as far out of the way as I could as they assessed him, transferred him off the EMS cart, and got permission from the peds neurosurgeon to take him straight to the CT scanner.
I stayed in the ER while they went to CT. When they came back, the chaplain came in with them. His ventilator bag was gone, and half the monitors were quiet. And I stood in the room, staring at the tiny pale face with the mussed dark brown hair, and I listened to the chaplain read him last rites, and I didn't know what had happened but I couldn't ask until later.
Later came, and Dr. S showed me the CT scan. Where there would normally be nice grey and white matter, sulci and gyri and all the landmarks I'm used to seeing, there was nothing but a flat and featureless grey haze, punctuated by tiny bright white pinpoints of blood and draped with the unmistakable light space of a subarachnoid haemorrhage. They call it diffuse axonal injury, and it's what happens when the brain dies from lack of oxygen. And it's permanent.
They pronounced him dead in the CT scanner. When he came back to the trauma room, he still had brainstem functioning - he was breathing on his own, he had pulses - but you could see his oxygen saturation dropping and his blood pressure falling. It was 72/40 when I left the room for the last time, and even though they'd started running oxygen again and using a bag to get it in, his oxygen saturation was well into the 60% range. And the plan was to continue supportive care - an IV drip of saline, a bag or a respirator - and nothing else. There's nothing else to do. They took him to the paediatric ICU to wait until his mother got there.
His mother was taken by ambulance to a closer, local hospital. Also two other children - 2 months and 5 years. All of them were restrained in the car. Buckled in. All of them were checked and released with only minor injuries. That's why I can name it murder by omission, O Best Beloved. If he had been in a carseat with the harness fastened when someone rearended their car, there's no reason to doubt that he would have had the same lucky fate as his family.
B. said to me, "was he restrained?" I told him no. B. said "They should hang parents for that." Dr. W turned away from his computer and said, very softly, "They've already had their punishment."

I don't know what that mother will think or do or say when she arrives at the hospital; my shift ended at 10:30 and I got to go home, walk out of the hallways where the curtain is still drawn around the double room that serves us as a trauma room, where there are still packets and wrappers at the edges, where they were just finally as I left removing the single crosswise bed with its tiny wooden backboard. I got to go home. I got to leave, and I can still hear his choking breaths, see the tiny chest with its tiny tubes and wires and stickers and all the things that couldn't preserve a life that had already fled. How much more agony must it be for the mother who has to ride an hour and a half with her still-living son to say farewell to a dead one? How much pain can one person bear?

Tonight, O Best Beloved, I was baptised by fire into the reality of death and the paradoxicality of it. I have never seen a person die; I saw a little boy, face marred only by the tubes in his mouth and nose, with skin somehow nearly undamaged despite a thirty-foot flight, despite being found face-up in a field, a boy whose body was nothing more than an empty, hollow, broken shell holding a heart and lungs and kidneys that would never grow again. I saw a tiny pair of tennis shoes in a bag, the only clothing the medics brought in. And I listened to the last rites and I cried inside, and something bright and innocent and vulnerable in me broke apart and bled like he did not. And then I bit back my tears and I swallowed the lump in my throat and I walked out of that brightly-lit room feeling older, somehow, and I wondered if it showed in my eyes or my face.

I went back to the doctors' station, then, and I went to the chart rack and I picked up a chart, and I looked at it, and I turned to Dr. S, and I said "All the labs are fine, and the CT looks good." And he said "She can go home, then. Why don't you go let her know?" And I walked into the room of a 50-year-old woman who'd just come off of a two-week drinking binge, and I smiled.
Nescafe rabbit

I need a vacation...

Today, O Best Beloved, ended with a code. A coda, if you will indulge me the black-humour wordplay, to last night's grief.
I don't know his name, his age, or his address - they had the information in the computer but I didn't hear them or spend the time to take a sticker from the chart. A gentleman in his 60's, by the medic's guess, found unconscious and in cardiac arrest. He'd been down for a little time at least, but less than an hour. He came in in v-fib (when your heart is just sort of randomly squeezing without purpose) and they shocked him, and started lines, and did CPR, and for a few brief moments he had a heartbeat, but then it went away again. V-fib/V-tach/Asystole. Again and again and again. And finally Dr. K looked up at the screen of the heart monitor, and the heart doctor looked down at the person doing the airway bagging, and Dr. K said "Stop CPR" and the heart doctor said "Stop bagging." And everyone looked down at the man on the cart, one arm hanging loose off of the edge where it had fallen during one of the jolts, and Dr. K said "Call it?" and the heart doctor said "Call it." And I looked over at the chaplain and I nodded, and she mouthed "Code?" and I nodded again.
They drew the curtains and they disconnected the machines and I left to tell Iwona that it was the end of my shift. She shooed me out of there. I went back to the trauma rooms, and I stepped inside the drawn curtains and looked down at the body. Not ten minutes had passed, but his face was grey and sunken, his eyes half-slits, still moist for now. Was-a-man, is-a-body, such a subtle change. They'd gotten hold of his relatives and the chaplain went to see them. I didn't. I stared down at him for a few more minutes, what was left of him, so different from the little boy of last night's drama and yet the same...
Someone said: Is this your first code? I said no, last night was. Someone else said: That wasn't the same, it was something strange. And it was, last night, strange and surreal. I found out some more things: There was a carseat. I don't know how he got dislodged from it. That takes away some of the fury. They did an EEG and found, as we predicted, no brainwave activity. They have him on basic supportive measures - a ventilator, fluids to keep his empty body going until his father arrives from Arkansas. His mother's already decided that whatever organs aren't too hypoxic to donate will be harvested and donated. That takes away some of the pain. They're still there, the fury and the agony and the indelible memory of his face, his half-slitted eyes (why do they open like that?), his heaving chest as the machinery of life struggled to keep functioning without purpose or guidance. But they're eased a bit, and with time, that bright broken innocent part of me will heal and cease to bleed. But I hope and I pray, O Best Beloved, that there will never come a time when I can look upon death without that breaking and wounding. I believe as firmly as you do, you who listen to my tales in the dark and lonely hours of the night, that I will never lose hope, never lose compassion, never cease to be stirred by all that is pain and injury in this world of ours. It is that which fuels me, which gives me the burning, driving need to heal where I can heal, comfort where I can comfort, and to leave some tiny footprint in the lives I touch, some tiny change for the better.

Things happened today, O Best Beloved, things that I wanted to tell you about. I wanted to tell you about the boy and his bicycle, when I stopped by the road and waited for the paramedics to come, and then saw them again in the ER later on. I wanted to tell you about the woman who accidentally took a pill that bought her a ticket to an overnight stay. I wanted to tell you about C, the PA student, and how we got to look over things together for a while and I felt that connection of camaraderie. But I think most of all I wanted to tell you about the man who died, and the boy from last night, and I wanted to tell you that the second time I've seen death it still hurt, still twisted, still bled inside me...but that sometimes it's easier to face and easier to understand than others. I walked out of the ER today without a smile on my face, but by the time I got to the car, I had placed the memory of his face in a part of my mind that sprung into being last night, a place to keep the things I must learn - if not to love - to accept the inevitability of. We live. We are hurt. We die, all of us, in the end.
I wish and I don't wish that knowing that made it hurt less.

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Over the next few days I'll be at a family practise conference in French Lick. I may or may not have Internet access. What I will have, however, is some time to absorb and consider the events of the last few days; time I desperately need. Bear with me, O Best Beloved, and I'm sure in time I'll have for you the bright tales and patient stories that have previously been my lot. Bear and learn, if you will.
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