We had just finished nailing a femur when the circulator handed me a note written on the back of a card.
“These are all the pages you missed when you were scrubbed.”
“Oh, thanks,” I replied, a little annoyed that I hadn't heard about the pages during the case. I scurried down to the emergency room as I looked at the card. Four new consults.
Rita was 90-years-old and pleasantly demented. I asked her what had happened; her story wandered, but I could follow. She had fallen in her nursing home and suffered a femoral neck fracture. I went on to ask about her medical history.
“Oh, I am very healthy,” she said.
“Nothing wrong? No problems? No medications you take for anything?” I asked.
“Oh there is one thing,” she remembered, “Ever since I had a stroke many years ago, I walk like a Jew.”
“I'm not quite sure I know what that means.” It was an honest reaction. Having spent my childhood outside New York City and Los Angeles, I failed to consider that she didn't recognize the name Friedman as connoting a certain ethnic identity.
“Oh, you know those Jews,” she continued. “They walk like all they care about is money.”
“Oh.” I said. Of course. Those Jews. “I guess I still don't know what that means,” I said, giving up on making sense of this.
“I wasn't asking for clarification.” I interrupted. “I want to talk to you about surgery. Is now a good time or would you like me to come back when your family comes?”
“Oh, better come back when my daughter gets here.”
“Okay. We'll talk later then.” With that, I left her room.
This was the first time an obviously discriminatory statement had been thrown my way. I was used to being called a nurse by my older male patients, but that was out of general confusion, not maliciousness. When I told my colleagues later about what Rita had said, they were quick to excuse her.
“She's 90,” one of them said. “She's demented!”
In a way, that bothered me more. I wondered if Rita's opinions were more commonly held but she was just free to express it, her mind disinhibited by her dementia. After a heated election season, I worried if this reflected a new social trend in which people were crueler to and less tolerant of one another. It surprised me how much her frivolous comment bothered me; I couldn't begin to imagine how my grandfather must have felt when he fled Poland, in fear for his life, ahead of an approaching army of Nazis.
Morning drew close. I finished the onslaught of emergency department consults, and it was time to get them on the board. Rita was medically stable, but complicated. Her fracture was closed and she was the least likely to get cleared for the OR that day. Her family needed to be tracked down for consent.
I talked to my attending and called the OR control desk to schedule my four patients for surgery. We decided Rita would go last because, medically, it was the right thing to do. Though I had played no role in determining the schedule of cases for the day, for a fleeting second, I got a special satisfaction in making her wait until the end of the day to get fixed. I realized I was no better than she was.
On my last day at Regions, a page sounded overhead calling the trauma team to the ER. The first responders ran in with a teenage boy on a gurney. He wasn't my patient, but I could not help watch at my desk opposite the trauma bay, partly out of curiosity about the unfolding commotion, and partly to look for any signs of bones sticking out of the skin that would keep me busy for the rest of the night.
“16-year-old male, found hanging from a tree by police, cut down after what is estimated to be 10 minutes. Rapid sequence intubated at the scene. No pulse!” The first responders shouted as they rushed the patient by me. He appeared much younger than 16. The responders strapped an automated CPR machine to his chest; its power and violence were a stark contrast to the unresponsiveness of the boy. They disappeared behind the curtain.
My eyes remained affixed on the curtain. I could hear the shouts and directions of the team running the code. Though I could not see, I could put the scene together in my mind. I knew the ending, but I stared ahead and wished it was not so. How could the world be so cruel to a child?
From across the room I heard a wail. The boy's mother. It was an ancient cry that hit me in my bones and in my gut. An attending met the mother, and shuttled her into the trauma bay. The commotion died down. It was done.
The staff removed themselves from the trauma bay. Activity in the ER emerged back into focus. I had fractures to reduce. I finished my work, as the sun rose over the State Capitol. Driving home, I thought about the last stanza of the Matthew Arnold poem, “Dover Beach”.
“Ah, love, let us be true
To one another! for the world, which seems
To lie before us like a land of dreams,
So various, so beautiful, so new,
Hath really neither joy, nor love, nor light,
Nor certitude, nor peace, nor help for pain;
And we are here as on a darkling plain
Swept with confused alarms of struggle and flight,
Where ignorant armies clash by night.”
And then I cried.
It was a few days before Christmas, when I was back on service with the trauma team. Responders rushed a young adult in his early 20s into our trauma bay. He had been t-boned by another car, and his side of the car had been obliterated. The responders struggled to intubate him in the field and were bagging him, but his oxygen sats were hovering in the 30s.
“Establish an airway in him, stat! We need to intubate now!” She ordered. All focus diverted to establishing an endotracheal tube in the patient.
His mop of brown hair remained neatly parted despite the chaos around him. His freckles stood out against the ghostly pallor of his cheeks. I stood at the foot of the bed with trauma shears and cut away his bloodied, muddied clothes to expose his injuries. We saw none. The only thing keeping him from looking as if he was just sleeping peacefully were the lines coming from his body and the stream of blood coming up his endotracheal tube with each breath.
His blood pressure and heart rate continued to move, like magnets with similar charges, in opposing directions. The massive-transfusion protocol was started and bag after bag of blood poured into his veins. An ultrasound FAST exam confirmed he had blood in his belly. There was no time for further imaging. He was whisked to the operating room, where an exploratory laparotomy was performed. What could be repaired, was repaired. What could not be repaired, like his spleen, was removed.
Once stabilized, a CT scan of the young man's brain showed a devastating, nonsurvivable neurological injury caused by prolonged hypoxia. He remained intubated while his family decided what to do next.
On rounds the next day, we discussed the patient and his grim prognosis. One member of the trauma team said, “It's sad what happened to him. And he looked like such a good kid, too.” I didn't have the courage to speak up, but I wondered what a bad kid looked like.