- guardian.co.uk, Saturday January 6 2001 12.08 GMT
A good scar
He was in so deep a coma that I didn't bother using local anaesthetic when I sutured the wound in his face. It was Sunday afternoon in the ICU, and I had been called in from home to close the man's lacerations. The night before, on a dark road, he had gone through the windshield.
It was really a job for a plastic surgeon. The wound extended from the top of his scalp deep into the tissues around his eye, then down his cheek into his mouth. I knew why they had called me, the intern. The man was not expected to live.
I did my best, matching up the creases of his skin, easing the bright half-moon of the needle in and out, daubing away the dark blood that rose in little balls from the needle-point, tying my knots like a fly fisherman. The thermostat in the room was turned up all the way, but he was cold - I could feel it through my gloves. After a while, his face began to lose distinction to me. The wound stood out, became an entity unto itself. The earlier intimacy I had felt - bending over him as he lay there, my breath all around him - began to recede into the task.
It took hours, my back aching, my scrubs damp under my blue gown in the heat. The only sound was the regular hiss of the ventilator. The soft brown skin around his eye was like a child's; his eye looked straight up, the pupil never moving, even as I tented his eyelid, trying hard not to slip the point of the needle into the eye itself. When I had finished, my hands shaking, I stopped, straightened, stepped away from the bed. He lay muffled in blankets, and it was only then that I saw, in the hollow between his knees, a single eagle feather and a small plastic bag full of yellow pollen, left by his family to save him.
The next morning I came back to check my work. His face looked whole; only the thin blue lines of nylon sutures betrayed the extent of his wound. It was only after at least a minute of admiring the job that I realised that the sound of the ventilator, my constant companion in the room the day before, was absent, and that the man was dead.
Sunday morning
We had a few minutes of calm, waiting in our gowns and gloves, our heavy lead aprons, as the radio filled the trauma room. A pickup truck, high-speed rollover, two coming in. Teenagers.
The black boy, who came in first, was dead. He lay unmoving, eyes half-open, with a clear plastic tube sticking out of his mouth, the paramedics still squeezing air into it through a blue rubber bag.
"He's in asystole," the paramedic said, meaning his heart was not beating. As I turned away, I noticed his hair, cascading to his shoulders, dark and shining, each strand braided and tied with red and green beads. It was the labour of hours.
The white boy was still alive, and the room changed for me; the silence on the far side, by the still gurney, instantly faded. They wheeled him in, and it began: the IV needles into his arms, the sudden, astonishing red of the blood spilled from them on the floor, the monitor wires to his chest, voices rising, the room suddenly full of noise and speed.
He was blue, barely breathing. I took the laryngoscope, put the blade into his mouth, and immediately felt how deeply unconscious he was, how soft and unresisting the muscles were. I lifted his tongue and jaw and saw, very clearly, his vocal cords, a neat triangle, like two white glittering sticks. It was easy to pass the tube past them into his lungs. The oxygen flowed, and his face turned slowly pink, alive again. He was big and strong, with earrings in each ear, the sides of his head shaved, his brush cut dyed blond, curly and full of clotted blood.
It was only a few minutes later, after the X-rays and calls to the blood bank, that I felt the back of his head. It was soft, and warm, and when I withdrew my hand it was covered with blood and grey tissue. The back of his head had been crushed. By that time I knew his name - John.
The clerk tapped me on the shoulder. "John's family is in the consultation room," she said. "Will you go talk to them?"
I knocked on the door, stepped inside. All eyes turned. "I'm sorry," I said, stiff, uneasy. "John is critically injured. The neuro-surgeon is seeing him now."
"How bad is it?" the mother asked, half rising from her chair.
"It's bad," I said. "I'm sorry. I think you should be prepared for the worst."
She sat back down. "This isn't happening," she said to herself, softly. "This can't be happening."
"Is Keith dead?" the father asked. "We heard that Keith might be dead. Is that true?"
"Yes," I said. "Keith is dead."
The room erupted - life in the presence of great damage, the overweight, middle-aged mother standing to weep in her husband's arms, the husband looking into the distance over my shoulder, at the white hospital wall. In the corners, a younger brother and sister, still children, began to cry.
"I'm very sorry," I said, knowing that anything I might say to them now would be simply sounds from a great distance.
"He was staying with us," the father said. "He was John's best friend. They were driving back from the lake. They must have fallen asleep."
Then, later, "His family is in Colorado."
I nodded. John's father looked up at me. "Can I see Keith?" he asked.
He was perhaps 40, white, with long hair, tattoos on his arms, wearing a muscle shirt. As I led him back to the trauma room where Keith's body lay, I saw that goosebumps had risen on his arms and legs and he was shaking.
The room was clean, all of the earlier frenzy gone, blood mopped up, everything back in place. The nurses had covered Keith's body with clean sheets so that only his face was visible, the clear plastic tube still sticking out of his mouth, and the amazing luxuriance of his hair. He looked almost unharmed. I stood in the doorway and let the man approach on his own.
He walked up to the body and stood for long seconds. "This is him," he said. "This is really him."
He fumbled under the sheet for the boy's hand. Then he bent down, his long, brown hair falling into the boy's face, and kissed him on the forehead.
It suddenly seemed very important that I look closely, as closely as I could, at this man taking on for the moment the role of the father to the dead son, kissing him softly, holding his hand, then turning back to me and the doorway.
Needle
I was walking past X-ray on my way back to the emergency room. The door to one of the X-ray suites was open, and, glancing inside, I saw a surgery resident I knew peering anxiously at a patient's monitor. Even from the door I could see what it said: blood pressure 60/40. Heart rate 130.
"What's up?" I asked. The surgery resident turned.
"He's an MVA from the trauma room. We had to intubate him because he was so combative, but the CAT scans of his head and belly were normal. He's only got leg fractures - but his pressure just dropped."
The patient was a young man, heavily sedated, on the ventilator. He was very pale. There were three of us in the X-ray suite - the nurse, the surgery resident and me - and in the half-dark of the room we looked at each other. Something was happening. Stepping up to him, I put my stethoscope against his chest. Each mechanical breath filled his right lung, with a faint whooshing sound, like feathers brushed across a rough surface. His left lung, though, was nearly silent. As I listened, the surgery resident opened the IV fluids wide, squeezing the bags in his hands to increase the flow.
"Let's get a chest X-ray," I said. "He's already on the table, and his pressure just came up a bit."
We spent a few anxious moments, watching his blood pressure, waiting for the film to be developed. The X-ray was still warm when we held it up to the light, and there it was: the left lung punctured, crumpled like a wet handkerchief, leaking air into the chest cavity, compressing the heart and the good lung. It was a classic, the kind that killed you in minutes: a tension pneumothorax.
I found myself sprinting down the hallway to the ER for a needle and syringe, fumbling in a drawer, turning, rushing back as patients and nurses stared at me. I felt like an actor in a melodrama, cutting around people with a needle in my hand, my white coat trailing behind me like a cape.
The man was ashen when I got to him, and I simply stuck the needle straight into his chest. Air hissed out of him like a bicycle tyre, in little bubbles of bloody froth. I took the 60cc syringe, attached it to the needle that was quivering between his ribs, and sucked. Then I detached the syringe, pushed the air out of it, and did it again - once, twice, four times, until the pull met resistance and the air was gone, the lung plump and full once more.
It was as dramatic an act as any I was likely to accomplish again, blood pressure rising to normal, heart rate falling to normal, all of us breathing hard. Almost as an afterthought, I realised that I had saved him, that he was alive because of me.
Late that night, after my shift, I went to see him in the ICU. He was already off the ventilator and breathing on his own, waking up, coming back, making dim animal noises through a haze of morphine and Valium. I knew that he would leave whole, and I sat there in the dark for a while, watching the red and blue lights of the monitor, savouring him, taking something for myself.
A difference of opinion
"I don't think any of us here seriously expects this man to survive," the attending said every morning when we reached room six. We expected the remark. The intern would begin the presentation, and it was always the same.
"This is ICU day 28 for Mr Johnson, a 26-year-old cowboy with pneumonia, sepsis, respiratory failure, renal failure and anaemia ..." A detailed analysis of each problem, in descending order of severity, then ensued. He was growing steadily worse. The ventilator had been at maximum settings for weeks, supplying the man's ruined lungs with just enough oxygen to ensure another identical presentation the next morning.
"This is ICU day 29 for Mr Johnson ..."
"I don't think any of us here seriously expects this man to survive," the attending would say, and we would move on, halfway through rounds and already worn out.
Mr Johnson was a bullrider, thrown at a local rodeo, who had broken several ribs. He'd gotten up, dusted himself off, gone home, and over a few days he had developed pneumonia in his injured lung. His family brought him in nearly unconscious, with both lungs full of pus, and over the ensuing weeks his other organs also failed: liver, kidneys, intestines. Mr Johnson lay drowning in his own fluid, the fever unrelenting, his family gathering and staring at him. Over the past few days they had stopped coming, consigning him, it seemed, to his fate alone.
One night, more than a month into his stay, I was on call when his blood pressure began dropping yet again. The intern and I stood looking at him, swollen like a toad on the ventilator. He always tormented us like this.
"Give him some more fluids," I said. "And let's go up on his dopamine." The nurse sighed; she'd heard all this before.
Listening to the ragged sounds of his lungs, I thought something had changed. His left lung sounded a bit quieter than it had the night before, an ominous sign.
"All right," I said, resigned. "Let's get a chest X-ray."
The chest X-ray had not changed much. Looking hard, though, the radiology resident thought he saw a slight difference on the left. "Could be a pneumo," he said, "though I'm not sure. Let's get a CAT scan."
He referred to the possibility that air was leaking out of a hole in the lung, collapsing it. The treatment for this is minor surgery, done at the bedside. You cut into the chest between two ribs, insert a finger into the chest cavity, and push the lung out of the way. Then you slide a long plastic tube between the lung and the chest wall.
When suction is applied through the tube, air and blood rush out, allowing the lung to re-expand. Mr Johnson had been the victim of this procedure so often that his chest was a mass of wounds that refused to heal and oozed blood-tinged fluid into the bedding.
The intern and I looked at each other, shaking our heads. This meant hours of work, wheeling him with his ventilator and multiple IV drips down to the CAT scanner, waiting for the scan to be read, then putting in the chest tube and getting X-rays to make sure we'd done it right. Any chance of sleeping that night vanished. It was already early morning, and we were tired. "Looks like a pneumo, all right," the radiologist said, pointing to the dark mass of air visible on the CAT scan. "A pretty big one. I'm surprised we didn't see it better on the X-ray."
Mr Johnson's lung, by the time I finally cut down to it through the deep, soggy tissues of his chest wall, felt exactly like a piece of cork. It was stiff, as if already embalmed. "You've got to check this out," I said to the intern. "Put on some gloves and feel this thing."
For a few moments he felt around with his finger, then withdrew it, covered with blood, and held it instinctively up in the air. "Feels like a piece of meat," he said.
The next morning we were reprimanded. "I think we should seriously consider the ethics of performing such aggressive procedures in this man," the attending began. "I should have been called. It's high time, in fact, that we considered withdrawing support altogether."
There was a long silence. "He's a young guy," I protested. "And we've done it before. And it helped." This was only marginally true. His blood pressure had come up slightly, but it was hard to know why.
About this time, another attending came on the service, and for the next few weeks he alternated call nights with his colleague. He had different views. "This is a young man," he would say when we reached room 6. "This is exactly the kind of patient we should be most aggressive with."
A bizarre dynamic developed. On even days we did almost nothing, checked no lab work, stopped antibiotics and tube feeds, and nodded solemnly as the attending shook his head and said things like, "The most important thing we can do now is keep this man comfortable."
On odd days it was the full-court press. We worked to undo the previous inactivity, checking arterial blood gases, blood cultures and X-rays, adding antibiotics and fluids, tinkering with the ventilator.
We nodded solemnly as the attending said things like, "This man deserves everything we can give him."
This went on for more than a week, until my tenure in the ICU came to an end and I rotated back to the emergency room, leaving my nightly struggles with Mr Johnson behind. I was glad; he had unfailingly robbed me of sleep, and I had come to dread him. I knew him intimately, had examined him dozens of times, turned him over to look at his back, put my gloved finger in his mouth, in his rectum, into the interior of his chest cavity, and I had never once exchanged a single word with him.
He was gone from the waking world, as nearly dead as a human being can be, lying at the edge but never quite crossing over, his body, his animal self just strong, or not strong, enough. I had hoped many times that he would die.
About six months later, I was walking down the long hall back to the ER from the cafeteria. It was mid-afternoon, a slow day. The door to the pulmonary clinic was open as I passed. A few patients sat in plastic chairs, waiting for their appointments. In one corner, leaning casually against the wall, a man stood reading a newspaper. The paper obscured his face, but as he turned the page I saw it, and I stopped immediately. I felt a strong and sudden force. It took me a few seconds: I knew the man, I knew his face was signicant, but I didn't know why. Then I realised, disbelieving.
"Mr Johnson?" I asked tentatively, stepping in through the clinic door.
He looked up at me from his newspaper.
"Are you Mr Johnson?" I asked, beginning to feel foolish.
"Yes," he said, looking at me suspiciously. "Do I know you?"
The secret
"You have to come and see this," the nurse said breathlessly, interrupting rounds. "It's the grossest thing I ever saw."
It was early on Sunday morning, and the trauma team had been shuffling around the surgical ICU for an hour, trying to impose some order on the carnage of the night before. It was a blur for me by then, a stream of wounds and bodies. There had been only two surgery residents and me, and we had been going for 24 hours straight, trying not to miss something big. I felt jumpy, distant from the world, and the bright, white coats and accusing fingers of the surgery attendings seemed like the fixtures of dreams.
I heard myself answering questions, searching my note-cards, I felt numbers emerging from my mouth, but I wasn't really there. I could smell the odour of my body rising from my scrubs, and my feet felt loose and wet in my running shoes. But she got my attention, anyway. She got everybody's. The grossest thing she ever saw ...
Her patient lay in his darkened room, heavily sedated on the ventilator. After two weeks, he was getting better, and for the past few days we had all virtually ignored him. A young man, drunk, in his car, the same story again, coming slowly back into the world.
"Watch," the nurse said, lifting the ashlight from the bedclothes. We gathered around the bed. With her left hand she moved the clear plastic ventilator tube to the side of the man's mouth, then carefully inserted her fingers between his front teeth and spread them apart. His jaw opened slackly, and she shone the light directly into his mouth.
His mouth was like a little pink cave. Inside were dozens of tiny white worms. As we watched, they began to move, to retreat into the darker recesses, away from the light, and in a few seconds they were gone.
"Oh my God," one of the residents said. "They're maggots. He's got maggots in his mouth." The room erupted. We were horried, but also excited, exhaustion washed away. He was alive, and we made her do it again.
We took turns, switching off the light for a minute or two until the maggots came back, then illuminating them, transxed by their retreat into the dark.
"What we need to do," Dr Whistler said, chortling, "is get a piece of bacon on a string and leave it in his mouth for a while. I've seen this before. This is why we don't like flies in the ICU."
One of the medical students went down to the cafeteria for the bacon, and before long the news had spread throughout the hospital. Nurses and medical students and residents from other services began filing through his room until finally the charge nurse put a stop to it. "This isn't a sideshow," she said, to settle the matter.
Tied to a string, raw and shiny with fat, the bacon worked beautifully. The nurse pulled it out every half hour or so, and each time it was alive with maggots. She wiped them off, dropped them into a bottle of alcohol, then replaced the bacon. "It's like fishing," she said, chuckling, shaking her head.
A month or so later, in the trauma clinic, I saw him again, stiff, thin, walking slowly with his cane. The nurse called his name, and he came slowly forward to the desk.
We sat a few feet away, and as he stood writing his name on the forms, weak and alive, we whispered: "That's the maggot man. Remember him? He's right over there."
No one had told him a thing.
Sugar
The little girl was running around the room, screeching happily, and when she saw me she hid under the bed. I could see her peering at me from between the legs of the gurney as I stood with her chart in my hand. Her father shook his head, grinned, and looked at his wife. "I told you there's nothing wrong with her."
I looked down at the chart. On it the triage nurse had written, in bold black letters, "Two-year-old acting weird."
"I'm Dr Huyler. What can I do for you?"
"Nothing," he said, and his wife hushed him.
"She's not acting right," she said. She wore an African print dress, and I found myself staring at the intricate pattern of swirling reds and browns. Her hair was cornrowed, a bead at the end of each strand.
"They're Medicaid," the triage nurse had whispered pointedly in my ear. The implication was clear: they wanted something for free. Tylenol, a work excuse. But it was 10 o'clock on a Friday night.
"What has she been doing?"
"It's kind of hard to explain. She just isn't acting herself. I noticed it right away. But she's been fine ever since we got here."
"Can you be more specic?" I could feel myself getting impatient. There were half a dozen patients waiting, the ER was full. I wondered why they hadn't called their regular paediatrician.
"Well," she said, thinking, "you know how people look when they're staring into a mirror? Kind of blank?" I nodded. "She's like that. Only there isn't a mirror. There's nothing there."
The child's vital signs were completely normal. Her mother coaxed her out from under the bed and held her wriggling in her arms as I listened to her heart and lungs, looked into her ears. I'm uneasy with children. I must have been a cold, white form to her, large, bending down with my stethoscope and light. I could see nothing wrong with her. She looked impeccably cared for, without any sign of the abuse I had been vaguely and secretly considering. I always do. It's been drummed into us.
"Does she have any medical problems at all?"
"No," her father said, anticipating my questions. "She's always been healthy. She's had all her shots. She's growing like she should, and she can talk a little, only now she won't 'cause she's shy." He wagged a finger, and she giggled, hiding her face with the bottle her mother had given her.
"Has she had any recent stress, something that might have upset her?"
They looked at each other. "I don't think so."
"Is there a history of seizures in the family?"
Her mother thought for a while. "I think my brother might have seizures," she said finally, "but I haven't seen him in a long time."
"And right now she's acting normally?"
"She's fine," her father said to his wife. "Come on, let's go. If she does it again we'll come back. It's past her bedtime."
I considered what I'd heard. A vague history of blank spells; it could mean anything, from a rare type of seizure to the vagaries of the two-year-old mind. She could see her paediatrician on Monday, I thought. She was a completely normal child. On my way out the door, though, I turned around. "Is there any chance she might have gotten into someone's medications? Does anyone in the family take medications regularly?"
"Well, she stays with my mother when we're at work. She takes medicines."
"What kind of medicine does she take?"
"I'm not sure. Something for her blood pressure and a sugar pill."
Oral hypoglycemics - sugar pills - are among the most dangerous of overdoses. They can drop blood sugar profoundly, cause brain damage, seizures, coma. Designed for adult diabetics, they are long-lasting, and one pill could kill a small child, even many hours later.
"Let's check her blood sugar," I said, "just to be sure. And please call your mother, find out exactly what she takes."
From the doctor's station I could hear the child shrieking as the nurse drew her blood. Her mother spoke into the phone a few feet away. "My mother takes glipizide," she said, handing me a piece of paper where she'd written it down. "She ran out of her blood pressure medicine two weeks ago."
A sugar pill.
The nurse came out of the room with a syringe full of blood. The child's mother and I watched as she eased a single drop from the tip of the needle onto the portable blood-sugar machine she held in her hand. It digested the blood for a few seconds, then displayed the number on the screen. Forty-two.
"Is that low?" her mother asked.
"It's about half of what it should be," I replied, stunned. "She must have taken one of your mother's sugar pills."
"My mother is legally blind. She probably dropped one and didn't notice."
"We need to keep her in the hospital for at least a day and give her sugar intravenously." I said it quietly, half to myself.
"Will she be all right?" She was afraid, staring at me.
"She'll be fine." And suddenly I began to shake. "But I'm very glad you brought her in. You may have saved her life."
"My husband wanted to put her to bed," she said softly, looking off down the hall.
It was suddenly clear. Sometime that afternoon, the girl had taken the pill, and by the time her parents came home she was showing the effects of low blood sugar: the staring spells, the blank look.
"What did you do when you saw she was acting weird?"
"We gave her a bottle," the father said, standing with us now. "And then we gave her a sucker."
They had given her sugar. When she arrived in the ER, her blood sugar had risen enough for her to look and act herself, but it wouldn't have lasted long. Later that night, when the whole family was asleep, it would have fallen again, and she might never have woken up.
As I watched the girl skip and jump around us, the pain of the needle forgotten already, I felt sick, cold and damp, terried by what I had almost missed. One question, an afterthought. That was all it had been.
From time to time I think about her. I imagine her playing in parks, jumping on the couch, shrieking in the bathtub. I imagine her head teeming with small thoughts, and the motion of her hands, her eyes, alive in the world, going out into it, entering it, decade after decade ahead.
© Frank Huyler.
• This is an edited extract from The Blood Of Strangers, by Frank Huyler, published by 4th Estate at £10.
Read an interview with Frank Huyler here.
