Читать книгу No Mercy - John Burley - Страница 12

Fifty minutes later, Ben found himself sitting in the darkened interior of the Honda as he headed east toward the Coroner’s Office. A tentative drizzle had begun to fall from the sky as his family had walked home together from the bus stop, and by now it had progressed to a steady drumming that pattered the car’s rooftop insistently with its heavy, hollow fingers. A light fog clung to the ground, and Ben was forced to negotiate the dark, rain-slickened streets slowly and with exceptional caution. He’d habitually turned on the radio as he started the car, but most of the local stations were running news of the murder, and the more distant ones that he could sometimes pick up on clear days were reduced to static in the mounting storm. He flipped the knob to the off position and decided to simply concentrate on driving.

Thomas had stepped off the bus that evening to the warm embrace of his relieved and grateful parents, and to the boundless questions of his spellbound younger brother. As it turned out, Thomas didn’t have much more information on the identity of the victim or the details of the crime than his parents had already received from Phil Stanner. This stood to reason, since the police were remaining tight-lipped until after they’d had a chance to notify the victim’s family.

What was clear from the moment Thomas stepped off the bus to join them was that he regarded the day’s events with a certain quiet thoughtfulness that Ben had not anticipated. He spoke very little during the walk home, and let his family’s questions wash over him without much comment. Ben wondered whether his son might be in a mild state of shock, or simply trying to wrap his mind around the idea of a violent attack so close to home and school. Ben felt that children of Joel’s age tended to regard death as an obscure and distant entity, far removed from their own daily lives and therefore relatively inconsequential. This view seemed to change as children entered their teenage years and began to explore and sometimes even to court this previously intangible eventuality. Popular movies often romanticized the notion with blazing shoot-outs among beautiful people against an urban backdrop at sunset, or titanic ships that slowly sank in the freezing Atlantic while lovers shared their final fleeting moments together aboard a makeshift life raft only buoyant enough for one. This was not the type of death that Ben encountered as a physician. He supposed it could be described as many things, but mostly his experience with death was that it was impersonal, and seldom graceful.

During his intern year as a medical resident, Ben had been working his third shift in the emergency department when paramedics brought in a fifty-eight-year-old man with crushing substernal chest pain radiating to his left arm and neck. Ben had examined the patient quickly in the limited time available, and after reviewing the EKG he’d decided that the man was having a heart attack. Emergency treatment for heart attack patients with certain specific EKG changes called for the administration of thrombolytic agents, powerful clot-busting drugs designed to open up the clogged blood vessel and restore adequate blood flow to the heart. The supervising physician was not immediately available and the patient’s clinical condition seemed tenuous, so Ben had given the order for the nursing staff to administer the thrombolytic drug to his patient. The results had been almost immediate. Within five minutes, the patient was complaining of worsening pain, which was now also radiating to his back. Eight minutes later the patient’s blood pressure plummeted, his heart rate increased to 130 beats per minute and he vomited all over himself and the freshly pressed sleeve of Ben’s previously impeccably clean white coat. Several moments later the patient lost consciousness, and Ben could no longer palpate a pulse. He attempted to place a breathing tube into the patient’s trachea but couldn’t see past a mouthful of emesis. Instead, the tube slipped into the patient’s esophagus, and each squeeze of the resuscitation bag aerated the patient’s stomach instead of his lungs. Ben began CPR, and the first several compressions were accompanied by the sickening feel of cracking ribs beneath his interlaced hands. ‘Call Dr Gardner!’ he shouted to the charge nurse standing in the doorway, and he soon heard the overhead paging system bellowing: ‘Dr Gardner to the ER, stat! Dr Gardner to the ER, stat!’

For eight minutes Ben pumped up and down on his patient’s chest, attempting to circulate enough blood to generate some sort of blood pressure. Every so often, he paused long enough to look up at the patient’s heart rhythm on the monitor. ‘Shock him, two hundred joules!’ he ordered the nurse, who would charge the paddles, place them on the patient’s chest, yell ‘CLEAR!’ and press the two buttons that sent a surge of electricity slamming through the patient’s body like an electric sledgehammer. ‘No response, Doctor,’ the nurse reported each time, and Ben would order another round of electricity to be delivered like a mule kick into the patient’s chest before resuming chest compressions over splintering ribs. Somewhere during the nightmare of that resuscitation – Ben’s first resuscitation as a physician – the patient’s bladder sphincter relaxed and about a liter of urine came rushing out of the man’s body and onto the bedsheets. A small rivulet of urine began trickling steadily onto the floor. Ben continued his compressions on the patient’s mottled chest, which was now tattooed with burn marks from the defibrillator paddles, as the nurse had failed to place enough conductive gel on the paddles before delivering each shock. The room stank of burnt flesh and a repugnant potpourri of human sweat, urine and the vomited remains of a tuna fish sandwich that the patient had apparently eaten shortly prior to his arrival. The endotracheal tube, temporarily forgotten, slipped out of the patient’s esophagus and fell onto the floor with a resounding splat.

‘What in the hell is going on here, Dr Stevenson?!’ Dr Jason Gardner, Ben’s supervising physician, stood in the doorway, gaping in disbelief at the scene. He appeared to be moderately out of breath from having run across the hospital from the cafeteria on the other side of the building. Ben noticed a small bit of pasta clinging like a frightened animal to his yellow necktie.

‘Heart attack.’ Ben’s voice was hollow and uncertain, small and desperately apologetic, and his words fell from his mouth in a rush as he tried to explain. ‘He came in with chest pain radiating to his arm, neck, and back. Only history was hypertension. He had EKG changes – an ST-elevation MI, I thought. I gave him thrombolytics. I was going to call you, but I didn’t think there was enough time. He coded shortly after I gave the ’lytics. I tried CPR and defibrillation, but I couldn’t get him back. I don’t understand it. I had the nurse call for you as soon as he lost his pulses, but—’

‘What did his chest X-ray look like?’

‘His chest X-ray?’ Ben thought for a moment. Had he ordered one? ‘I … I don’t know. I think they got one when he first came in, but I didn’t get a chance to look at it.’

‘What do you mean you didn’t get a chance to look at it?’

‘I just … he started crashing, and there wasn’t enough time …’

‘For God’s sake, Stevenson! Stop doing compressions and go get me the goddamn chest X-ray!’

Ben looked down at his hands, surprised to see that they were still pressing up and down on the patient’s chest. He forced them to stop. ‘Maybe if we tried another shock …’ he suggested hopefully.

‘The patient’s dead,’ Gardner growled. ‘You can shock him all you want, and he’s still going to be just as dead. Now, go get that X-ray. Let’s see what you missed.’

Ben left the room and walked across the hallway to the viewing box. A wooden repository hung on the wall containing several manila sleeves of radiographic images. He shuffled through them, found the appropriate one and returned with it to the resuscitation room. Dr Gardner stood next to the cooling body, leafing through the patient’s chart. Ben noticed that the dead man’s eyes remained open, staring lifelessly at the door through which he’d recently entered. Throughout the course of his career, Ben would never forget the look of those eyes, which were not accusatory or vengeful, but simply, unabashedly dead. For some reason, that was the worst of it – the detached finality of that look. It was the first thing he learned that day; when things go bad in this line of work and someone dies, there is always plenty of blame to go around, but there is only one soul who truly no longer cares.

‘Let’s see that film,’ Gardner grunted, and Ben handed him the envelope. He watched the man remove the X-ray from its sleeve and slap it onto the resuscitation room’s viewing box. The seasoned physician studied it for a minute, then queried, ‘Well, what do you make of it, Dr Stevenson?’

Ben cleared his throat hesitantly. ‘The lung fields are somewhat hyperinflated. Cardiac silhouette appears slightly enlarged, although that can be an artifact of a single AP view. Costophrenic margins are well visualized. No evidence of an infiltrate or pneumothorax.’

‘Uh-huh. And how would you describe the mediastinum?’

‘Widened. The aortic knob is poorly visualized.’

‘Exactly. What comes to mind, Dr Stevenson, in a fifty-eight-year-old gentleman with a history of hypertension, who presents with chest pain radiating to his arm and back and has a widened mediastinum on chest X-ray?’

‘Aortic dissection?’ Ben ventured. ‘But what about the ST elevation on the patient’s EKG?’

Gardner snatched up the EKG, glanced at it perfunctorily, then handed it to Ben. ‘Inferior ST elevation consistent with a Stanford type A aortic tear dissecting into the right coronary artery. Pushing thrombolytics on this man was a death sentence. He bled into his chest and pericardial sac within minutes. He would’ve stood a better chance if you’d just walked up to him and shot him in the head with a .38.’

Those last words – Dr Gardner’s final commentary on the case – hung in the air, defying objection. Ben stood in the room between his boss and the dead man, unable to conjure any sort of meaningful response. His face burned with anguish and humiliation. In the corner of the room, a nurse pretended to scribble notes on the patient’s resuscitation sheet. She glanced up briefly in Ben’s direction, her face cautiously guarded.

‘Notify the medical examiner, and submit this case to the M&M conference on Friday,’ Dr Gardner instructed him. ‘Get back to work. You’ve got three patients in the rack still waiting to be seen. Oh, and Stevenson?’

‘Yes?’ Ben looked up, needing to hear some token of consolation from his mentor, this man he respected.

‘Try your best not to kill the rest of them,’ Gardner advised him blandly, and left the room without looking back.

One of the hardest things about being a physician, Ben now thought as he recollected this horrendous experience in the ER as a young intern, was forcing yourself to continue along in the wake of such catastrophic events as if nothing had happened. The three patients still waiting to be seen had turned out to be a child with a common cold, a drunk teenager who was brought to the emergency department by her friends and a forty-two-year-old man with a wrist fracture. Routine, mundane cases, in other words. Ben had attempted to clear his head as best he could, and he interviewed and examined them all carefully and professionally. But while looking into the child’s ears with an otoscope, he thought to himself, I just killed a man. While ordering an anti-emetic for the teenager now puking through the slots between the side rails of her gurney, he thought, There’s a man in Resuscitation Room 2 covered by a white sheet because I was in too much of a hurry to look at a simple chest X-ray. In the middle of examining the man’s broken wrist, he recalled holding the wrist of the dead man in his hands as he searched for a pulse that was no longer there. During these moments, his patients were aware of none of this. Two more people arrived in the department during the time he had taken to examine and treat the previous three patients. After that, an ambulance had shown up with a moderately severe asthmatic, and four more people checked in to triage.

In most jobs, when something horrible and traumatic happens to an employee, they are instructed to take the rest of the day off and are possibly sent for counseling. There is time to process what has happened, to remove oneself from the environment. There is time to take a breath, to discuss the incident with your spouse, or to simply get wasted at the local pub. In medical training, you are instructed to notify the medical examiner and to get back to work. You are given the helpful advice ‘Try not to kill the next one,’ and you are desperately afraid that you will. Recovery from such events occurs on your own time, in private, once you’ve fulfilled all of your other duties and obligations. And in medicine, those duties are never truly fulfilled. There is always another patient, another conference, another presentation, another emergency in the middle of the night, another fire to be put out. Always.

The night’s precipitation continued to fall on the darkened street ahead. Xenon headlights cast their artificial glare on a hundred tiny rivers of water racing desperately toward the town’s sewers, and wherever they might lead beyond that. Four miles from here, Nat was preparing the body of a young boy for his final medical examination. It was going to be a long and exhausting night, and Ben was pretty sure there would be more to follow. Things would get worse before they got better. Things like this always did. He didn’t want to be here, driving away from his family on a night like this. It didn’t feel like the right thing to do, and he wondered to himself, not for the first time, exactly where his allegiances were. He could feel the storm tugging at the hole inside of him, another chunk of earth pulled loose by the water’s greedy fingers. He imagined himself being swept away into the sewers, one nearly imperceptible piece at a time. What will it feel like when there’s nothing left? he asked himself. And will I even know when that moment comes? Within the car there was only silence, except for the steady thrum of the rain falling all around him.