Читать книгу My Crescent Moon (A Collection of Short Stories) - Joseph Dylan - Страница 5

It was late March, and the late afternoon light filtering through the blinds of the ICU bay were grim and grey. Water poured from the skies like someone wringing out a mop as the last winter cold front passed through Albuquerque. As a senior resident, I was helping my intern on the medical service, Ann Hodges, insert a Swan-Ganz catheter, in a diabetic patient whose name was Ernesto Gonzales. At the time, his temperature was raging at one hundred and three degrees, and his systolic blood pressure was sinking like the desert setting sun of the high plains of New Mexico. The interns had not reached journeyman status quite yet, and I was there to assist her in the procedure in which we would pass a the Swan-Ganz catheter from the subclavian artery in the the right side of the heart in middle-aged diabetic who was in septic shock from a skin and bone infection that had flowered in his left leg. When one pushed on the dorsum of his foot, it spit out horribly smelling pus. I was sure that for Mr. Gonzales, he would eventually have an amputation in order if he made it through his sepsis. Both Ann and I were in light blue paper scrubs to maintain a sterile environment. No sooner than she had made a small nick in the skin under his clavicle to ease the entry of the catheter into the subclavian vein, my beeper went off. The nurse helping us held our beepers should someone call. The nurse returned the call, telling the person on the other end of the line that I was in the midst of performing a procedure.

“It’s Turley in the ER,” said Connie, the nurse. She said to call back as soon as you could.”

“Okay, thanks. Be glad you’re not on the bubble, Ann. You’ve got enough on your hands with Gonzales. This one is for John. See if he can keep his lucky streak going.” Ann laughed. She had already scrubbed his right shoulder and neck with Betadine solution to sterilize the skin where the catheter would be placed, so as not to add to the infectious burden that Gonzales’s was dealing with, and would most likely carry him into the next life before he got out of the ICU. It was incumbent on Ann to measure his fluids with the catheter for his systolic blood pressure would not ease into the eighties despite flooding his veins with two liters of normal saline. Despite the fluids, despite the antibiotics, and despite the vasopresors, we could not get his systolic blood pressure higher than eighty. For Mr. Gonzales, I thought that the Almighty had punched his card. On physical exam, all the findings were there, the fever, the low blood pressure, the rapid heart beat and the obvious infection. Once Ann had inserted the guide wire into the subclavian vein, and had taken the central line out, she slid the Swan-Ganz catheter over the wire. At the end of the Swan-Ganz catheter, there were three ports. Finally, with the catheter in one of the pulmonary arteries, his wedge pressure was low, and so too was his cardiac output. All the catheter findings were consistent with sepsis, and they were also consistent with a fluid deficient state. I suggest to Ann that she press ahead and keep him on the antibiotic and vasopressors while giving him more fluid. His blood pressure, currently, was 76/44 mm Hg with wide open liters of normal saline pouring through IV tubing into his veins in both his arms, and norepinephrine going in one IV to raise his low blood pressure. Gonzales was barely responsive and he was drifting farther and farther out to sea. While we performed the procedure, Joan Duffers, the nurse helping us, held both Ann’s and my beeper. Leaning over the bed, in my sterile gown, Joan, showed me the number on the dial. It was for the emergency room. “Jesus, they’re coming out of the woodwork today.” Ann just nodded. By now we were through, and I took my beeper back from Connie. I called the emergency room and asked to speak to Turley. I was told that she was through with her shift. Paul Perkins, another of the emergency room interns, picked up the other end of the line and informed me that he had a GI bleeder who needed to be admitted.

“Who’s on call for gastroenterology?” I asked Jennifer, the ICU secretary. Every day they are handed a list of the different services and who is covering for them. “It says Jim Valdez is.” This would be my third ICU admission, and it was not yet four. I still had my two admissions on the floor, as well as the patients who were already on my service.

“Turley had told me the GI bleeder was fairly stable when she called you,” said Jennifer. Julie Turley had been one of my interns in July. Her competence impressed me. That she was an emergency department resident, I didn’t hold against her. But I didn’t care for a lot of the interns from the program. They were too proud. Beginning my third year of internal medicine, the university medical center started an emergency medicine residency, taking in a half dozen residents each year. They were the top students in their classes from across the country. Unlike the rest of the residents at UNM Medical Center, they wore bright, blue emblems on their white lab coats, signifying that they were not only residents, but that they were residents in the Emergency Medicine Department. No, they were too proud. While we were busy managing patients in the internal medicine, general surgery and pediatric departments taking care of patients, the cloth emblem exuded an attitude that bespoke a bias saying: “We’re here saving lives.” Just what were we doing? Their interns in the emergency department residency program spent a couple of months doing their internship on the internal medicine wards. And that was how I knew Julie.

I nodded at the secretary and thanked her as I watched Ann suture the Swan-Ganz catheter to the patient’s skin with thick, black silk thread so it would not slide out, nor farther into subclavian vein. I looked up and out of the window of Mr. Gonzales’s room. The rain that began that morning, had turned to sleet and the weather was all aslant. Sleet balled up on the windowpane and dripped down in thick rivulets. The cold front coming through central New Mexico was turning into a tempest. So many of the homeless with any ailment would be presenting to the emergency room and the urgent care, searching for a warm bed, clean and dry, rather than under nature’s tempest. Though days like these seemed endless for a resident, I couldn’t help but feel sorry for the homeless. For those so down-on-their-luck, they had no roof over the heads. And God knows there were enough of them in this city slung in the swale of the Rio Grande Valley. “You’re did fine, Ann,” I said as she checked the balloon at the tip of the Swan-Ganz catheter one more time. Now once an hour, the nurse attending Mr. Gonzales would inflate the balloon long enough to record the wedge pressure while taking the rest of his vital signs.

Feeling someone at my shoulder, I looked up from Mr. Gonzales chest to find one of my other interns. It was John Naylor. He was known to the other residents and the medicine interns as “The Terminator.” He had earned this appellation from so many of his patients succumbing from their medical problems under his care. But the nickname was unfair, for John was a good intern. Live had just dealt him the sickest patients. In the internal medicine rotation, each intern gets their patients in the order they present to the resident from the emergency room or the urgent care. John couldn’t help the fact that the deck seemed loaded to him. “John,” I said. “I have another admission for you. A GI bleeder. I have to go down to see him when Ann and I are finished here. Then you can see him when we move him up to the intensive care unit. I looked back down at Mr. Gonzales. As Ann finished attending to Gonzales, I took the back stairway that led down to the emergency room, the emergency department in the medical center being directly below the intensive care unit.

But if my nerves were set on edge by all the beeping telemetry units, the groan of the ventilators, the constant ringing of the telephone, I was even more dismayed when I entered the emergency department from the staircase from the ICU. It looked like a Fellini film, each gurney holding someone deep in misery, from the elements, and from some medical or surgical emergency.

Now that Turley was no longer on, I sought out Paul Perkins, the intern who took her place in the emergency department. Turley had gone off shift not more than an hour ago, not long after she had beeped me. Unfortunately, so too had the nurses who had taken care of Jose Garcia, my GI bleeder. That was all too typical for an emergency room in a busy medical center like UNM. But she had signed out Paul Perkins, and I sought him out. When I found Paul Perkins, he was wearing that white lab coat with the emblem that I detested. “Paul, tell me about this guy?”

“I only know what Julie told me about him. She said the nurses put an Ewald tube down him and it was positive for blood. Apparently, Albuquerque’s finest brought him in after he complained of abdominal pain. That caught him driving drunk. He’s on a police hold.” He handed me his ER chart. On it were his complaints, his exam and his labs. On the emergency room record, Julie wrote he had been brought in by two police officers complaining he had abdominal pain and then thrown up blood. The nurses put an Ewald tube down his throat and into his stomach, the return looking pink, which they believed consistent with a bleeding ulcer. I perused his notes quickly. His hematocrit, the percentage of blood in the blood after one lets them settle out in a tube, was 39%. Yet his last pressure recorded on the notes was 99/60 mm Hg, and his pulse was one hundred and twenty. I looked for a nurse who had taken care of him, hopefully the one who had put the Ewald tube into his stomach. None was to be had. He had been in the emergency room for almost three hours according to the log sheet.

As the saying goes: When in doubt, ask the patient.

I strode over to Jose’s gurney. His eyes were shut and he was moaning. “Mr. Garcia,” I asked. “I was told you were throwing up blood and that’s why we’re admitting you to the hospital.”

“I never threw up any blood.” Pain sparkled in misery in his eyes. He looked startled. It appeared as though he was not trying to move; as if it hurt too much to move, as if death would bring welcome relief. The nurses had prudently hooked him up to a cardiac monitor and place two intravenous lines. Though it was clear that he was inebriated when he was brought to the emergency room, he seemed quite sober now.

“Here it says you were throwing up blood.” I held the ER record upside down so he could see it.

“No man, that’s not it at all. I was drinking. I was drinking more than I should have been. I admit that. I was pulled over in the south valley for driving erratically. The cops who pulled me over beat me up back at the police station. I’ve had belly pain ever since they hit and kicked me.”

“That’s a different matter,” I said puzzled. “Show me where you’re having the pain.” He lightly stroked his whole belly. “I’m going to push down on your belly. I pressed lightly on every piece of real estate of his abdomen. He winced each time. It was rare to see a GI bleeder in as much pain as Garcia was. In fact, I had never seen one in that much pain. “Pay attention to me, Jose. Does it hurt more when I push down or let up? It’s important to determine where the pain is coming from.” He winced as I slowly pushed against the center of his belly. But what caused Jose to nearly scream, was when I suddenly let up. He had what is called rebound tenderness. In this he demonstrated there was peritoneal irritation of some sort in the abdominal cavity. Bleeding, if he had it, was pouring into his abdomen. Unless he had an ulcer that penetrated the abdominal cavity, the exam confirmed what he had told me. He had been beaten so badly that his assailants had perforated a blood vessel or two. None of seemed to make sense. On the IV pole that recorded his blood pressure, and it was slowly sinking, like a receding tidal bore.

I asked the ER nurse to get another CBC on him and finished evaluating him, trying to my full extent to determine something else was going on. When the nurse left with his blood sample, I asked her to have them run it stat.

“I went over to Garcia’s bedside. You’re swearing that the two police officers beat you up?”

“Yeah, I do. Now can you just get me something for pain.”

“Can you give him fifty milligrams of Demerol and twenty-five milligrams of phenergan?” I asked his nurse.

Apologizing to Garcia, I had the nurses put another Ewald tube into his stomach. The returning secretions were clear – there was no blood.

I walked over to the doctors’s partition. I took the one unused phone and asked the hospital operator to get the surgeon on call for me. If I had had a hard day so far, I was certain his was just as trying. In a few moments, he rang me back. I started to tell him about Garcia, but he said. “Hold that thought for a minute, Bill. I will be down in a few minutes.” And so I waited.

No more than fifteen minutes later, Hank Bertrand, tapped me on the shoulder, having come up behind me. He sat down next to me. I him as clearly and succinctly what I knew about Jose Garcia. Once or twice he nodded, but I could tell he didn’t believe me. While he was examining Jose, the blood count had come back. His hematocrit had dropped by 6%.

“He needs to go to the OR,” said Hank looking at me haughtily. I could put up with the surgeons’s egos, but not those of the emergency room doctors.

While he did, I called the police station. I asked to be transferred to the desk sergeant. After introducing myself, I told him that the surgeons thought Jose Garcia had some internal bleeding. “Exactly what did happen when the officers brought him in?”

“Well officers Peterson and Martinez brought him in quite intoxicated. He had handcuffs whose ends were joined at his back. At the desk, he mouthed off to them. They tightened the bracelets that were behind his back. When he mouthed off again, they took him outside and talked to him. About a half hour later he was complaining so much about belly pain that we sent him your way. He was crying and moaning like a little kid who’d been in a fight.”

“He was,” I reported to the desk sergeant. They beat him up enough to cause internal bleeding. He’s in surgery right now.”

“There were no questions on the other end of the line. The desk sergeant just hung up on me.”

They finished surgery at about nine-thirty. Hank called me when they finished surgery on Jose. He had one omental and two mesenteric bleeders in his belly. He might well have bled out in the emergency room. I related what the desk sergeant had told me.

In the morning, I went by the Surgical Intensive Care Unit. I always dreaded going in there. More likely than not, Martin Gittes, who was the surgeon in charge of the ICU would throw you out of the unit if you were not a surgical resident. He detested internal medicine residents who had the temerity to encroach on his territory. Hank reassured me that Jose was doing relatively well. To see him through surgery, the surgeons administered four units of blood.

On Monday morning, just as we were finishing with rounds, I pulled Pete Anderson aside before he went to sign off on all the charts. He was my attending physician that month on the wards. I told him Jose’s story. I asked what I should do. There had been a spate of protests against police violence ever since I had been an intern. He said, stroking the fluff of mustache surrounding his mouth, “I wouldn’t mention anything about it. It wouldn’t hurt to tell administration and let the hospital attorney know.

I went up to the administrator’s office, to meet Barbara Hawkins, the hospital’s attorney of record. As I was ushered into her room, she told me that she could give me five minutes of her time. As I spoke, telling for the umpteenth time the story of the unfortunate Jose Garcia. “So your question is what,” she said rather pointedly.

“It seems like I have some place in protecting the patient and bearing witness to this clear physical violation.”

“Listen to me, Dr. Saunders…”

“It’s Spencer. What if it was your brother?”

“It wasn’t.” She shuffled some papers on her desk. “Well for now, just don’t say anything. If anyone from the press approaches you, you refer them to me. Now I need to finish up some loose ends.” Taking the cue I left her office. I didn’t even bother to thank her. It was people like Hawkins who allowed this absurdity of police bleeding to go on.

Each day he was in the hospital, I went by Jose Garcia’s room. He had no recollection of me, so after he had been in the hospital for about four days, I quite going by. When the day came for him to leave, I left him my phone number.

He never used it, though. I have no idea why he didn’t. He would have gotten a good settlement from the city and by my reckoning, would have rid the police department of two bad cops. But he didn’t. I’ll never know why.

It wasn’t a month later that I was in the UNM ER when the ambulance brought in an unconscious patient. He had been arrested for some reason. Using their billy clubs, the arresting officers struck him so hard over his head that he had a depressed skull fracture.

But Jose would go home. Never had I cared for the police in Albuquerque. This did little to change my mind.