As I sat this morning and knitted and listened to “This American Life,” my mind wandered pleasantly between the pattern of the stitches, the topic of the podcast (“Shouting Across the Divide”), and how nice it was to have Nala home to chew on my toes last night.

But the podcast ended, and I found myself reflecting on the fact that when I am called to the ER these days, it is never for anything hopeful. I am forced to find hope in my day job, my 8-5 outpatient job, because when all hands are called in to the ER, hope has already been lost.

A code green indicates that a disaster has occurred and that the ER staff is overwhelmed by the casualties from the situation. The van of immigrants that overturned was a code green. A code green means that the ER needs all the help it can get.

I was eating breakfast and reading The New York Times online, getting ready to leave for Flagstaff in 30 minutes, when I heard the hiss of my pager. “Code Green in the emergency room, Code Green in the emergency room….” This is a standard code call to all pagers — the color of the code, the location. Then the page continued.

“Please, we need everyone, anyone, here. Please come in.”

My hands were already shaking as I ran to put in my contacts, pull my hair back in a bandana, throw on some scrubs. I know what the sound of code greens are, and I could hear it ringing in my ears already. I heard the siren of the ambulance wail as I jumped into my car, as it screamed towards the clinic. I glanced at the EMS parking lot — empty. All three ambulances out.

I punched the button that opened the doors of the ER, and was instantly overwhelmed by the cacophony.

“His pulse is 134, O2 sat is 87 and dropping.”
“I need a catheter set now!”
“aaaaauuuuUUUUUGGGGGGHHHHHHHHHHHHHnnnnnnn….”
“Do we have any information on John Doe number one?”
“Kayenta Base, this is EMS 14, we are on scene, ETA to the ER is 20 minutes.”
“aaaaaHHHHHHHHHHHGGGGGGGGHHHHHHHH!”
“Classic will be here in 30 minutes, they’re sending two rotors!”
“Stop fighting me, man! You are all fucked up, stop fighting me, let me help you!”
“nnnnnnnNNNNNNNNNNNNOOOOOOOOOOOOOoooooooo!”

There were five victims in the ER. Two were walking wounded and stable, holding bandages to their cuts. One was stable and on a backboard, and had been left alone on his cot to simply wait.

Two men were critical and dying. Both exhibited agonal breathing, which sounds like a combination of gasping and screaming at the same time — the lungs have been traumatized, and the body is fighting to keep breathing. It rattles and echoes and adds a whole level of psychological torment to the atmosphere.

“Martha, get me a catheter set!” yelled one of the experienced trauma nurses. I went to work. I fetched equipment, dug through the carts for ambu bags, charted Critical Two (the less-severely injured man) as he went through RSI, Rapid Sequence Intubation. One nurse was bagging him, another starting a second large-gauge IV, and two of our flight paramedics started the intubation. “5 versed, 9 vecc, 100 lidocaine, 5 fentanyl, 160 succs…” came the chant from the man pushing the paralytic IV drugs. I called back everything and wrote it down. They tubed him on one, and one of the sets of agonal breathing stopped as we began to breathe for him.

Critical One – the most severely injured man – was still moaning. His eyes were completely rolled back in his head. He was bleeding from his penis, indicating a pelvic fracture that had punctured his bladder. His pulse was racing, his O2 sats lousy, his BP dropping. The lead clinical nurse was fighting to get an IV line started. “Start pulling his RSI drugs, I want him ready to go the minute we have access!” yelled the doc. The night nurse, my old preceptor, who had finished her shift 45 minutes earlier and had been deeply asleep for twenty when her pager went off, started pulling drugs into syringes, her eyes hollow and empty.

One of the secretaries stood up. “EMS will be here in two minutes, they’re bringing a Code Blue – she isn’t breathing!”

It was a car accident. Car accident. It sounds so simple and straightforward. People have car accidents all the time. It happened right here in town. I still don’t know what happened — I was too busy with the patients to follow the EMTs and the docs and the police as they tried to piece together what happened, but I overheard bits and pieces of it.

There was a large pickup truck and a sedan. The passenger of the pickup truck grabbed the wheel from the driver, the truck swerved, t-boned a sedan at highway speed, and the truck flipped. The sedan was pancaked, its wheels out from the frame at a ninety-degree angle. There was alcohol involved. Nobody was wearing a seatbelt. The sedan was full of people. When the truck flipped, the passenger was only partially ejected through his window before the truck landed on him, killing him instantly.

Did the people in both vehicles know each other? Were the people in the sedan drinking? Were they racing?

I don’t know. I just don’t.

The EMS crew came running through the back door with a victim on a stretcher. “She’s not breathing; I tried to tube her in the rig,” yelled the lead paramedic as they ran the cot over to an empty and waiting bed. The high level nurses and all the docs ran to the bed to transfer her and begin CPR. I and the techs and two other nurses stayed with Critical One and Two, bagging them and keeping them alive while everyone tried to save her.

I glanced over for a moment. I saw one of the EMTs doing chest compressions, the strength of his arms making her whole body jump with each compression. I saw another tech cutting the victims clothes off to assess for injuries. The victim was wearing teal underwear. For some reason these weird little details stick out in my brain.

I charted another BP on Critical Two, checked his sats, conferred with the air flight crew, heard the whump-whump-whump-whump of helicopters as the critical care transport crews landed in the clinic driveway.

I glanced back at the cot — and the commotion over there had stopped. And my brain said, “Wow, they stabilized her!” And at the same time, my eyes processed the sheet that had been pulled over her head. She was dead.

Critical Two was the first out the door to the helicopter; he was flown to San Juan Regional in New Mexico, about a 45-minute flight away. Critical One was a difficult intubation; there was a lot of blood in his airway, and the doc determined that he had a hemothorax — his lung had been punctured internally, and he was bleeding out into his lungs. The doc and the transport crew fought to insert a chest tube. It’s not a terribly technical procedure. You take a long, sharply pointed metal rod, jam it between two of the lower ribs into the shrunken, soggy lung, and insert a wide plastic tube into the hole and hook it up to intermittent suction. Blood poured onto the cot, the floor, then into the tube, into the collection container.

He was stabilized 20 minutes after the chest tube went in; and went off in the helicopter to Flagstaff Trauma, with four units of blood pouring into his veins to keep him alive. Trauma care is all about stopping the clock long enough to get to surgery. Nothing that any on-scene trauma team can do will keep someone alive if there’s some vessel ripped and bleeding out inside. Only a surgical team that can work fast can sew it up.

Just before Critical One went out the door, we got a call that the last victim from the accident scene was being brought in to the ER — the driver of the pickup truck. We were running out of room, and so we pushed the cot with the dead body halfway into the bathroom, and cleared a space for the last victim. We have a morgue here, but the body had to be held for the Criminal Investigation team to arrive from the scene.

The driver was brought in, tied and taped to a backboard, fighting and screaming. He had been trapped in his truck for over an hour, next to the dead, crushed body of his friend, the passenger.

“Let me GO! Let me DIE! Let me DIE WITH MY FRIEND! Fucking let me go, you motherfuckers! Let me fucking DIE!” He screamed and cried constantly on the board. His blood alcohol level was 281. His blood pressure began to drop, and we realized he was probably bleeding internally as well. We sedated him, paralyzed him, tubed him, and sent him with the fixed-wing crew to Phoenix, along with the other man on the backboard, who had been silently waiting on his cot for the past two hours, listening to us fight the battle to save his friends.

Trauma staff deal with this by doing their job — that is, this is just another day at work. It’s a shitty day at work, no doubt, but just another day. As we intubated patients, shoved plastic tubes into their bodies, pushed IV fluids and drugs, the conversations flowed above and around the patients among the different crews gathered.

“How was your vacation?”
“Hey, have you seen that new movie?”
“You know, I heard that she moved out of town — hey, can you grab me more gauze?”
“So, Martha, when are you coming back to the ER crew?”

Pained smile. “Ha ha ha. Good one, Peter. Tell me another.”

The only time this conversation ceased entirely was when they tried to save the girl. After we pushed her into the bathroom, one doc known for his stoicism walked away, shaking his head in disgust and disappointment. One of the crew from the fixed wing team walked over and lifted the sheet to look at her. The crew member shook her head, and pointed to the curtain where the driver was being stabilized. “I hope he fries for this. I hope he fucking fries.”

Health care is done on a need-to-know basis. I don’t just go into medical records and read random charts. If I’m not working on a patient, I don’t need to know about them. Naturally, this standard is broken on a regular basis as one nurse decompresses and talks to another, but doing something as obvious as looking at a dead person, when there’s other people to be cared for, is pretty egregious.

But I couldn’t stop myself. In a lull, I walked to the bathroom. I stood next to her head, and lifted the sheet. She was younger than me. Her face was smooth and unlined underneath the rivers of blood that had flowed over it and dried there. She had bled from her nose, her ears, her mouth, from the multiple wounds on her head and neck; her hair matted to her skull by blood. Her skin was already the waxy yellow of death. The endotracheal tube was still in, the end still sticking out of her mouth. I wanted to pull the ETT tube out, and wash her face and her hair, to clean her before someone came to identify her. I thought back to my work in nursing homes, in hospice care, where death is welcomed with dignity and readiness, a clean bed and a clean body and a soul ready to leave. And realized I was witnessing the opposite.

This young girl had woken up yesterday, put on teal underwear under her jeans and gone out with friends.

Her body was now evidence in a criminal investigation, and I could not touch her.

When another doc brought a man in from the waiting room, and lifted the sheet, the man stated her name, and began to sob.

When the ER was clear, I left and went to the trading post to get donuts and OJ for the day crew that had just started their shift in this horrible way. I came back, and one of the techs was outside with the cot of Critical One, spraying off the clots and rivulets of blood with a garden hose.

I went and got my dogs.

I went to a friend’s house and had dinner.

I slept for fourteen hours, and had nightmares about my wedding (“oh my gosh, it’s only three weeks until the wedding day? We haven’t sent the invitations!”).

And now…well…I guess this is how I decompress from these things. I write it out, read it a few dozen times today, fill in the spaces between the words with the sounds and smells and images that I can’t possibly transmit onto paper.

And knit. And listen to This American Life. Drink hot chocolate. And remember to be kind to myself. It’s a bigger task than you think.