Part I: Land

The phone at my hip rang.

“They’re wheeling a Level Two back to room six right now,” said the triage nurse. “Chest pain, shortness of breath.”

“All right,” I said, turning on my heel and heading down the hall. My mind was already spinning up, planning my next steps.

“FYI – the last time she had these symptoms it was a pericardial effusion, and they rushed her to IR to drain it.”

I raised my eyebrows at that one. “Nice change of pace from a typical MI. Thanks.”

“May the force be with you,” said the triage nurse, and hung up.

~

She was a petite lady, late middle age, well-dressed, hair and makeup flawless, obviously from money. She had three female friends with her, an equally well-heeled entourage. They were displeased when I halted them halfway down the hall.

“I’m going to need some space in the room to get her settled and assessed. After the physician sees her, I’ll bring you all back in.”

Their faces made three identical moues of distaste. I bitch-smiled all the way to her room, and shut the door.

There were patients in the city that lived on the hill, and patients in the city that lived under the freeway. I was not terribly skilled at hiding my preference.

~

My tech had already completed the EKG and placed the patient on the monitor. I glanced at the reading – no ST-segment elevation, no T-wave inversions, a surprisingly normal read. Blood pressure, normal. Heartrate mildly elevated, but she was obviously in pain, and breathing a little quickly to manage it.

“It just hurts everywhere,” she said, bracing herself against the bed. “It’s like my bones ache from it.”

“All right,” I said, pulling my stethoscope out of my pocket. “Let me take a quick listen, and I’ll go get the doctor and see if we can get you some pain medication.” I wanted to listen to her heart, to see if there were any murmurs, squeaks, rubs, hushes, the weird and alien sounds a heart makes when it’s drowning.

I popped the stethoscope in my ears, and she leaned forward, wincing in pain. Left lung, clear. Right lung – I paused, and moved the edge of the gown a bit. There, stuck to the skin over her right scapula, was a fentanyl patch. I frowned, confused.

“Go ahead and lean back,” I said. I unsnapped the shoulder of her gown, and started to pull it down. “Let me take a quick listen to your heart –”

And with the bell of the stethoscope in my hand, I froze, staring at her right breast. The skin over it was puckered and twisted, knotted around the marble-sized masses underneath. The nipple was inverted, the areola pulling viciously to the right. It was half again the size of the left breast, swollen and deformed.

Out of habit, and nothing else, I placed the stethoscope over her breastbone, but I had already stopped listening, and I didn’t hear a thing.

~

“….radical mastectomy is strongly suggested. Patient states she is terrified of the side effects of anesthesia and fears post-operative pain. States she is not ready to consent to surgery at current time…”

“…patient is highly educated and aware of the lethality of this diagnosis, however, patient expresses extreme fear of the side effects of chemotherapy, and wishes to pursue alternative treatments…..”

“…she has recently returned from California, where she underwent intravenous vitamin infusions, concentrated oxygen therapy, and morning and evening meditation sessions. Patient also states that she was able to choreograph and perform her own interpretive dance for the community, and felt that the masses her in breast were noticeably smaller afterwards. Patient appears optimistic and positive here today…”

Clicking quickly through her electronic health records, I scanned over dozens of entries from the oncology center, horrified. It read like a terrible novel, like a joke from a late-night movie about healthcare scam clinics in Mexico.

I had never read such thorough, highly-detailed narrative notes. Every single healthcare provider that had ever interacted with her had over-charted, emphasizing again and again that they tried to balance respecting her wishes with conveying the gravity of her situation. It was, over and over, a brokenhearted CYA.

The resident and the attending came out of her room together. The attending looked stunned. The resident looked like she was going to cry.

“Give her Dilaudid,” said the attending, steadying herself with a deep breath. “A lot of it.”

~

I walked back into the room, syringes full of medications in my hands. I opened the door, stepped inside, closed it quietly behind myself. I glanced up at her. She was wrapped in a blanket, eyes closed, her head back, breathing slowly and deliberately through the pain. One of the entourage was holding her hand, and breathing with her, like a midwife coaching a woman through labor.

The other two members of the entourage eyed me. Distrust and defensiveness permeated the room. I suddenly realized that they weren’t her entourage, they were her bodyguards. She no longer had the strength to ward off the medical establishment on her own, to hold at bay the tidal wave of world-class doctors and nurses in the city desperate to stop her from deluding herself to death.

“…patient now using high-dose fentanyl patch as well as oral narcotics. Patient not willing to undergo PET scan, but based on pain complaints and symptomatology, it is assumed that bone metastases are present and widespread. However, patient still unwilling to undergo either surgical or chemotherapeutic treatments due to fear of side effects….”

“…patient repeatedly states during this office visit that she still feels that she is beating the cancer, and that she will live…”

For the second time in my career, I stared at a patient, and saw her future. It was equally as bleak and hideous.

But there was nothing I could do to stop it now. It was not my place to try to ‘convince’ her to take aggressive cancer treatment; that had been tried by dozens of professionals vastly more qualified than I. It was not my place to chastise or shame her for her choices; the Janus-coin of free will means repercussions come with our decisions, and adults are allowed to spend that coin in any way they choose.

The one and only thing I could do was to make this one ER visit a little easier.

I tucked away my bitch-smile, regretting having used it, as I always do. The patient opened her eyes and looked at me, guardedly, bracing herself. The smile I gave her and the bodyguards was genuine this time. The tension in the room lessened a fraction.

I gestured to the syringes in my hand. “I brought you some pain medication.”

~ ~ ~

Part II: Sea

By the time a good Samaritan fished him out of Puget Sound and hauled him back onto the dock of the marina, Alan had been in the water for nearly 20 minutes, splashing and gasping, working desperately to keep himself from drowning.

My team jumped into action the moment the paramedics rolled through the door, transferring him smoothly to the ER gurney, replacing the heavy wool blankets from the ambulance with a Bair Hugger blanket preheated and roaring away. Another nurse dropped in an 18-gauge IV, and fired up the fluid warmer, infusing a liter of warmed normal saline every hour.

We worked quickly underneath the Bair Hugger, and inserted a foley catheter with a temperature probe into his bladder. His body temperature was 31*C.

He was so cold that his muscles were spasming, his arms folding up at the elbows, jerking in towards his body in an eerie mimicry of decorticate posturing. The spasms were excruciating, and he cried out in pain every four or five seconds. I fought my way to the head of the bed, and laid my hand on his forehead. His long grey hair was wet and tacky with salt water, his skin the bluish-purple tinge of acute hypothermia. He smelled strongly of alcohol.

“Alan, look at me,” I said, and lightly tapped his forehead with my thumb. He kept his eyes screwed tightly shut, crying out again as another violent spasm shook him. I laid my other hand on his upper arm, waiting. The spasm stopped, and I was reassured by the fine, constant shivering I felt beneath my fingers. He was cold, but he wasn’t so cold that he could no longer shiver. He’d been fished out in time.

“ALAN,” I yelled, and his eyes popped open. They were a shocking pale green. His eyes met mine, and he saw me.

“My name is Martha, I’m one of the nurses. I’m going to take care of you, ok? We’re going to get you warm and keep you safe, all right?”

He nodded jerkily. “OK. Thank you,” he mumbled, and started to cry.

~

He slept for hours after he started to get warm. His lactate came back at 10, a result of the prolonged spams, so we dumped more warm saline in him. His alcohol level came back over 400.

When his call light went off around 2 in the morning, I walked up to his bedside to find him giving me a slightly horrified look.

“What’s up?” I said, concerned.

“Um,” he said, his voice tremulous. “Um. Is there…..something in my dick?”

I grinned at him. “Yep.”

He nodded slowly. “OK.” His eyes met mine again, the expression of a desperate man. “Can you take it out, please?”

~

We chatted for a little while after I removed the foley. He was still heavily intoxicated, but he was friendly in a cynical, rough-edged way. He was normothermic again, and I turned off the Bair Hugger. The room reverberated with silence in its wake.

“How much do you drink everyday, man?” I asked him, leaning against the siderail of the bed.

“Well, you know, probably a six-pack or so,” he replied, glancing at the wall over my left shoulder.

I gave him a sour look. Every drunk has their ‘standard’ answer to that question. Some will cop to a twelve-pack, some will cop to a fifth of vodka. Nobody will admit the truth.

“Don’t bullshit me, Alan,” I said, but not in an unfriendly way. We were simply players in a scene we’d rehearsed a dozen times; the nurse asks the question, the patient lies, the world keeps spinning. “Your alcohol level was over 400. You don’t get there from a six-pack.”

“Yeah, well, we did some vodka shots, too,” he said, and I knew it was as close to the truth as I was going to get.

“This shit’s going to kill you, drinking like this. Your liver’s going to go at some point. It’s a pretty shitty way to die,” I commented casually. I was willing to make one effort with every patient. Why do you drink so much? Why do you stick a needle in your arm? Why did you swallow the whole medicine cabinet? What are you running from?

To my surprise, Alan laughed a little bit, his green eyes squinting up at me in amusement. “Did you guys check my liver today?”

I nodded.

“And was it normal?”

I nodded again. His labs, other than his lactate and his alcohol, were shockingly normal for a heavy-drinking fifty-something-year-old man.

“That’s the thing,” he said. “My liver’s always ok. They always check it, and it’s always normal. Everything is always normal. Nothing’s wrong with my body. I could probably live to 100 if I wanted to.”

And then he shrugged, and the amusement in his eyes faded, and he held my gaze. “But I don’t want to. I just keep drinking because…living….you know, it just…..it just doesn’t really matter to me.”

I raised an eyebrow. “You wanna kill yourself?”

He shook his head vehemently. “No, no. Nothing like that. But, you know, tonight? If that guy hadn’t come along, and I’d drowned in the Sound?” He looked at me, watching my face to see if I understood.

I nodded slowly this time. “It would’ve been ok, wouldn’t it?”

“Yeah,” He sighed, relieved, and his eyes drifted shut. “It would have been ok.”

~

The doctor walked up to me with Alan’s discharge papers. “He’s good to go. See if you can convey to him how lucky he is that he’s not dead tonight.” He gave me a cynical smile, and walked back to his computer.

I glanced down at the printout.

“YOU MUST STOP DRINKING ALCOHOL. YOU HAD A LETHAL LEVEL IN YOUR BLOOD TONIGHT, AND IT COULD HAVE KILLED YOU. PLEASE SEEK COMMUNITY RESOURCES TO ADDRESS YOUR ALCOHOLISM.”

I sighed, and walked into Alan’s room. He was sitting on the edge of the bed, his hair sticking out wildly, his ruddy face and nose laced with an intricate web of thread veins. He was dressed in a pair of dry sweatpants and sweatshirt that we gave him from our supply; his own clothes were still sopping wet, tucked into the plastic bags where the paramedics had stashed them.

I looked at the printout in my hand again, and then quickly folded it into quarters, and shoved it into the bag with his clothes. I watched as the seawater from his jeans soaked into the paper, the ink dissolving letter by letter, smearing into a wash of grey.

There was nothing printed there that Alan didn’t already know.

I clapped him on the shoulder. “Get out of here. Try to drink some water along with the vodka tonight.”

He grinned. “You’re a funny lady.”

And as he walked out through the ER doors, the dark of the winter’s morning submerged him once again.