A warning to readers: Along with the standard Canticle fare of death, obscenities, and substance abuse, this post also includes a reference to a childhood sexual assault.
The doctor had his fingers pressed to one side of her neck. I had my fingers pressed to the other side. I don’t feel a pulse, I thought to myself.
“I don’t feel a pulse,” said the doc. “Start CPR.”
I locked my hands together — “Someone get the code cart,” I called over my shoulder — centered them over her breastbone, a little lower than I would have liked — someone placed the V lead wrong — and shoved.
On the first compression I felt the cartilage connecting her ribs to her sternum begin to give way. pop. pop. pop. Less than a second later, on the second compression, the rest of the costochondral joints disconnected under the pressure from my arms, crunch-crunch-crunch.
From the third compression onward, I felt nothing.
On younger patients, the sensation is sharper under your hands, the cartilage more elastic, the ribs stronger. It sounds like a gunshot as the patient’s chest breaks. It can take half a dozen compressions to finally separate the sternum from the ribs and allow the full force of the compressions to squeeze the heart.
But on a patient in her eighties – as she was – with a body already failing, already worn from time and illness, it took less than the space of a breath. It was rice krispies under my fingers. It was bubble wrap under a shoe. snapsnapsnap gone.
I hadn’t made it past the tenth or eleventh compression when the triage nurse came racing into the room, followed closely by an elegant woman in her 60’s, wearing a light blue suit. “STOP-STOP-STOP!” yelled the nurse. “She’s a DNR!”
“She’s a DNR,” echoed the elegant woman, staring in shock at her mother lying on the bed.
I literally threw my hands in the air and jumped away from the patient. I lost my balance and staggered backwards into the monitor on the wall. I planted a hand on the nurse server and glanced again at the daughter. She was motionless in the doorway.
And in the weirdness that occurs when stressful things happen too fast, too automatically, my brain processed the wrong thing first, and I thought to myself:
That’s a beautiful suit.
I’m sorry I broke your mother.
~ ~ ~
The word “break” is an interesting one. Your standard ER nurse will immediately think of a broken bone, he broke his tib-fib on the left, the x-ray shows a break at T5. You can break your spleen, although we call it a fracture or rupture. You can also break your penis – if you’ve got one – although it’s technically a vascular injury. I’ve learned to never make the joke about a “broken bone” in that situation unless the patient says it first (which occasionally happens after a generous dose of morphine).
But when we put the verb break into the past participle, broken begins to carry the connotation of duration, and perhaps permanence. It is no longer something simply physical, something that can be repaired in the operating room. It is the rare human amongst us who has not suffered a broken heart. He broke his promise to me. We speak of creatures with a broken spirit. Her will has been broken.
And yet interestingly, the noun break has a positive connotation, at least in my ER. All right, I’m heading out on my break, see you in an hour. It is an interruption, a pause in the flow, a welcome relief from running at full-speed for eight or ten or twelve or fourteen hours.
Of course, an interruption is not always positive. We’re taking a break from our marriage.
So what happens when the noun and the verb occur simultaneously?
What happens when transience and permanence collide?
~ ~ ~
When my patient started to stir from his drunken stupor, I wandered over to his bed in the hallway of the ER and struck up a conversation.
Do you know where you are? Yes. Do you remember what happened? Not really. Do you usually drink this heavily?
And then he started to cry.
I dropped the side rail of the bed and sat down next to him. What a strange tableau we must have made. Average-size blonde nurse, scrubs and sneakers, purple hospital gloves. Six-foot-plus inebriated man, heavily bearded, a dozen years younger, sobbing openly. He talked. I listened. After ten minutes or so he calmed down and I got called away to help someone else. He curled up again on the cot.
But over the next hour things slowly and steadily began to change. His crying fits happened more and more frequently. He became more and more restless, flinging himself from his front to his back, from side to side. He whispered to himself. Then I glanced up and realized he was tearing the pillowcase apart with his teeth.
I rose from my chair, and at the same time he sat bolt upright in the bed and yelled, “HOW DO I GET THE FUCK OUT OF HERE?”
Alarmed, I walked over to him, and rested my hand on the siderail. This was not the reasonable but emotional patient I had chatted with an hour earlier. “David, what’s going on, man?” I said, quietly.
He didn’t look at me. His face flushed bright red, and he screamed, “WHOSE DICK DO I HAVE TO SUCK TO GET OUT OF THIS PLACE?”
And then, in front of my eyes, he broke.
It was as though I had dropped a teacup, and was watching it fall in slow motion.
It slipped from my hands.
David tensed all of his muscles.
It rushed towards the ceramic tiles of the kitchen floor.
Sweat broke out on his forehead.
I reached for it reflexively, missed catching it by millimeters.
He began to hyperventilate.
It shattered into a million pieces at my feet as I stood by, helpless.
“YOU THINK I ASKED TO BE RAPED? YOU THINK I WANTED THAT? YOU THINK A SIX-YEAR-OLD WANTS HIS GRANDFATHER TO FUCK HIM?”
I had never heard someone shout so loudly. It reverberated throughout the ER. I stood by the bedside, frozen. Out of the corner of my eye I saw a nurse hit the button for a Security Code. Another headed to the supply cart to grab a set of restraints.
“YOU FUCKING NURSES HAVE ALL THE ANSWERS, DON’T YOU? YOU ALL THINK YOU’RE SO SMART BECAUSE YOU HAVE VAGINAS? YOU DON’T HAVE THE ANSWERS, FUCK YOU!”
A part of my brain braced for him to hit me. I was ready for him to reach out and grab me by the throat, to close his fist and hit me in the face, to strike out with a foot and catch me in the chest. I had been kicked in the chest by a patient before, many years ago, a patient half his size. The blow had sent me flying backwards across the room, where I crashed to the floor, tangled in a metal bedside table. A kick from David would break my ribs.
“THAT’S RIGHT, LITTLE KIDS GET FUCKED HERE IN THE UNITED STATES, AND WE JUST HAVE TO TAKE IT, WE JUST HAVE TO TAKE IT TAKE IT TAKE IT!”
And with that, he threw himself backwards onto the cot, and began howling with agony.
I saw my chance, and kicked the bed out of lock and into steer. I rolled him, on his cot, into the seclusion room, trailed by half a dozen staff members and security personnel. He continued to scream and curse and rail, some of it nonsensical, some of it painful and raw in its honesty. But he never struck out at me. He never struck out at any of us. He didn’t fight us as we locked his wrists and ankles to the frame of the bed.
Once he was safely secured I leaned against the wall, shaken. David wept, shackled, unable to wipe the snot from his nose or the tears from his eyes or the spit from his beard. I waited for a few moments, just breathing. Then I walked again to the side of his bed. He opened his eyes a fraction of an inch, all that he could manage, red and swollen as they were.
“David, do you want me to sedate you?” I asked, quietly.
Whispering, he nodded. “Yes. Please.”
I gave him a cocktail of sedatives and anti-psychotics, injecting it deep into his thigh. He didn’t even flinch as I darted the needle in. I closed the heavy metal door of the seclusion room behind me, and at the nurses station I turned on the video monitoring that would allow us to watch him from the desk. Every few moments we could hear him scream and shake his restraints, and then we saw his body tremble as he cried.
I logged onto a computer to begin the complicated charting that accompanied any use of the locked restraints on a patient, trying to distract myself from how very deeply the episode had affected me. Another nurse came and stood next me, and together we watched the monitor in silence for a few moments.
She shook her head. “Man. That broke my fucking heart.”
~ ~ ~
There isn’t a splint or a cast that immobilizes the fractured heart, allowing it to heal over the next six to ten weeks. There isn’t a laproscopic surgery to cauterize a bleeding soul.
There is no suture fine enough to reassemble the fragments of a shattered mind, to hold them closely enough for scar tissue to form in the fissures, to bring a person back to a close-enough approximation of who they were before IT happened.
And if we bear such a terrible injury while knowing that there is no cure, some of us search for relief anywhere we can find it.
~ ~ ~
“Number thirty-two?” I called out to the waiting room.
A woman rose from a hard plastic chair, her clothing dirty, her hair knotted and gnarled, her face pale and worn and tired. She looked ancient. I knew from checking the computer that she was forty-five years old.
“How are you doing today?” I asked as we walked together down a short hallway, and into a conference room.
“Not so good,” she replied.
I stopped in front of a large metal tray sitting on top of an enormous red plastic biohazard container. “I’m sorry to hear that,” I said, picking up a pair of long metal tongs. “What’s going on?”
She dropped the huge purse she held onto the floor, and began to unzip the top. “My boyfriend got picked up last night, and he’s back in jail,” she said, her voice catching on the last word. She took a deep breath, regained her composure, pulled out a bulging purple Crown Royal bag from the depths of the purse, and upended it.
Dozens of used needles spilled out across the metal tray.
In silent partnership — she nimbly using her hands, me using the tongs — we started to count them into piles of ten.
The needle exchange is open for three hours once a week. We see about 80 people during the exchange, and more than half of them exchange 100 used needles for clean ones — the maximum we allow per person per week.
In the most conservative sense, we pull more than 4,000 dirty needles off the streets every time we’re open. I have no doubt that the actual number is vastly higher. But more importantly, our clients re-use their needles much less often, leading to fewer abscesses, infections, and critically-ill septic patients showing up at the ER. They also don’t have to share their needles — or the rampant Hepatitis C that frequently accompanies it here in the county.
But my father and I sat at the dinner table one night and did the math.
“So a person brings in 100 used needles every single week. That means that they’re using fourteen needles a day. Let’s say they sleep eight hours a day, that means they’re awake for sixteen.” His face fell as the numbers came together.
I nodded. “At 100 needles a week, they’re shooting up once an hour.”
“Every. Single. Day.”
We counted sixty needles from the Crown Royal bag.
“Hang on, I have more,” she said, kneeling on the floor next to her purse.
“Take your time,” I said softly, and I meant it. I would wait as long as it took.
She found an eyeglasses case, and opened it, and pulled seven needles out, placing them on the tray. I quietly kept the count, and she began to talk as she searched.
We’re living in a trailer out in his brother’s yard. She unzipped an inner pocket and pulled out four needles. There’s no water or electricity, but the roof don’t leak and it’s safe there. She opened a large wallet, and pulled a needle out of the crease. But his brother don’t like me, and if he’s back in jail then he’s gonna kick me out. She opened a plastic container originally designed for baby wipes. Inside was a half a soda can, a lighter, and twelve more needles. I ain’t got no money and I ain’t got nowhere else to go.
She was crying now, and would stop digging through the purse sometimes to wipe her eyes. He’s all I got in this world; he’s a good guy, he ain’t never hit me or hurt me. She opened a small notebook and pulled a needle from between two pages. And I love him so much, and if he goes to prison this time I ain’t even got a way to go see him. She pulled an uncapped needle from the purse, the inside of the barrel dark with oxidized, congealed blood. I don’t got no idea what to do now. I just don’t.
Finally, as she neared the bottom of the purse, she pulled a final needle out and dropped it on the tray.
“One hundred,” I said. “Go ahead and dump them.”
She tilted the metal tray and the needles clattered down, a cascading orange and black waterfall, settling onto the skeletons of hundreds of others already in the biohazard container below.
I gave her a box of clean needles, clean water, clean cookers, clean cottons, a clean tourniquet, a few bandaids, a few alcohol wipes. I offered her a brochure for a women’s emergency shelter, as well as that of the homeless shelter here in town, but she waved them away.
“I’ll figure something out,” she said.
I nodded. “Good luck. Please take good care of yourself.”
“I will. Thank you.” And as she stepped out the front door and onto the sidewalk, she disappeared from my view, lost amongst the flow of humans rushing along in the autumn rain.
~ ~ ~
There are broken things in this world that cannot be repaired. For all the advancements of modern medicine in the past twenty years, for all the highly technical equipment I have at my disposal, for all the unimaginable skill in the fingertips of a surgeon, there are still things that bloom solely in the realm of death, and we are not invited there.
But we do ourselves and our patients a grave injustice if we automatically assume that “broken” equals “irreparable.”
And just because I myself cannot fix it, it does not mean that it is not fixable.
This is the great vanity – and the greatest danger – of the ER.
I cannot fix your addiction. I cannot heal the break that led you to the tip of the needle. But you are not irreparably broken.
I cannot fix your psychosis. I cannot re-balance the chemicals in your brain that leave you in such misery. But you are not irreparably broken.
I can’t fix it. But I can be kind.
And sometimes kindness is the hardest thing to give someone, especially someone who is cruel, manipulative, angry, violent, broken. I fail at this frequently, have to step back, reset my brain, and try again, because it matters. It matters to me to get kindness right.
Because within every act of kindness is the smallest, faintest glow of hope.
And hope is where healing begins.
~ ~ ~