In From the Cold

Part One:  Hands

Someone had already turned the lights down in my patient’s room, a small but noble attempt to minimize the stimuli surrounding him.  The ventilator next to the head of his bed sighed and breathed, the triple-stack of IV pumps on the other side of the bed whirred and clicked, the monitor on the wall glowed yellow and bright in the dimness.

In an unintentional renaissance, he presented the classic tableau of an ICU patient in the ED but for one notable exception:  his hands, extended awkwardly away from his body, were immersed in two pink basins of warm water.

As I had been driving to work, fighting a January snowstorm alongside the appalling evening rush hour traffic, a passerby on a city street noticed a strange shadow in a snowbank.  They edged closer to find, to their horror, that the shadow was a man lying facedown.  Paramedics arrived to find him unresponsive and barely breathing.  He reeked of alcohol, and beneath a filthy jacket he wore nearly half a dozen layers of mismatched clothing.  A hat covered his head, a scarf covered his face, and his socks and boots had protected his feet.  But his gloves were gone.  And his hands were icy and shockingly white.

He was intubated by the medics and stabilized in our trauma bay.  His CT scan showed no head injury, and other than being severely hypothermic, he was remarkably stable.  They moved him out of the bay as I walked into work.

The intensivist resident was in the room as I walked in.  She glanced at me.

“Drunk, homeless, facedown in a snowbank, went down with hands outstretched?”  I asked.

She nodded.  “Plastics and ortho will deal with the hands tomorrow.  I can probably get him off the vent when he’s warm.”  I looked up at the monitor.  A foley catheter with a temperature probe had been inserted into his bladder, and his core temperature reading was still dangerously low.  She sighed.  “Go ahead and warm him up with tap water in the NG.”

I blinked.  Blinked again.  “What?”

This time she looked directly at me.  “Warm tap water?  Into his NG?”

I shook my head.  I’d never heard of such a thing.

“Simple.”  She pointed to the sink.  “Warm water, not hot.  Push it through the NG tube, maybe 300cc at a time.  Let it dwell for a bit, then suction it back out.  Then do it again.”  She grinned at my startled expression.  “Watch the core temp when you do it.  You’ll be surprised.”

~ ~ ~

I attached the end of the 50cc syringe to the end of the NG tube, and tentatively pushed the water through.

An NG – nasogastric – tube is a slender, flexible plastic tube that is inserted through one nostril, passed down through the sinus cavity and the back of the throat, threaded into the esophagus, and finally settled with the tip in the center of the stomach.  A small opening at the end of the tube in the stomach allows air and gastric contents to be suctioned out.

Keeping air out of the stomach keeps it decompressed, an important step when someone is mechanically ventilated.  A stomach distended with excess air — usually from bagging during resuscitation — can push up against the diaphragm, compressing the lungs.  A stomach full of partially digested stuff — in this case, alcohol — can regurgitate those contents back up the esophagus, and they can sneak down the trachea into the lungs, causing pneumonia.

But in this case, instead of pulling stuff out of the stomach, I was putting stuff in.  I felt the cognitive dissonance frisson down my spine.

I repeated the warm water push, again and again.  Finally, 300cc later, I stopped, put the syringe down, and waited.  I glanced at the monitor.  His core temperature hadn’t changed.

In the dim light from the equipment I glanced down at the basin nearest me.  His right hand floated just below the surface, a silent unmoving creature of the sea, dark and blurry as the water gently vibrated with my movements against the bed.  I looked up at my patient.  He was deeply unconscious, sedated, his eyes closed.

I gave in to my curiosity, and raised his arm out of the bath.

~ ~ ~

It was a terrible sight.

The hand was monstrously swollen, nearly twice its normal size.  The flesh of the hand was raggedly open in a dozen places, raw and weeping, a deep fiery red.  The skin had split and splintered, hanging off in thin strips.

On the cellular level, we are all mostly water.  And when water freezes, it expands.  And when the water in the cells of our body freezes, it expands so much that the cell cannot stretch enough to contain it.  The cell wall bursts open, destroying itself in the process.

It is frequently irreparable damage.  It is the reason that the men and women who climb the highest mountains in the world will come back missing a toe, a finger, an earlobe, their nose.

You cannot re-form hamburger meat back into a steak.

I sighed, and gently placed his ruined hand back into the warm water in the basin.  I looked at him, and wondered, fleetingly, of his life.  To be homeless, and sheltering yourself from a frigid northern winter with seven layers of clothes.  To be alcoholic, and to drink so much that you cannot maintain balance, or consciousness, or both.  And to lose your gloves, just before you tumble into the snow, your hands instinctively outstretched to protect yourself.

I thought of the outreach crews in Milwaukee, driving from overpass to overpass, from park to park, begging the homeless men and women they found there to come to the shelter, just for tonight — the temperature was due to drop so low that they would not be able to survive a night in the cold.

I thought of a man recently found near that same city, curled under a blanket, a bottle of cheap liquor clutched in his lifeless, frozen hands.

And I thought of the man in a neighboring state who had also collapsed, drunk, in a snowbank along a highway.  The driver of the snowplow, working late in the night to clear the road, never saw him.

The edge of the plow tore him into pieces.

~ ~ ~

The monitor beeped softly, and I glanced up, startled out of my thoughts.  I focused my gaze and realized his core temperature had risen by several degrees Celsius.  I gave a mental kudos to the intensivist, and connected the NG to wall suction.

I had deeply personal reasons for disliking alcoholics, and had never been very successful at masking my distaste when forced to care for them in the ED.  But I had never wished them harm.  And I had certainly never wished for them to be so terribly maimed as this man was doomed to be.  I knew — and still know — nothing of orthopedics or plastic surgery, but I knew that short of a miracle his hands would likely be amputated in the coming days.

The suction canister on the wall sputtered as the last of the water was pulled from my patient’s stomach.  I disconnected the NG from the vacuum, picked up my 50cc syringe, drew up more warm water.  I knew I was helping to save his life, albeit at an unimaginable cost.  But there was nothing I could do to change his past, and the movements and motions of his future were – ironically – out of my hands.

So I did the only thing I could.  I pushed the water into the NG, and slowly warded off the cold.

~~~~~

Part Two:  Heart

My friends and I sat crammed into a booth at one of our favorite breakfast joints.  Two of us had just finished 12-hour night shifts, and two of us were smugly describing our respective night off (primary activity: sleeping).  Coffee was poured, sugar packets passed around, orders placed for eggs, pancakes, omelets, french toast, bacon, sausage, hashbrowns.

We had all once worked together in the same ED, and although life and the passing of time had seen us all move on to different jobs in different hospitals, we stayed close.  Our communal breakfasts were a cacophony of gossip about coworkers, bitching about administration, one-upmanship on patient stories, and reforging that beautiful, strange, tenacious bond that all ED nurses innately share.

There was a brief lull in the conversation, and one nurse cleared her throat and sighed.  My hair instantly stood up on end.  I knew what she was about to say.

“We lost a patient last night.”  She looked down at her cup of coffee.  “It was really bad.”

I reached for her shoulder.  “I’m so, so sorry.”

Across the table, a friend nodded.  “Tell us.”

~ ~ ~

The 911 operator answered the call, and the man on the phone screamed, “She’s been shot!  She’s bleeding everywhere!  She’s at the warehouse!”  And described an empty, abandoned warehouse at the edge of an industrial area in town.

The paramedics knew exactly where to go — they’d been called to this particular area on a number of occasions in the past.  A large but fluid homeless population moved amidst these warehouses, and IV drug use was rampant.  They’d responded to several overdoses — but never to a shooting.

They found her alone, unconscious on the ground, surrounded by more blood than they had ever imagined could come from one human being.

Our friend was the primary trauma nurse that night, and her team was amped up and ready when the medics roared through the door.  “We just lost her pulse!” they yelled, and hauled her quickly over to the ED bed.  A wave of blood spilled from beneath her as she transferred.  A tech jumped to the bedside and started CPR.

It was the strange controlled chaos that pervades a truly stellar trauma bay in full swing.  “We have an IO in the left humerus!”  “Get two units of O-Neg on the rapid infuser NOW!”  “I need suction, there’s too much blood, I can’t see the cords!”  “I can’t get a line, she’s track-marked and scarred!”  “Drilling, IO in the right tib!”  “Get that chest tube hooked up to suction!”  “We’re at 2 minutes of CPR!”  “No pulse, resuming CPR!”

They fought to save her for more than 20 minutes.  Eventually they realized that the bullet that tore through her chest had likely plowed through her liver, tearing apart the highly vascular organ and the vessels surrounding it.  For every unit of blood they poured into her body, it flowed right back out again, pumping out with every chest compression.  It ran off the edge of the bed, pooling on the floor.

After a final check with his team to ensure that no possible life-saving intervention had been missed, the trauma doc stopped the code, and pronounced her dead.

~ ~ ~

We were silent around the table, not needing to speak.  We had all done this.  We had all watched someone die beneath our hands, beyond our desperate skill to save.  Our friend sighed again.  “We don’t even know her name.  She’s in the morgue as a Jane Doe.”

Across the table, another friend spoke up.  “How old?”

She shrugged.  “Maybe twenty.  A baby.”  And then she looked angry.  “I’ve got a dead, homeless, drug-addicted CHILD in my morgue who was shot by someone for god-knows-what reason, and I don’t even know her name.  I can’t even call her mother to tell her her child is gone for the last time.”

We waited.  Our friend was almost there.

She stared at the table again.  “Some mother’s child just died in a warehouse, cold, nameless, and alone.”

~ ~ ~

That was the heart of the matter.  She had children of her own, and we knew that’s where her thoughts were circling.  She would want to know.  She would do everything in her power to ensure her children never ended up homeless, never ended up addicted to heroin, never ended up spending the winter in a frigid abandoned warehouse, alone but for those with whom she shared her needles.

But if the worst happened, she would want to know.

Outside the bubble of our booth at the restaurant, other patrons laughed over their breakfasts, chatting with each other and the waitresses.  Christmas music played quietly on the radio in the background.  Dishes clattered together in the bus tub, the grill in the back of the restaurant hissed and coughed, the coffee maker steamed.

And we sat at our table, quiet but present, a brief vigil for the girl with no name and for our friend’s troubled heart.

But then I frowned.  I angled myself towards her.  “But that’s not true.  She didn’t die in that warehouse.  She died in your trauma bay.  And she didn’t die alone.  She died with dozens of people who cared, people who were trying to save her life.”

I squeezed her shoulder again.  “If she had any awareness left at the end, she knew.  She knew that she wasn’t alone.  She knew that you were all there.  She knew that she mattered.”

“And she knew that, for one last time, you’d brought her in from the cold.”

~