“What did his chest X-ray look like?”
“His chest X-ray?” Ben thought for a moment. Had he ordered one? “I… I don’t know. I think they got one when he first came in, but I didn’t get a chance to look at it.”
“What do you mean you didn’t get a chance to look at it?”
“I just… he started crashing, and there wasn’t enough time…”
“For God’s sake, Stevenson! Stop doing compressions and go get me the goddamn chest X-ray!”
Ben looked down at his hands, surprised to see that they were still pressing up and down on the patient’s chest. He forced them to stop. “Maybe if we tried another shock… ,” he suggested hopefully.
“The patient’s dead,” Gardner growled. “You can shock him all you want, and he’s still going to be just as dead. Now, go get that X-ray. Let’s see what you missed.”
Ben left the room and walked across the hallway to the viewing box. A wooden repository hung on the wall containing several manila sleeves of radiographic images. He shuffled through them, found the appropriate one, and returned with it to the resuscitation room. Dr. Gardner stood next to the cooling body, leafing through the patient’s chart. Ben noticed that the dead man’s eyes remained open, staring lifelessly at the door through which he’d recently entered. Throughout the course of his career, Ben would never forget the look of those eyes, which were not accusatory or vengeful, but simply, unabashedly dead. For some reason, that was the worst of it—the detached finality of that look. It was the first thing he learned that day: When things go bad in this line of work and someone dies, there is always plenty of blame to go around; but there is only one soul who truly no longer cares.
“Let’s see that film,” Gardner grunted, and Ben handed him the envelope. He watched the man remove the X-ray from its sleeve and slap it onto the resuscitation room’s viewing box. The seasoned physician studied it for a minute, then queried, “Well, what do you make of it, Dr. Stevenson?”
Ben cleared his throat hesitantly. “The lung fields are somewhat hyperinflated. Cardiac silhouette appears slightly enlarged, although that can be an artifact of a single AP view. Costophrenic margins are well visualized. No evidence of an infiltrate or pneumothorax.”
“Uh-huh. And how would you describe the mediastinum?”
“Widened. The aortic knob is poorly visualized.”
“Exactly. What comes to mind, Dr. Stevenson, in a fifty-eight-year-old gentleman with a history of hypertension, who presents with chest pain radiating to his arm and back and has a widened mediastinum on chest X-ray?”
“Aortic dissection?” Ben ventured. “But what about the ST elevation on the patient’s EKG?”
Gardner snatched up the EKG, glanced at it perfunctorily, then handed it to Ben. “Inferior ST elevation consistent with a Stanford type A aortic tear dissecting into the right coronary artery. Pushing thrombolytics on this man was a death sentence. He bled into his chest and pericardial sac within minutes. He would’ve stood a better chance if you’d just walked up to him and shot him in the head with a .38.”
Those last words—Dr. Gardner’s final commentary on the case—hung in the air, defying objection. Ben stood in the room between his boss and the dead man, unable to conjure any sort of meaningful response. His face burned with anguish and humiliation. In the corner of the room, a nurse pretended to scribble notes on the patient’s resuscitation sheet. She glanced up briefly in Ben’s direction, her face cautiously guarded.
“Notify the medical examiner, and submit this case to M & M conference on Friday,” Dr. Gardner instructed him. “Get back to work. You’ve got three patients in the rack still waiting to be seen. Oh, and Stevenson?”
“Yes?” Ben looked up, needing to hear some token of consolation from his mentor, this man he respected.
“Try your best not to kill the rest of them,” Gardner advised him blandly, and left the room without looking back.
One of the hardest things about being a physician, Ben now thought as he recollected this horrendous experience in the ER as a young intern, was forcing yourself to continue along in the wake of such catastrophic events as if nothing had happened. The three patients still waiting to be seen turned out to be a child with a common cold, a drunk teenager who was brought to the emergency department by her friends, and a forty-two-year-old man with a wrist fracture. Routine, mundane cases, in other words. Ben attempted to clear his head as best he could, and he interviewed and examined them all carefully and professionally. But while looking into the child’s ears with an otoscope, he thought to himself, I just killed a man. While ordering an anti-emetic for the teenager now puking through the slots between the side rails of her gurney, he thought, There’s a man in Resuscitation Room 2 covered by a white sheet because I was in too much of a hurry to look at a simple chest X-ray. In the middle of examining the man’s broken wrist, he recalled holding the wrist of the dead man in his hands as he searched for a pulse that was no longer there. During these moments, his patients were aware of none of this. Two more people arrived in the department during the time he took to examine and treat the previous three patients. After that, an ambulance showed up with a moderately severe asthmatic, and four more people checked in to triage.
In most jobs, when something horrible and traumatic happens to an employee, they are instructed to take the rest of the day off and are possibly sent for counseling. There is time to process what has happened, to remove oneself from the environment. There is time to take a breath, to discuss the incident with your spouse, or to simply get wasted at the local pub. In medical training, you are instructed to notify the medical examiner and to get back to work. You are given the helpful advice “Try not to kill the next one,” and you are desperately afraid that you will. Recovery from such events occurs on your own time, in private, once you’ve fulfilled all of your other duties and obligations. And in medicine, those duties are never truly fulfilled. There is always another patient, another conference, another presentation, another emergency in the middle of the night, another fire to be put out. Always.
The night’s precipitation continued to fall on the darkened street ahead. Neon headlights cast their artificial glare on a hundred tiny rivers of water racing desperately toward the town’s sewers, and wherever they might lead beyond that. Four miles from here, Nat was preparing the body of a young boy for his final medical examination. It was going to be a long and exhausting night, and Ben was pretty sure there would be more to follow. Things would get worse before they got better. Things like this always did. He didn’t want to be here, driving away from his family on a night like this. It didn’t feel like the right thing to do, and he wondered to himself, not for the first time, exactly where his allegiances were. He could feel the storm tugging at the hole inside of him, another chunk of earth pulled loose by the water’s greedy fingers. He imagined himself being swept away into the sewers, one nearly imperceptible piece at a time. What will it feel like when there’s nothing left? he asked himself. And will I even know when that moment comes? Within the car there was only silence, except for the steady thrum of the rain falling all around him.
5
Nat had been right about one thing: The press was going to have a field day with this one—a regular three-ring circus. Ben could make out the congregation near the front entrance to the Coroner’s Office from a quarter mile away. The usually dimly illuminated front steps of the CO were now bathed in bright artificial light as at least three different television crews jostled for position. Two patrol cars were parked just across the street, and a third one blocked the left lane of traffic to allow room for the news crews to set up their equipment without running the risk of being plowed over by a distracted motorist. Ben quickly decided there was no way he’d attempt to enter through the CO’s front entrance; instead, he turned left on Broadway and right on Oregon Avenue, hoping to sneak in through the building’s rear delivery access.