of his lungs. Ben began CPR, and the first several compressions were accompanied by the sickening feel of cracking ribs beneath his interlaced hands. ‘Call Dr Gardner!’ he shouted to the charge nurse standing in the doorway, and he soon heard the overhead paging system bellowing: ‘Dr Gardner to the ER, stat! Dr Gardner to the ER, stat!’
For eight minutes Ben pumped up and down on his patient’s chest, attempting to circulate enough blood to generate some sort of blood pressure. Every so often, he paused long enough to look up at the patient’s heart rhythm on the monitor. ‘Shock him, two hundred joules!’ he ordered the nurse, who would charge the paddles, place them on the patient’s chest, yell ‘CLEAR!’ and press the two buttons that sent a surge of electricity slamming through the patient’s body like an electric sledgehammer. ‘No response, Doctor,’ the nurse reported each time, and Ben would order another round of electricity to be delivered like a mule kick into the patient’s chest before resuming chest compressions over splintering ribs. Somewhere during the nightmare of that resuscitation – Ben’s first resuscitation as a physician – the patient’s bladder sphincter relaxed and about a liter of urine came rushing out of the man’s body and onto the bedsheets. A small rivulet of urine began trickling steadily onto the floor. Ben continued his compressions on the patient’s mottled chest, which was now tattooed with burn marks from the defibrillator paddles, as the nurse had failed to place enough conductive gel on the paddles before delivering each shock. The room stank of burnt flesh and a repugnant potpourri of human sweat, urine and the vomited remains of a tuna fish sandwich that the patient had apparently eaten shortly prior to his arrival. The endotracheal tube, temporarily forgotten, slipped out of the patient’s esophagus and fell onto the floor with a resounding splat.
‘What in the hell is going on here, Dr Stevenson?!’ Dr Jason Gardner, Ben’s supervising physician, stood in the doorway, gaping in disbelief at the scene. He appeared to be moderately out of breath from having run across the hospital from the cafeteria on the other side of the building. Ben noticed a small bit of pasta clinging like a frightened animal to his yellow necktie.
‘Heart attack.’ Ben’s voice was hollow and uncertain, small and desperately apologetic, and his words fell from his mouth in a rush as he tried to explain. ‘He came in with chest pain radiating to his arm, neck, and back. Only history was hypertension. He had EKG changes – an ST-elevation MI, I thought. I gave him thrombolytics. I was going to call you, but I didn’t think there was enough time. He coded shortly after I gave the ’lytics. I tried CPR and defibrillation, but I couldn’t get him back. I don’t understand it. I had the nurse call for you as soon as he lost his pulses, but—’
‘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 the 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 had 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 had 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
