The Children's Hospital

27

The Committee proclaimed the end of another rotation, and Jemma got to visit Jarvis in an official capacity when she switched onto the NICU/PICU team. Rob joined the surgeons, Vivian took Jemma’s place on the heme-onc service, and Maggie, the pale, chinless goat of their class, came onto the intensive-care service with Jemma. “At last,” she said, “some really sick kids,” actually rubbing her hands together, while she and Jemma were waiting for their orientation lecture from Emma. Maggie had not planned, before the Thing, to work with children much more than was necessary to graduate. Kids creeped her out and big-headed googly-eyed kids creeped her out especially. Her brother and sister, senior residents at one of the most prestigious and toxic internal medicine programs of the Northeast, had a place reserved for her to come suffer and thrive and fulfill her bright, evil promise. She’d only been in the children’s hospital that night because she was doing a rotation in pediatric anesthesia, seeking to learn procedures made more challenging by tiny airways and veins, and she still lusted shamelessly after every sort of insertional intervention. She had a little six-word song she kept singing, and kept trying to get Jemma to sing with her. “I just can’t wait,” it went, “to intubate!”

Jemma could wait. Though there had been, before, a certain amount of junior professional pride that came with successfully completing a procedure, she was already sick of them. She never wanted to see another epiglottis again, but she and Maggie had not been in the unit an hour when she was presented with one. Emma stood in a PICU conference room and gave them their orientation lecture, a plain exhortation to do good work and not be overwhelmed by how complex the patients were, modified for the new days with a coda in which she told them the unit was the best place to be at a time like this, because when you’re doing chest compressions and such you really don’t have time to worry about all the really horrible shit. Already exhausted not an hour into her day, Jemma still had thirty-five hours of call before her. It didn’t matter that what Emma was saying was vitally interesting — past a certain threshold of exhaustion all lectures were soporific. Jemma stared out the window at the sea, and another beautiful morning — the sun was behind them, so the PICU looked out into the ice-cream-cone-shaped shadow of the hospital.

“It was always important,” Emma was saying when they were interrupted, “to keep them, to save them, though there was a point where you always said, after this it’s more suffering than living. Maybe that shouldn’t have changed, but it has. Now there’s a new rule: never let them go, never ever, because we can’t lose one more. Not even one. This was never an easy place to be, and now it’s even harder — they’re all sicker, they really are — so listen: I’m always here, if you see something that makes you want to chew off your fingers and you need someone to stop you. Just ask the angel to call me, or page me yourself the old-fashioned way: 719-0058.” She made them recite her pager number, and did not smile, but her face softened a little under its cap of curls. Maggie raised her hand, but before Emma could acknowledge her they were interrupted by the soft tinkling of the code bell, and the angel’s calm alarum: “A child is dying.” Emma was off in an instant, Maggie and Jemma followed close behind.

They didn’t have far to go. A child had collapsed just a few yards from the conference room, the brother to a boy in the unit, an eight-year-old who’d arrested during soccer practice. He’d spent four days on bypass, and emerged ruined from the interventions of the intensivists, alive but unable to move or speak or probably even think. The cardiologists had fallen swiftly upon the whole family, but come up with no answers. The boy whose code inaugurated Jemma’s unit experience, the youngest child, had been put on an antiarrythmic despite a normal EKG, but had, it turned out, been cheeking and spitting the little yellow pills since the great storm.

“Marcus, my friend,” Emma said to him as she felt in his neck and groin for a pulse. “What do you think you’re doing?” When she couldn’t find the pulse she told Maggie to start chest compressions.

Not again! Jemma thought, because she was still having nightmares about Jarvis, who lay intubated a few beds down. He followed her around on her sleepless peregrinations or they were living out a married life in his basement nest or she was crack whore to his stylish pimp and he called her “motherfucker” or “stupid bitch” and kicked the shit out of her all night long. But she didn’t say it out loud. And she didn’t run away, like she wanted to do.

She hated to bag, but Emma made her do it. She’d never managed to force the mask tight enough against the face for a good seal, and always worried, even with big people, that she’d squeeze so much air into them that she’d pop their lungs.

“Shouldn’t I intubate?” Maggie asked. Emma ignored her. Dr. Tiller arrived at the head of a mob of nurses.

“What’s this?” she asked Emma.

“Pretty much what it looks like,” she said. She pressed a pair of defibrillator paddles against the boy’s chest and looked briefly at the rhythm. “V-fib.”

Emma announced the all clear. Jemma, too intent on the bagging, didn’t hear. “That means you, especially,” Emma said, nudging her with her knee. “There now,” she said, as she delivered a shock and the child went back into a normal rhythm. By the time they’d moved him to a bed, though, he’d become pulseless again.

There was something dreamlike about the time that followed, maybe because the deep, sighing breaths Jemma was putting into the boy were breaths in the cadence of sleep, and they cast a dreamy pall over her, and even over the activity in the room, which was as graceful as it was frenetic. Jemma considered, as she breathed, how every actor in the room, except the patient, was a female, and wondered if that had anything to do with the exquisite coordination that was taking place. Dr. Tiller stood at the head of the bed, ataraxic and remote, arms folded across her chest. Emma got access, and the nurses pushed the code drugs barely a half minute after Dr. Tiller called for them. Emma called for some atropine and handed the laryngoscope to Jemma, though Maggie, still laboring at compressions, made a swipe at it as it was passed off. Jemma had the irrational feeling, as she beheld the thing, that the boy’s epiglottis was somehow indicting her as a procedure thief. She missed it twice but Emma would not take it from her. “There’s no hurry,” she said. “We’ve got him right where we want him, he’s not going anywhere. I’ll just bag a little while you think of something peaceful.”

“I never get these,” Jemma whispered. “It’s okay.”

“Mountain streams. Or just mountains, never mind the water. Dry mountains — they’re green on the bottom and white on top. You’re going to get this one.” Maggie was twisting in place like she had to pee, and derailed Jemma’s thoughts — she was trying to envisage a calm green mountain pasture — so she could only see a beautiful bathroom in her mind’s eye, a fancy-toilet-catalog bathroom. Maggie sat on a toilet of amber and gold and alabaster, peeing serenely. “Now here you go,” Emma said, stepping away, and Jemma finally got it. She hooked up the bag to the tube, and breathed in time with him, and found herself developing strange feelings for the dying boy. It wasn’t enough, just to squeeze the bag. She wanted to squeeze him in a big hug, or put her naked hands around his twitching heart and squeeze that, too. She yearned toward him — toward his pretty white lungs, his smooth red liver, his fat purple spleen. She was leaning a little over him, almost about to lay herself on top of him — she wanted him so badly all of a sudden, and that was the way to have him, pressing herself close against him, skin to skin — when Maggie pushed her roughly on the shoulder between compressions. “Watch it,” she said. Jemma blinked, shook her head, and blushed.

The dream ended not long after the tube went in. The boy could not stay out of the bad rhythm. After fifteen minutes Dr. Tiller called the makeshift bypass team — Dr. Walnut and Dolores. When they arrived someone else took over the bagging from Jemma, and Maggie, her hair in a sweaty flip, was excused from the chest when she started to drip on the sterile field. A couple of words slipped out of the corner of Emma’s mouth as they passed her where she stood, arms folded over her chest, in the doorway: “Good job.” She handed them each a list with their respective patients circled, and told them to spend the rest of the afternoon getting to know them.

“You,” Maggie said to Jemma, as soon as they were out in the hall. She jerked her thumb at the doorway to the conference room where Emma had spoken with them earlier. “In here now.” Jemma followed her in, and watched her, just for a few moments, as she stood with her hands on her hips, panting furiously, wet stains still growing on her scrub shirt. What was coming was obvious. Jemma gathered up her things and moved toward the door. “Oh, no, missy. You’ve got something to hear, first. That was my tube you took away. It belonged to me and don’t tell me, don’t you dare tell me that you didn’t see my name on it. I’ve got a list, and you don’t want to be on it.”

“See you later,” Jemma said. Maggie, hands still on her hips, stepped quickly to the door, looking much more like a ballerina or an aerobics instructor than a raging crabby-ass.

“How dare you! How dare you! You don’t even care about it. I heard you. I saw you. The whole thing was wasted on you.”

“I just want to leave,” Jemma said. Maggie put her face closer to Jemma’s and tried to thrust out her chin, but only succeeded in pursing her lips. “You’re making me sick,” Jemma said, because an intense wave of nausea was rising up from her belly.

“You make me sick, too!” Maggie said, and then her voice was drowned out by the noise of Jemma’s blood rushing in her ears. She felt dizzy; a strange green shade was drawn across her vision. For a moment she couldn’t see anything. She fell to her knees and vomited, her sight coming back only after her stomach was empty and she was retching miserably. She’d barfed on poor angry Maggie, who seemed to have thrown herself literally into a fit. Jemma adjusted her head and pushed some furniture out of the way to give her a safe space to seize in. Then she opened the door and screamed, “Emma!”

It seemed like a violation, to pry open Maggie’s mouth and look into her throat, and it would have been unforgivable, Jemma was sure, for her to intubate her classmate. It had to be done — it took a half hour to get her to stop seizing, and by that time she was so loaded with meds she was only breathing five times a minute. But she was so chinless that she proved difficult even for Emma to do. She got hooked up — the nurses descended on her, overcoming their distaste for adults — she was really only as big as a ten-year-old, anyway — to stick her for blood and an IV and hang her fluids and get her on the monitor. If you didn’t look at her face, her expression still impatient and dissatisfied even after eight milligrams of ativan, and two hundred each of phenobarbital and fosphenytoin, and another hundred of pentobarbital, she could have been a child in the fancy ICU bed, vacated just that morning by a CP/DD moaner-groaner with pneumonia who, kicked back to the ward, left behind one of his mobiles. A dozen winged monkeys floated over Maggie’s head. Emma wound up the mobile after Maggie was all tucked in, and, wings flapping, the monkeys circled and the box played a tinny version of “Yesterday.” Jemma watched her for a little while, imagining it was her in the bed, overcome with toxemia or hyperemesis or simple fatness or demon-baby syndrome, while tourists from other wards, drawn by the novelty of a sick adult, passed by the glass walls of the room and cast their eyes on the sleeper. Maggie was all covered up, but Jemma knew that when it was her a boob and a succession of dirty panties would be displayed to the passers-by, and, seeing her, they would all appreciate what a simple blessing it was to be awake and ambulatory and unintubated.

“Don’t you have somewhere else to be?” the nurse asked her finally.

“Feel better,” Jemma said to Maggie. She left the room and hesitantly embraced her new duties. Emma had done her the grueling honor of assigning her ten patients, five downstairs in the PICU, five upstairs in the NICU. Downstairs she had Jarvis, Marcus, and three others — a fifteen-month-old boy whose father had beaten his head against a barbecue, a fifteen-year-old girl who, undergoing treatment for leukemia, had gotten a bag of infected platelets infused into her veins the day before the flood and swan dived into septic shock and respiratory distress syndrome, and a post-op cardiac patient, a girl born a week before the storm with no left side to her heart. Upstairs she had three preemies, a three-month-old with leprechaunism, and little Brenda.

Out on the floor she’d thought she’d come to know how rounds were perpetual, but at least out there was always a chance to sit down, at some point during the long day. In the units she was in near constant motion, circling from room to room, bay to bay, and even from floor to floor, going constantly from patient to patient, because there was always something acutely wrong with them — if she collapsed at a table in some hidden corner of the PICU her pager sounded immediately. Rob had told her about the circling; on him it had a calming effect. “Sometimes at night,” he said, “if I’ve been going long enough, it feels like I’m everywhere at once, in every bay, upstairs and downstairs, and it’s like I can almost hold the whole place in my head, and all the collective fucked-upness of the kids becomes very individual and distinct, and it’s like I know everything about them, and can almost predict who’s going to code next.” Jemma said that sounded like a pretty bad trip to her.

But she felt it too, or something like it, that very first night. She was ostensibly covering both units, and even though it was largely a sort of pretending — Emma took care of most everything, or advised Jemma over the phone about even the smallest points of management — it was as overwhelming as it was exhilarating. Emma moved in her own circles, and Dr. Tiller was attending. Jemma succeeded spectacularly at avoiding her, and developed, before Rob’s sensor of fucked-upness, a Dr. Tiller proximity alarm that steered her away from particular bays just in time; a bit of dread in the air would push her away, or she’d see the distinctive shadow of Dr. Tiller’s headdress stretching around the corner on the wall or floor. Moving away from Dr. Tiller, or in search of Emma to get a question answered, she started, after she had accomplished a few dozen circumnavigations, to feel something akin to what Rob described: the place started to seem whole in her mind, yet the children became more distinct from each other. She could visit the bays and rooms and shape an imaginary child in her head before she arrived there in person, even if she could never distinguish the unique anatomic pathologies of the cardiac patients — she mixed up tetralogies and tricuspid atresias and simple VSDs in a way that seemed ill-fitting for the daughter of a cardiac surgeon. But beyond what Rob had described, there was something else, a sense that, though she was perpetually in motion, she was floating in the still center of the hospital. True, it was in the character of the intensivists to consider themselves the most important doctors in the hospital, and to consider the drama of the rest of the hospital inferior to that of the unit. But also, since the Thing, the patients, instead of striving to leave the hospital, seemed to strive to enter the PICU, and every time a child improved enough to move out of the unit another came immediately to take its place. Jemma, fatigued by hour twenty-three of wakefulness into a pretty trippy state of mind, thought she could feel the great lines of attraction, grooves in the unbodied essence of the hospital, along which critically ill children moved as certainly as the stars in their courses.

It was a very different sort of rounding than she’d become used to, and the novelty of it helped to propel her through the dawn despite her exhaustion. She slowed, as the sun rose, pausing longer and longer at each bedside. She was surprised to miss the conversation with her patients out on the ward, even when she had been just their talking doughnut. It was much harder to socialize with the comatose, even with Maggie, who, deep in her pentobarb coma, had reached a personal apogee of pleasantness. The barbecue boy twitching and crying in his troubled sleep; the spoiled-platelet girl flapping her hands gently in her restraints; the little hypoplast with the recently reopened chest, an opaque window of antiseptic tape fluttering over her heart; Marcus lying still in his bed, staring blindly at the ceiling, dead alive while his blood slid around the room through the crazy-straw architecture of the LVAD: at every bed Jemma looked at the numbers and did a brief exam, and then stood watching over them with increasing solemnity, until, as she stood over Jarvis, it was almost as if she was visiting his grave. She watched him, feeling something catch in herself every time his respirator gave him a breath. She counted them, eighteen a minute. He did not breathe over that rate, nor did he move a muscle in his body, though he wasn’t paralyzed, like other patients on the ventilator. His pupils, when she pried open his lids to look in his eyes, were fixed. When she pinched his fingertip, as hard as a bite, he did not draw away. On the second day after Jemma had carried him out of his nest he’d developed cerebral edema and herniated, though Dr. Tiller raged powerfully against his decline.

By the time Jemma left him the shrunken sun was disappearing into a bank of clouds, and the day had turned sufficiently that her pager quieted and she was no longer on call. Tousled, wrinkly Dr. Chandra found her to get signout on his patients.

“Are they all alive?” he asked her.

“Oh yes,” Jemma said. “Everybody did okay. Let’s see. Bed 1 had a k of 2.0—I bolused. Her pressure was in the eighties after she got some fen-tanyl — so I gave albumin. She spiked, I cultured. She had a film this morning, but I haven’t seen it yet.”

“I hate this place,” he said, stretching and yawning. It was a very different morning than yesterday’s. All that bright sunshine seemed a year ago now to Jemma. The sea was the color of bile and the sky slate-gray. “Don’t you hate it?” he asked her.

“It was only my first night,” she said.

“That’s enough to know. The places are like people, and first impressions count for a lot. I liked the one ward better. They’re nicer up there. I don’t know what it is — the kids are almost as sick upstairs, but down here everyone’s always in a bad mood.”

“They’re not exactly hanging leis up there, either.”

“It’s like they hate me down here. They all think I’m stupid.”

“Nobody thinks you’re stupid,” Jemma said, though she had heard it said of him that he could not diagnose his way out of a wet paper bag.

“They think I’m stupid upstairs, too, but they’re nicer. They’re just nicer people.”

“You know more than me,” Jemma offered.

“You’re a student,” he said simply. “Sort of. I guess there aren’t any students any more. We’re all in the program now, caught in its clutches. The program — I’d been counting down the days left in residency and now it’s going to last forever. It’s not that different than before. You never get to leave and there’s no life outside, and everybody’s horribly depressed because nothing good ever happens here, and it’s the ugly truth about the program that they pretend to care about you eating and sleeping and learning and not wanting to die every minute of your work day, but really they care about you only as far as they can kick you or as deeply as they can fuck you, and nobody pretended more lamely or cared more superficially than our director. How are you? he’d say, and stare at you with his zombie eyes. Call me Dad. We’re all one family — what a horribly unfunny joke. I used to be so jealous, sometimes, watching all the regular people outside — I’d sit in the park and even the homeless people seemed as happy and free as fat little hobbits. But now”—he clapped his hands together, startling Jemma, who always had trouble staying awake around hour twenty-four, and was starting to drift—“just like that, the hospital ate the whole fucking world, and now nobody will ever get out or go home. Do you ever wonder if it would be more pleasant around here if Dr. Tiller were dead? It’s probably a sin to think like that. The angel says it’s okay, but I don’t believe her.”

Jemma wasn’t sure if she should continue with the signout, so she said, “The angel’s a good listener.”

“Yeah,” he said. “What about Bed 3?” She told him the night’s story on that patient, and on the others he was responsible for, 5 and 8 and 13 and 17 and 18, and then his ten babies upstairs. She became lost in her notes, not sure who had thrown up and who hadn’t, or who had spiked, or which baby got the weird purpuric blotch that was shaped just like lost Australia. Chandra was sympathetic. “They’re all kind of the same, anyway,” he said.

When they were finished she went upstairs to start her official morning rounds before Dr. Sasscock could find her — she had carried some of his patients overnight, too. Brenda was lounging in her isolette, looking quite relaxed and even, in her own way, rather healthy. Sound asleep, she nonetheless lifted an arm to point as soon as Jemma stepped up on the dais.

“Hello, little thing,” Jemma said. “I get to visit you every morning now, you know, and be your own special moron. Your very own moron, to do a little dance for you when you’re sad, to lie down at your feet when you need to lord it over somebody, and when you are hungry you can say, Hey, moron, peel me a grape!” The baby dropped her arm, but continued to stare while Jemma felt her head and listened to her chest and belly. She had grown — now she was a thirty-six-weeker, almost big enough to be born, and almost big enough to have gone home, in the old world. Jemma had pictures of her in her new camera, and stored on the computer in the call room, documenting her many visits. Day by day and week by week she looked more human, though never much like a normal baby, with her toaster-shaped head and her train-wreck face and her many-fingered hands, not to mention the tubes that grew as certainly as her more natural appendages. There was still not much body to cover, and not much work involved in a full exam, even as her improving health allowed more detailed probing and firmer poking. But Jemma, when she was done with her exam, felt suddenly tired. It often happened this way. The first twelve hours of call were all right. Fifteen was a logy hour, but sixteen through twenty were fine. Zombie time started at hour twenty-four, and the big crash came in the morning of the next day, at hour twenty-five, when she could hardly remember her name and might fall asleep on her feet if she stopped moving for too long. She felt the crash impending now; to ward it off she closed up the isolette and put her head down on top of the box, meaning to keep it there ever so briefly — sometimes three minutes of sleep could keep you going for another hour. She fell asleep immediately, her hands relaxing where they hung at her sides, and her mouth opening a little, so her breath clouded the plastic.

There now; goodnight, Jemma. Sleep well, for you’ll not sleep long, and since I am not a preserving angel I’ll not be able to catch you when the drop attacks come during walk-rounds, the creeping sleepiness that you feel coming more completely over you as the endless seconds pass and Emma tries to make you understand the differences between the three types of total anomalous pulmonary venous return. The big velvet sheet drops down over you, somehow managing to cover your feet and legs and belly and chest and shoulders before it covers your head and your eyes, and then you’ll be on the floor, awake already as soon as you’ve hit, all the insensitivists peering at you, disappointed at the already dissipated scent of a likely intubation. Sleep on, hard and deep. The customary morning bustle of the NICU will proceed around you, and the nurses will pay you, for the most part, only cursory attention. Nobody bears you any ill will, though one or two of them understand that you must have a pile of work to do, and yet they do not wake you because the prospect of your suffering pleases them just a little. Anna, arrived to feed the baby, doesn’t wake you, either, but her motives are pure: she thinks you need your rest, thinks you look worn out and a little ugly, and while she is waiting for the formula to run down through the tube, does your hair for you, and you will wake in half an hour with none of your morning work done but with a hairdo, three braids coiled on top of your head in a pattern that seems to your fuzzed-up mind as complex as the worst congenital heart lesion, that makes you, in your blue-green scrubs and dancing clogs and canary-colored robe, the very picture of post-call glamour.