The Surgeon

Twelve

Jane Doe has moved.

I hold a tube of her blood in my hand, and am disappointed that it is cool to the touch. It has been sitting in the phlebotomist’s rack too long, and the body heat this tube once contained has radiated through the glass and dissipated into the air. Cold blood is a dead thing, without power or soul, and it does not move me. It is the label I focus on, a white rectangle affixed to the glass tube, printed with the patient’s name, room number, and hospital number. Though the name says “Jane Doe,” I know who this blood really belongs to. She is no longer in the Surgical Intensive Care Unit. She has been moved to Room 538—the surgery ward.

I put the tube back in the rack, where it sits with two dozen other tubes, capped with rubber stoppers of blue and purple and red and green, each color signifying a different procedure to be done. The purple tops are for blood counts, the blue tops for clotting tests, the red tops for chemistries and electrolytes. In some of the red-top tubes, the blood has already congealed into columns of dark gelatin. I look through the bundle of lab orders and find the slip for Jane Doe. This morning, Dr. Cordell ordered two tests: a complete blood count and serum electrolytes. I dig deeper into last night’s lab orders, and find the carbon copy of another requisition with Dr. Cordell’s name as ordering physician.

“STAT arterial blood gas, post-extubation. 2 liters oxygen by nasal prongs.”

Nina Peyton has been extubated. She is breathing on her own, taking in air without mechanical assistance, without a tube in her throat.

I sit motionless at my workstation, thinking not of Nina Peyton, but of Catherine Cordell. She thinks she has won this round. She thinks she is Nina Peyton’s savior. It is time to teach her her place. It is time she learned humility.

I pick up the phone and call Hospital Dietary. A woman answers, her speech pressured, the sound of trays clanging in the background. It is near the dinner hour, and she has no time to waste in chitchat.

“This is Five West,” I lie. “I think we may have mixed up the dietary orders on two of our patients. Can you tell me which diet you have listed for Room Five-thirty-eight?”

There is a pause as she taps on her keyboard and calls up the information.

“Clear liquids,” she answers. “Is that correct?”

“Yes, that’s correct. Thank you.” I hang up.

In the newspaper this morning, Nina Peyton was said to remain comatose and in critical condition. This is not true. She is awake.

Catherine Cordell has saved her life, as I knew she would.

A phlebotomist crosses to my station and sets her tray full of blood tubes on the counter. We smile at each other, as we do every day, two friendly coworkers who by default assume the best about each other. She is young, with firm high breasts that bulge like melons against her white uniform, and she has fine, straight teeth. She picks up a new sheaf of lab requisitions, waves, and walks out. I wonder if her blood tastes salty.

The machines hum and gurgle a continuous lullaby.

I go to the computer and call up the patient list for 5 West. There are twenty rooms in that ward, which is arranged in the shape of an H, with the nursing station located in the crossbar of the H. I go down the list of patients, thirty-three in all, scanning their ages and diagnoses. I stop at the twelfth name, in Room 521.

“Mr. Herman Gwadowski, age 69. Attending physician: Dr. Catherine Cordell. Diagnosis: S/P emergency laparotomy for multiple abdominal trauma.”

Room 521 is located in a parallel hallway to Nina Peyton’s. From 521, Nina’s room is not visible.

I click on Mr. Gwadowski’s name and access his lab flowsheet. He has been in the hospital two weeks and his flowsheet goes on for screen after screen. I can picture his arms, the veins a highway of needle punctures and bruises. From his blood sugar levels, I see he is diabetic. His high white blood cell counts indicate he has an infection of some sort. I notice, too, that there are cultures pending from a wound swab of his foot. The diabetes has affected the circulation in his limbs, and the flesh of his legs is starting to necrose. I also see a culture pending on a swab from his central venous line site.

I focus on his electrolytes. His potassium levels have been steadily climbing. 4.5 two weeks ago. 4.8 last week. 5.1 yesterday. He is old and his diabetic kidneys are struggling to excrete the everyday toxins that accumulate in the bloodstream. Toxins such as potassium.

It will not take much to tip him over the edge.

I have never met Mr. Herman Gwadowski — at least, not face-to-face. I go to the rack of blood tubes which have been sitting on the counter and look at the labels. The rack is from 5 East and West, and there are twenty-four tubes in the various slots. I find a red-top tube from Room 521. It is Mr. Gwadowski’s blood.

I pick up the tube and study it as I slowly turn it under the light. It has not clotted, and the fluid within looks dark and brackish, as though the needle that punctured Mr. Gwadowski’s vein has instead hit a stagnant well. I uncap the tube and sniff its contents. I smell the urea of old age, the gamey sweetness of infection. I smell a body that has already begun to decay, even as the brain continues to deny the shell is dying around it.

In this way, I make Mr. Gwadowski’s acquaintance.

It will not be a long friendship.

Angela Robbins was a conscientious nurse, and she was irritated that Herman Gwadowski’s ten o’clock dose of antibiotics had not yet arrived. She went to the 5 West ward clerk and said, “I’m still waiting for Gwadowski’s IV meds. Can you call Pharmacy again?”

“Did you check the Pharmacy cart? It came up at nine.”

“There was nothing on it for Gwadowski. He needs his IV dose of Zosyn right now.”

“Oh. I just remembered.” The clerk rose and crossed to an in box on the other countertop. “An aide from Four West brought it up a little while ago.”

“Four West?”

“The bag was sent to the wrong floor.” The clerk checked the label. “Gwadowski, Five-twenty-one-A.”

“Right,” said Angela, taking the small IV bag. On the way back to the room, she read the label, confirming the patient’s name, the ordering physician, and the dose of Zosyn that had been added to the bag of saline. It all appeared correct. Eighteen years ago, when Angela had started work as a newly minted nurse, an R.N. could simply walk into the ward’s supply room, pick up a bag of IV fluid, and add to it the necessary medications. A few mistakes made by harried nurses, a few highly publicized lawsuits, had changed all that. Now even a simple IV bag of saline with added potassium had to come through the hospital pharmacy. It was another layer of administration, another cog in what was already the complicated machinery of health care, and Angela resented it. It had caused an hour’s delay in this IV bag’s arrival.

She switched Mr. Gwadowski’s IV tubing to the new bag and hung the bag on the pole. Through it all, Mr. Gwadowski lay unmoving. He’d been comatose for two weeks, and already he exuded the smell of death. Angela had been a nurse long enough to recognize that scent, like sour sweat, that was the prelude to the final passing. Whenever she detected it, she would murmur to the other nurses: “This one’s not going to make it.” That’s what she thought now, as she turned up the IV flow rate and checked the patient’s vital signs. This one is not going to make it. Still, she went about her tasks with the same care she gave to every patient.

It was time for the sponge bath. She brought a basin of warm water to the bedside, soaked a washcloth, and started by wiping Mr. Gwadowski’s face. He lay with mouth gaping open, the tongue dry and furrowed. If only they could let him go. If only they could release him from this hell. But the son would not even allow a change in the code status, and so the old man lived on, if you could call this living, his heart continuing to beat in its decaying shell of a body.

She peeled off the patient’s hospital gown and checked the central venous line skin site. The wound looked slightly red, which worried her. They had run out of IV sites on the arms. This was their only IV access now, and Angela was conscientious about keeping the wound clean and the bandage fresh. After the bed bath, she would change the dressing.

She wiped down the torso, running her washcloth across the ridges of rib. She could tell he had never been a muscular man, and what was left now of his chest was merely parchment stretched across bone.

She heard footsteps and was not happy to see Mr. Gwadowski’s son come into the room. With a single glance, he put her on the defensive — that’s the sort of man he was, always pointing out mistakes and flaws in others. He frequently did it to his sister. Once Angela heard them arguing and had to stop herself from coming to the sister’s defense. After all, it was not Angela’s place to tell this son what she thought of his bullying. But she need not be overly friendly to him, either. So she merely nodded and continued with the sponge bath.

“How’s he doing?” asked Ivan Gwadowski.

“There’s been no change.” Her voice was cool and businesslike. She wished he would leave, would finish his little ceremony of pretending to care, and let her get on with her work. She was perceptive enough to understand that love was but a minor part of why this son was here. He had taken charge because that’s what he was accustomed to doing, and he wouldn’t relinquish control to anyone. Not even Death.

“Has the doctor been in to see him?”

“Dr. Cordell comes in every morning.”

“What does she say about the fact he’s still in a coma?”

Angela put the washcloth in the basin and straightened to look at him. “I’m not sure what there is to say, Mr. Gwadowski.”

“How long will he be like this?”

“As long as you allow him to be.”

“What does that mean?”

“It would be kinder, don’t you think, to let him go?”

Ivan Gwadowski stared at her. “Yes, it makes everyone’s life easier, doesn’t it? And it frees up another hospital bed.”

“That’s not why I said it.”

“I know how hospitals get paid these days. The patient stays too long, and you eat the costs.”

“I’m only talking about what’s best for your father.”

“What’s best is that this hospital does its job.”

Before she could say anything she regretted, Angela turned and grabbed the washcloth from the basin. Wrung it out with shaking hands. Don’t argue with him. Just do your job. He’s the kind of man who’ll take it all the way to the top.

She placed the damp cloth on the patient’s abdomen. Only then did she realize that the old man was not breathing.

At once Angela felt the neck for a pulse.

“What is it?” asked the son. “Is he okay?”

She didn’t answer. Pushing right past him, she ran into the hall. “Code Blue!” she yelled. “Call a Code Blue, Room Five-twenty-one!”

Catherine sprinted out of Nina Peyton’s room and rounded the corner into the next hallway. Personnel had already crowded into Room 521 and spilled out into the corridor, where a group of wide-eyed medical students stood craning their necks to see the action.

Catherine pushed into the room and called out, over the chaos: “What happened?”

Angela, Mr. Gwadowski’s nurse, said: “He just stopped breathing! There’s no pulse.”

Catherine worked her way to the bedside and saw that another nurse had already clapped a mask over the patient’s face and was bagging oxygen into the lungs. An intern had his hands on the chest, and with each bounce against the sternum he squeezed blood from the heart, forcing it through arteries and veins. Feeding the organs, feeding the brain.

“EKG leads are on!” someone called out.

Catherine’s gaze flew to the monitor. The tracing showed ventricular fibrillation. The chambers of the heart were no longer contracting. Instead, the individual muscles were quivering, and the heart had turned into a flaccid bag.

“Paddles charged?” said Catherine.

“One hundred joules.”

“Do it!”

The nurse placed defibrillator paddles on the chest and yelled, “Everyone back!”

The paddles discharged, sending an electrical jolt through the heart. The man’s torso jerked off the mattress like a cat on a hot griddle.

“Still in V. fib!”

“One milligram epinephrine IV, then shock him again at a hundred,” said Catherine.

The bolus of epinephrine slid through the CVP line.

“Back!”

Another shock from the paddles, another jerk of the torso.

On the monitor, the EKG tracing shot straight up, then collapsed into a trembling line. The last twitches of a fading heart.

Catherine looked down at her patient and thought: How do I revive this withered pile of bones?

“You want — to keep — going?” asked the intern, panting as he pumped. A drop of sweat slid in a glistening line down his cheek.

I didn’t want to code him at all, she thought, and was about to end it when Angela whispered into her ear:

“The son’s here. He’s watching.”

Catherine’s gaze shot to Ivan Gwadowski, standing in the doorway. Now she had no choice. Anything less than a full-out effort, and the son would make sure there was hell to pay.

On the monitor, the line traced the surface of a storm- tossed sea.

“Let’s do it again,” said Catherine. “Two hundred joules this time. Get some blood sent for STAT lytes!”

She heard the code cart drawer rattle open. Blood tubes and a syringe appeared.

“I can’t find a vein!”

“Use the CVP.”

“Stand back!”

Everyone stepped away as the paddles discharged.

Catherine watched the monitor, hoping that the jolt of shock-induced paralysis would jump-start the heart. Instead, the tracing collapsed to barely a ripple.

Another bolus of epinephrine slithered into the CVP line.

The intern, flushed and sweating, resumed pumping on the chest. A fresh pair of hands took over the ambu-bag, squeezing air into the lungs, but it was like trying to blow life into a dried-out husk. Already Catherine could hear the change in the voices around her, the tone of urgency gone, the words flat and automatic. It was merely an exercise now, with defeat inevitable. She looked around the room, at the dozen or more people crowded around the bed, and saw that the decision was obvious to them all. They were just waiting for her word.

She gave it. “Let’s call the code,” she said. “Eleven thirteen.”

In silence, everyone stepped back and regarded the object of their defeat, Herman Gwadowski, who lay cooling in a tangle of wires and IV tubing. A nurse turned off the EKG monitor, and the oscilloscope went blank.

“What about a pacemaker?”

Catherine, in the midst of signing the code sheet, turned and saw that the patient’s son had stepped into the room. “There’s nothing left to save,” she said. “I’m sorry. We couldn’t get his heart beating again.”

“Don’t they use pacemakers for that?”

“We did everything we could—”

“All you did was shock him.”

All? She looked around the room, at the evidence of their efforts, the used syringes and drug vials and crumpled packaging. The medical debris left behind after every battle. The others in the room were all watching, waiting to see how she would handle this.

She set down the clipboard she’d been writing on, angry words already forming on her lips. She never got the chance to say them. Instead she spun toward the door.

Somewhere on the ward, a woman was shrieking.

In an instant Catherine was out of the room, the nurses right behind her. Sprinting around the corner, she spotted an aide standing in the hallway, sobbing and pointing toward Nina’s room. The chair outside the room was vacant.

There should be a policeman here. Where is he?

Catherine pushed open the door and froze.

Blood was the first thing she saw, bright ribbons of it streaming down the wall. Then she looked at her patient, sprawled facedown on the floor. Nina had fallen halfway between the bed and the door, as though she had managed to stagger a few steps before collapsing. Her IV was disconnected and a stream of saline dribbled from the open tube onto the floor, where it formed a clear pool next to the larger pool of red.

He was here. The Surgeon was here.

Though every instinct screamed at her to back away, to flee, she forced herself to step forward, to drop to her knees beside Nina. Blood soaked through her scrub pants, and it was still warm. She rolled the body onto its back.

One look at the white face, the staring eyes, and she knew Nina was already gone. Only moments ago I heard your heart beating.

Slowly emerging from her daze, Catherine looked up and saw a circle of frightened faces. “The policeman,” she said. “Where is the policeman?”

“We don’t know—”

She rose unsteadily to her feet, and the others backed away to let her pass. Heedless of the fact she was tracking blood, she walked out of the room, her gaze darting wildly up and down the hallway.

“Oh my god,” a nurse said.

At the far end of the corridor, a dark line was creeping across the floor. Blood. It was trickling out from beneath the supply room door.