Peter Clement - Mortal Remains

Stepping to his side, Lucy quickly grabbed a ventilation bag and mask. “Let me help you,” she said, handing them to him. For a second, he felt her hands linger on his and give them a squeeze. The orchestrated chaos and noise of a resuscitation swirled about them – people shouting orders, running to draw bloods, sticking in needles, snapping on electrodes.

Her touch steadied him.

He placed the mask on Nell’s face and squeezed a few trial puffs of oxygen into the woman’s lungs. There was a lot of resistance, the effect of her airway closing off. He scissored her mouth open with his fingers, removing the partial plate. But his thoughts finally slipped his control and streaked unchecked toward reckless conclusions he never would have even considered twenty-four hours ago.

The explosion must have been deliberate, to prevent her from telling him anything, just as someone had silenced Victor Feldt and Bessie McDonald. What’s more, he and Lucy would also have been in the blast had they arrived on time. That couldn’t be an accident either.

Lucy handed him the laryngoscope, snapping it open and illuminating the blade.

Taking it with his free hand and keeping Nell’s mouth pried wide apart with his fingers, he slid the instrument along the side of her cracked and swollen tongue. This was going be a difficult intubation. As calculating as a computer, his brain flashed to the alternative, a tracheotomy, or cutting a hole directly into her windpipe.

Nell’s eyes snapped open, her pupils wide with fear, and she grabbed at his hand. Her lips moved around the blade of the scope as if she were trying to say something.

He took it out.

Her attempts to form words continued.

He bent down to hear, once more fighting back his nausea at the terrible smell.

In a high-pitched whisper no louder than a breath, he heard her say, “What’s my chances?”

He involuntarily glanced along a length of her blackened skin where it had split open and glistened in its own juices. The rest remained intact. She might survive the burn, the tub having protected her, but not the ordeal on the respirator that lay ahead, pneumonia being the most likely cause of death. Beyond that, if the burns were truly just second-degree, she’d avoid painful skin grafts and a protracted recovery. Comfort her with a lie, or give her the truth? Or a bit of both. He usually had more time to make such calls.

She seemed to sense his hesitation, widening her eyes and imploring him with her gaze to answer.

Before he hooked her lungs up to a machine, before he submitted her to the indignities of ventilators, catheters, and mind-numbing drugs, before he stole her voice by sticking an tube through it, she’d a right to say “Yes” or “No.”

“The skin doesn’t appear to be too bad, Nell. Your airway, though, needs help.”

“Odds?” she whispered back.

“Four to one against, for most eighty-year-olds. But you’re way better than most. And once the swelling goes down in your throat, they get way better.”

He wasn’t sure she’d heard him as a darkness seemed to gather behind her eyes again. But then she shook her head. “No lingering… on a chest pump… and don’t let me… choke to death.”

The sounds in the resuscitation room seemed to grow very distant.

“You understand what that means-”

Her stare silenced him.

What she wanted was clear as a shout. To be put out of her misery, pure and simple. He imagined Charles Braden leering over his shoulder. “Nell, I can’t do that,” he whispered.

She retreated into the black recesses where such final decisions are made, but not before he saw an unmistakable flash of contempt in her gaze.

“What’s the delay, Mark?” Carla asked.

“She refuses a respirator, but asks us to keep her from choking to death.”

“Wants to go to heaven, but doesn’t want to die,” muttered a young nurse behind him.

He ignored her and, agonizing over the ordeal he was sentencing Nell to, made his decision. “That means I sedate her with midazolam, we intubate to protect her airway, and you keep her topped off with morphine to combat her pain. Remember, she gets the same compassion you would give your own grandmother…”

As he spoke, looks of distaste spread over the faces of Carla and her staff. It was a gray call. No one in ER was ever comfortable with half measures that violated their pull-’em-back-from-the-brink-no-matter-what mentality. Little wonder. They didn’t see what some of their successes had to go through once they got upstairs. At the same time Nell would feel betrayed by his sticking a tube down her throat. Yet he wouldn’t give in to what she asked. He could no more commit active euthanasia than will his heart to a standstill. So he’d do what he could live with, no matter how anybody else in the business might second-guess him, or his patient despise him on her deathbed. And Charles Braden could go to hell.

“Nell, can you hear me? I’m going to make you sleep. Whenever you wake up, they’ll give you more medication to keep you under. But I’ve got to intubate…”

No response. Whether she ignored him, or had gone beyond hearing anything, he couldn’t tell.

He injected the fast-acting tranquilizer, followed by a shot of succinylcholine, a short-duration paralytic. Together they’d make it easier to open her jaw and visualize her vocal cords despite all the boggy swelling in her upper pharynx. Provided this time he could get by her tongue. The paralytic would also stop her breathing. If he bungled the procedure, he’d have precious little time to go in through the trachea, and Nell might end up with what she wanted in the first place.

He navigated around the tongue to where the lining of her throat bulged like a blackened frog belly. Parting the puffy tissues with the laryngoscope, he slid the endotracheal tube through the V of her cords and attached an Ambu bag, pumping hard and sending squeeze after squeeze of oxygen into her lungs until she recovered enough from the injections to breathe on her own.

Now he had Nell in the odd limbo of morality where doctors, himself included, willingly committed euthanasia, albeit the passive kind, withholding heroic treatment if it’s either futile or against the patient’s wishes, yet doing what’s necessary for comfort. If she continued to breathe by herself, she’d survive. If in the name of controlling her pain or sedation they suppressed her respiration, unintentionally hurrying her to her death, so be it. The law, most physicians, and he could live with that as well. Such were medical ethics in the “gray” zone. To the layperson it might sound like word games. To the one faced with pushing in the plunger, that nuance of intent meant being able to sleep at night. The best Mark could tell himself as he walked out of emergency? He’d saved her the agony of asphyxiation, and bought her a bit of time to have a change of mind about dying. As for the weeks and maybe months of suffering he’d imposed on her, that’s what would keep him awake at night. But for now, perhaps for all eternity, she wouldn’t be telling anyone what “tidbits” or “name” she’d claimed to have for him.

“Make sure someone lets me know if she regains consciousness,” he called back to Carla.

“You were great back there,” Lucy told him.

“I don’t think so.”

They sat side by side on a soft leather couch in the doctors’ lounge at Saratoga General, a room outfitted with tastefully upholstered chairs, potted plants, recessed lighting, and an espresso machine that would have done Starbucks proud. “Those were tough calls, and I doubt even an anesthetist could have pulled off that intubation-”

“That was how my father died,” he said, holding a mug of cappuccino with both hands as he took a sip. The warmth didn’t help the icy grip on his stomach any, nor the cold in his fingers, and his insides were still shaking. “Except there was no one there to help him.”