Stephen White: Critical Conditions

Her tone was mildly admonishing as she said, “You’re just too sensitive for the current managed care environment. There are worse companies than MedExcel, let me tell you.”

“I don’t want to know about them.”

“But you’ll see her anyway?”

“Sure, I’ll send you the bill, Ren. You’re rich.”

She found my threat amusing, “Go right ahead. If you think insurance companies are hard to deal with, wait till you try to get a dime out of me.”

I took a quick shower and thought about Lauren. She was, I guessed, sitting by her mother’s bedside in a hospital in eastern Washington. Had she been home, I think she might have said something to caution me about what I was doing.

I ate a banana and some toast and peanut butter, and poured a cup of coffee for the road. Emily’s dish had plenty of fresh water.

I have found every intensive care unit I have ever visited to be an eerie place. Almost by definition, ICUs are hallowed temples of tragedy or triumph. The final results of the labors there are binary, either a zero or a one. The practitioners are either heroes or they are failures. The mood in the space, in the area that exists between the linoleum tiles and the ceiling tiles, is subdued, as though the players-the doctors, the nurses, the therapists-don’t even pause to acknowledge the immense stakes that are always on the table.

I greeted the ward clerk in the Community Hospital ICU, identified myself, and asked where I could find the new transfer from the ER. Without looking up from a duty roster, he asked, “Which one?”

“Adolescent OD. Female. Don’t have a name. I’m Dr. Gregory, for a psych consult.”

He raised his head and gestured toward the far corner and said, “Ms. Doe. She’s in bed four.” As I walked past him he said, “Good luck.” In the vernacular, I assumed he meant that for her more than me. A dividing curtain was partially pulled in front of the bed in the distance, so from the nursing station I couldn’t see much more than the footrail.

I asked, “Is her chart here?”

“No, her nurse has it out there.”

On the far side of the bed a stocky woman with red hair wearing a brilliant chartreuse top was adjusting the controls on an infusion pump. I wondered where Adrienne was.

I turned back to the ward clerk and asked, “Is Dr. Arvin here?”

“Is he the attending?”

“No. She’s the urologist.”

“The little one?”

“Yes.”

“She’s over there, I think, with the patient. Was a few minutes ago, at least. I haven’t seen her come back out, but I was in the john for a minute.”

A glass wall separated the nursing station from the eight ICU beds. The moment I was through the glass door into the unit I was confronted with the familiar but disconcerting smells and sounds of last-chance medicine. My breathing grew more shallow.

I found Adrienne behind the drawn curtain. She was sitting on the edge of a chair, her eyes fixed on the monitor above the bed. The indicator for number of respirations per minute read a sharp red “ 09.”

Way too low.

She was holding her new patient’s limp hand.

Adrienne didn’t turn, but she knew I was there. She said, “I didn’t tell you before on the phone but, downstairs? She was in Cardiac Three. When they brought her in that’s where they took her. And that’s where I saw her. So this one’s special to me. Okay?”

Adrienne had become a widow in Cardiac 3, the number three cardiac treatment room of the Emergency Room. Peter-her husband, my friend-died in Cardiac 3 after a brutal knife attack.

I said, “Okay,” and touched Adrienne on the shoulder. With her free hand, she felt for my fingers.

Staring at the bright red numbers on the monitor, I stated the obvious as I gestured at the pale figure on the bed. “She’ll be on a ventilator soon, won’t she?”

Adrienne nodded gravely. “Her gag reflex is gone; she’s stopped controlling her airway. They’re setting up for the vent right now.”

On masking tape at the endrail of the bed someone had written, DOE, M. in bold capital letters.

M. Doe was a tall girl. In unconsciousness, she seemed to stretch out over the length of the hospital bed. Monitor wires snaked from the upper end of her torso, which was immodestly covered by a pastel hospital gown that had seen about fifty too many washings before it had been pulled over her thin frame.

“Do you mind covering her up a little better please, Ren?” I asked.

The nurse turned and said, “I’ll do it.”

I thanked her and introduced myself. She smiled at me with a patronizing face that said, “We have a lot of work to do before you’re going to do any good.”

An automated blood pressure cuff began to inflate on the girl’s upper arm, a drain gurgled, and the infusion pump measured another dose of fluid into her IV tubing. A nice little ICU symphony.

Adrienne said, “Don’t you think she’s lovely? I think she’s really pretty.”

My first thought was that in these circumstances, no one was lovely. But I said, “Yes, she is,” trying to imagine what M. Doe looked like twenty-four hours earlier, and what events, what pain, had brought her here.

The child moaned and rolled her head to the side. She coughed once, a tiny cough, an infant’s cough, before her eyes opened slowly and froze on me. Her eyes were puzzlingly clear, the same luminescent purple as my ex-wife’s. And like Merideth’s always had, this girl’s eyes pierced me instantly in a way that compromised my balance.

“Hello,” I said, moving forward half a step.

She blinked once before her eyes closed again.

Adrienne said, “She’s done that a few times so far. Don’t be fooled, it doesn’t mean anything.”

“Is she responsive to pain?”

“Was earlier, now only minimally to deep pressure. But I haven’t played any Barry Manilow CDs yet. That might get a scream out of her.”

I smiled.

Behind us we heard the squeak and drone of rubber wheels on linoleum. I turned and saw Marty Klein accompanied by a scrub-suited doc whom I didn’t know. Behind them, a respiratory therapist was pushing a ventilator and a treatment cart our way. I said, “Hello, Marty.”

He nodded. In other circumstances, I knew we would end up talking about bicycles, my passion, and golf, his. Not this time. He said, “Hi, Alan, thanks for coming, sorry she’s not too talkative. We’re here to get her on the vent. Step out a minute, please. Okay?”

“Of course.” I had no desire to watch what he was about to do. None.

Adrienne asked, “Marty, do you need me?”

“No, Adrienne. We’re fine. I’ll have somebody call you with the kidney functions as soon as they show any change.”

“You have my home phone?”

“It’s on the chart, right?”

“Yes. I want to talk with the parents, too. When you find them.”

“I’ll find you, don’t worry. Get out of here. Go play catch with your son or something,” he said as he pulled the curtain farther around the bed.

I began to follow Adrienne away from the bed when I remembered why I was there. “Just a sec,” I said. I walked back and reached inside the curtain and grabbed the chart and flipped a few pages. Beside me, Adrienne had begun pacing. I think Marty’s admonition about spending time with Jonas had some special meaning as this young girl hovered near death with her parents nowhere to be found.

“You have a pen?”

She gave me one. I used it to sign onto the case and then scribbled a brief progress note that reported an apparent overdose, an unconscious patient, absent family, and no progress. On the order sheet, I wrote, “When patient attains consciousness: Suicide precautions should be in place, including 1:1 staffing × 24 hrs.” I also left instructions that I be called immediately when the parents were located or the patient became oriented.