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The other day in surgery, Dale Edson just had to open his mouth.
"I can't believe that, about Carter being a user," he said. "It
just goes to show, you think you know a guy -- "
"It's always a shock when a colleague develops that sort of a
problem," Dr. Hicks answered him calmly, trying to shut him up. To me:
"Have you heard from Dr. Carter recently, Peter?"
Shock. I've seen patients in hypovolemic shock many times. It's one of
the first things you learn about as a med student. How circulatory failure
affects first one system, and then another, and another.
A patient who's in shock and has lost too much blood has less blood going
to the brain. The nervous system responds by losing control of the vital
functions, including the lungs, which starves the heart of oxygen, and the
heart stops pumping blood effectively to the brain. And it
continues on, a vicious circle leading to death. In the ER we can try to
keep our trauma patients from going into shock. Once they go over that
line, it's much harder to bring them back.
So you look for the signs. I've seen patients slipping into the
danger zone. You come to know the glassy, faraway look in the eyes that
tells you there's not much time left to work with. I saw that look in
Carter's eyes when we were bringing him up to the OR the night he was
attacked.
And I saw it again that day in Curtain Three when we were all
standing there staring at him, asking him those questions, trying to open
him up without a scalpel.
I know that Anspaugh and Weaver probably saw
the slightly vacant look in his eyes as one of a narcotic user who
probably just taken a dose, and maybe he had. But I saw that faraway look that the trauma patients get right
before they slip past the point of no return, where they look right
through you and just aren't there. And so to me, Carter was a trauma
patient, and that's how I saw him from that moment.
A critical trauma,
walking and talking unnoticed, and not in the place where he should be being
treated. Impossible. Almost surreal. How could that have
happened in this hospital?
I'm a surgeon in this hospital. I need to find out.
It's funny with Carter. I've had my hands inside this man's gut, up to my
wrists in his blood, examining every surface of his internal organs for
damage, handling them with utmost care. You can't get any closer to
someone than that. I've seen and dealt with parts of him that he'll never
see or deal with. For that matter, so has he with me. He gave me an
emergency appendectomy once. So we've both been there, poking around
inside each other, doing our jobs.
And yet, there's something a little
more than a professional distance between Carter and me when we're both
awake and ambulatory. I never thought about it too much, but now I wonder
if there's something just as surreal and wrong about that, as that look in
Carter's eyes was in Curtain Three.
I remember the time Jackie bitched at me when I was telling her
something or other about one of Carter's annoying habits: "Doesn't that
poor kid have a first name, Peter?" She was just being Jackie,
so I ignored her. But as I recall the surgery on Carter
that night, it does seem like she has a point, in a female kind of way.
I can imagine what she'd saying if I were telling her all this now. She
wouldn't hold back: "You can pick up this guy's colon, but you can't
condescend to call him John?"
We operated on Carter for two hours, Anspaugh and I, first repairing
his renal lac and then trying to hunt down which artery had been
nicked to cause all the continuing hemorrhaging. If Anspaugh hadn't been
there, I would have blown it and Carter would be walking around today
without a kidney. I hadn't lost my head in the O.R. like that since I was
an intern. These days, when something goes wrong in surgery and I lose my
concentration, I'm thinking about what I'll tell the patient's family if
we should have an unanticipated outcome.
But now that I recall, I don't
think I was thinking that way that night. I was just in a state of raw
panic. Well, thank God for Anspaugh. I don't ever want to be in that
place again. (Once, when Reese was born, was enough for me.)
So we found the bleeder. We got it tied off. The kidney was
saved. The temporary colostomy was completed. Carter was extubated and
brought to recovery. He woke up promptly from the anesthesia. His crit
was up again. Or so the monitor said.
But that distant look in his eyes, in Curtain Three weeks later, told me we'd
missed something. Somewhere deep inside, he was still hemorrhaging. All
that time, all those months, some quiet little bleeder that somehow
escaped my notice. But I had promised Carter, when we were prepping him
in the O.R. that night, that I would explore the abdomen, check out
everything.
He had seemed so relieved, so grateful. "I'm glad it's you,"
he'd said. So trusting of me, as always, so full of the admiration that I
never have been able to quite handle from him since day one.
I'd made a surgeon's promise in the heat of the moment, and I
thought I'd carried through. But there I stood in Curtain Three with
Anspaugh and the others, watching Carter crashing before my eyes: in a
cold panicky sweat, arms folded around himself, his reasoning systems gone
haywire, behaving in the irrational way that trauma patients do when
they've gone into shock and need immediate intervention. That's
what Weaver called it -- an intervention -- but all I could think,
confronted with the all too familiar signs of patient distress, was how
much I wanted to go back in time to that O.R. and do things differently.
Had I kept my promise? What had I missed?
I knew I'd done my job thoroughly that night in surgery. We
hadn't missed anything. The hemorrhage had to be from another source.
I admit that I could never stand being around Carter long enough
to become very familiar with his personal life. When he began his
surgical sub-i in his final year of med school, pretty much all I knew
about him was that he was from a well-off family, was dating a pretty med
student down in the E.R., and was occasionally late for rounds. I hadn't
known anything about home life until the day of his graduation when he
followed me around babbling excitedly about all of his cousins, and
extending an invitation to a private party with his parents.
I can't
remember exactly how I turned him down, but I do remember that he seemed genuinely unhappy. To be honest, I was
real glad to be rid of him at
that point. He really did try to suck up too much to people, a bad habit
in him that I felt I should do my part to break.
I never hesitated to tell him what I really thought about him
wanting to be a surgeon, either. When he joined the Blue Team at the
last minute, I was constantly trying to define to him what
a good surgeon was and why he wouldn't fit the mold. For his part,
he seemed too busy trying to cling to me for some reason, always
either trying to get my attention by pulling some silly stunt (like
the time he pretended he had a pheochromocytoma scheduled for
surgery), or thanking me profusely when I did give him the
attention and approval he seemed to crave.
But he was a very
promising surgical intern, although not the most ambitious, not
the most aggressive. I never thought he had it in him to become
a truly great surgeon, but he was still the best intern I'd had.
It wasn't until a long, painful time later that I began to
understand why he left the program.
Carter seemed to be conflicted from deep inside almost as
soon as he left the surgical department. I remember one evening
when he practically threw
himself at me outside the hospital, demanding that I treat him
better, give him more attention. That's when I blew up at him,
because I really was furious that he'd ditched his surgical
residency. I should have known he had some issues. I used to
wonder aloud if he wanted me to handhold him for the rest of
his career, but that wasn't it. Carter never needed handholding,
never. He seemed to need approval, yeah, but
he could always stand on his own two feet as a doctor.
I really never knew much about his family. His parents just never
seemed to be around. His grandparents seemed to be in charge
of everything, and I was surprised to get the drift from
someone or other that they really bitterly disapproved of his
medical career. This blew my mind -- since my
entire family gave everything they had to support my
going to med school. But I never thought about it.
I'd never
felt comfortable talking about life outside the hospital with
Carter, anyway. When Dennis Gant died, I could tell he
wanted to talk, to know more -- about me. (To him, I apparently
was no
different from any patient; maybe that's why he
got on my nerves so much.) I basically all
but told him to shove off, white boy. He didn't like
that. He said something about me wanting to make Dennis
into something that he didn't know anything about.
You know, something black. He didn't say that, but I knew
he sensed exactly why I didn't want him bothering me.
Now that I looked at him in Curtain Three, I realized he was slowly bleeding out
inside from old wounds that I knew nothing about. Maybe he always had
been. And just that passing thought chilled me to the bone.
I had never passed out in a trauma room like some of the guys I knew in
med school, but I could sympathize with how they felt when
confronted with their first critical patient: just coming face to face
for the first time with the overwhelming reality of how much blood there
really is in an average human body, how much can be lost, how much
physical pain can be suffered without the merciful respite of
unconsciousness. That physical stuff, it never bothered me, and I guess I
was just lucky to have that thick skin. And possibly I was a little smug
about it too.
But how much emotional pain there could be in an ordinary life...
I'd thought I knew. But like the green med students flopping on the floors
in trauma, I suddenly realized that I had no real sense of it at all.
Seeing Carter in that state brought it all up in my face.
Not just Carter's reality, but the reality of every patient I had ever cut
open, performing meticulous and thorough procedures, exploring the
wonderfully complex world of the human interior I thought I knew so well,
closing the incisions so neatly...but leaving so many places left dark,
unexplored, unhealed. Suddenly it seemed like everything I knew about
being a doctor was inadequate.
And for the first time in my career, I felt sick about it.
When I first had these thoughts that night in Curtain Three, I was
able to push them away. But now I think more and more about the things
Carter used to say to me when we were on the Blue Team together, and the
things he did. Things which I honestly and sincerely did not get.
How he could walk off in the middle of a post-op talk to make sure that a
kidney donor and his sister saw each other after a rough surgery. How he
could defy Don Anspaugh in front of the whole ER and refuse to join rounds
if it meant more time to arrange for an LOL to get into a nursing home.
I've thought of a dozen "Carter stories" that I used to roll my eyes at
up in the O.R., after getting reports from Edson after Carter left his
surgical residency. They seem different now, for some reason.
Less funny.
When Reese was born, I was like Christopher Columbus,
discovering this brave new world of slowing down and taking time to be
there for another human being. I'd do anything for Reese, but I guess I
keep my feelings saved for him. I haven't needed them for my job. But that was
never Carter's way. He couldn't understand my insistence on keeping my
feelings out of my work. I must have been just as much an annoying
mystery to him, as he was to me.
He once asked me, "How did you ever put
up with me when I was a student?" Now I almost feel like asking him the same
question. It's funny. I was his student, too, and I never even knew it
until just now. The way he saved my ass with patients who I couldn't
get through to. The way he used to occasionally blow up at me and tell me the truth
when I would rather have bought into the bullshit.
And the anger I felt when he snuck out of the surgical program. It
feels different now, I can hardly explain it. Maybe it's because seeing
him exposed like that in Curtain Three that night finally drew back the
curtain for me in some way. When Carter left the surgical residency
program, it never occurred to me to think of it as anything other than a
cowardly retreat. I tried to be charitable toward him in my mind:
surgery wasn't for everybody, and so on. But I still looked down on him for it.
In fact, most of the surgical staff never understood Carter's decision, and mostly talked about
him ever afterward as if he'd gone to the land
of the dead. As for me, I could never grasp why he'd want to waste so much of his
time on patients who were
unfixable.
But now I think I understand why he had to go. There's a
whole world out there, in patients' pain and suffering, for a healer. A
bigger world with more to it than I thought. Maybe it's even bigger, more complicated than
the surgical field.
And even though it was calling him, he kept working with me perhaps longer
than he should have.
I used to think that he was always confronting me just to annoy me. Maybe
he was just trying to express that he cared, that he wanted me to somehow
come with him into that world.
Maybe that's why Carter is so good with the patients. The ER
staff never comes out and says it, but everyone down there knows he has a
gift. (He probably doesn't realize it, but Weaver actually deliberately
gives him the geriatrics on most days -- I've seen her switch them on the
board, with a little self-satisfied look on her face, like all's right
with the world.)
I'd be lying if I said I never admired Carter's way with
patients. But I used to think it just all came too easily to him for it
to be really worth much. I used to say to Corday that if I
was born with Grandma holding out my trust fund and never had to worry
about the rent or student loans, I'd be Sunshine Superman too. But I knew
that wasn't true about Carter's family life. I knew he'd lost a brother
to leukemia and I knew his parents were never around and I knew there
were drug problems in his family. But I guess I just didn't think. Or maybe I didn't care.
Now, I'm turning that all over in my mind. You think about
someone's problems, the pain in their personal life, and you realize they
couldn't possibly know how to connect with a patient who's suffering
unless they knew something about suffering, too. That's
got to be Carter's thing. Why he's got the gift. I don't know what it is
exactly. Probably his family. That sounds like such an ordinary thing to
cause such a deep and dangerous old wound, doesn't it. You've got to take
it seriously, though. Because I'm beginning to understand that hurt
and healing aren't as separated as I've been taught to think.
And that's why I had to tell Carter the truth he didn't want to hear.
Maybe I already knew all this stuff deep down, and that's why I
knew what I had to do when he stormed out of that exam room that night.
The man was stealing fentanyl out of the trauma room almost in plain
sight. You couldn't play soft with him, and Mark Greene knew it. (Weaver
told me later what he'd said: "It's Carter, your mind just doesn't go
there.") I didn't really believe it at first, but by the time Carter got
done tearing up everyone in that room, I knew it had to be
true. I knew it was true when I saw his eyes, and knew he wasn't healed.
He was drugged, he was in denial, and he was dying inside.
Was he high that night? I don't know. All I knew deep down was
that he was in a bad way. I'm not talking about the pain. I knew the
hematoma on his back wasn't resolving itself as fast as Anspaugh and I had
figured it would. I can't think of anyone I know who deserves to suffer
less than Carter, especially after what he went through this past winter, losing his
student like that.
But to think of him self-medicating, shooting up, shutting himself
off from all feeling, even his own... That's why it's so wrong
when a doctor uses, do you understand? There's something about it
that destroys not only your good judgment and your skill.
If it cuts you off from all honest feeling, numbs you,
makes you deny your own pain --
how can you suffer with those who come to be healed?
Carter tried to teach me this truth. I'm just learning it on my own.
I wasn't thinking of any of this consciously at the time. I knew he'd
walk out, and I was
just desperate to keep him from slipping away. All I could think about
as I followed him down the hall was the last thing I promised him before his surgery all those
months ago. How I would check everything out. Find the source of
the problem. Things had been left undone, and I would finish them. I thought to myself,
"I'm a surgeon. He's my patient. I can do this." But whether I could actually
do anything for Carter once I found out why he was in such trouble,
I just didn't know.
I ran out of the ambulance bay after him when he wouldn't stop.
I think he wanted to stop, or else
he could have gotten out much faster. He threw accusations at me, of
course. I asked him if he wanted to die, or worse, end up like his
cousin Chase.
That's when he hauled off and hit me. I honestly didn't see it
coming. But now I know all too well why he reacted that way when
I brought up his family. I'm sorry I did, but also not sorry. Carter never
spared me the truth when I needed to hear it, and I owed him
at least that much.
It took me a moment to realize how upset he was becoming. I
honestly didn't know what he was going to do next. And out of the corner
of my eye, I could see that two of the EMT's in the ambulance bay, who'd
drifted over when they saw Carter connect with my jaw, were still
watching, and it pissed me off.
There was nothing I could do for Carter right now, no way to fix this
horrible catastrophe his health and career had become.
But I couldn't just stand there and let those Neanderthals
enjoy the show. I wanted to give the poor guy some privacy, some place to
hide. But there was no place for him to hide, except with me.
So I took him.
He kept crying against my shoulder, clinging to me a little, and
he reminded me so much of Reese. I still don't know who I reminded him
of.
Maybe someday I'll get a clue.
There isn't much else to say. But all these things keep going
over and over in my mind, and I'm trying to put them together somehow.
In some ways, it's a lot easier trying to put a patient back together in
trauma when they go into shock. You plug where they are bleeding, and get
their pressure up, and wait. You shock their hearts back into rhythm, and
wait. And then they come back, stabilize enough for surgical
intervention. Maybe. And if they stabilize, you operate and then wait to
see if their oxygen-starved organs recover, or if their brain still
functions the way it used to. That's something they never prepare you for
in med school when they get you all excited about being a surgeon: the
waiting, the maybe of it all.
And while you're waiting, you find yourself wondering if you even
have any right to call yourself a doctor.
A few months before she broke her hip, Ma gave me a clipping from
one of her magazines. I found it in stuck in my copy of Gray's Anatomy -
why I put it in there, I don't know. Maybe because I hardly ever read
Gray's any more, and I didn't want to have to remember Ma making me feel
guilty for not going to church. But now that I read it again, I'm glad
she cut it out. I wish I'd had it a few months ago. For that matter, a
few years ago.
The hospital is the Lord's
And the operating-rooms thereof,
The wards, and they that dwell therein.
For He hath founded it in loving kindness
And established it upon the mercy of Christ.
Who shall ascend unto the house of health?
Who shall serve in the holy place of healing?
He whose hands have been made surgically clean
And in whose heart is the pure love of truth...
I put the clipping in my wallet this morning before I left for
the airport. Mark Greene was going to go instead, but had to cover in the
E.R. at the last minute, so I was recruited on my day off.
I've been waiting. Now I'm scanning the faces of the crowd coming into the terminal
through the gate, and I almost miss spotting him. He's put on a little
bit of weight, and he's saying chatty goodbyes to a pretty, blonde
passenger.
Carter, I'm glad it's you.
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