a season of endings

dying is a mean and difficult business.

we are ill equipped, most of us for that journey, despite the ubiquity and inevitability of it.

We are all, always losing someone. Whether we realize it or not.

——————

The red rocks are stunning. They rear up from a flat desert outline, monuments to the past. clean lines span their width, straighter than any artist’s hand could possibly draw. Each line a few human centuries thick, maybe a few feet. Their craggy faces were battere'd by some genius hand, what remains behind tells us stories, a thousand stories.

The lack tells a story too.

How many eons stretched across each face of these enduring plateaus? They keep record, as the wind, water, and time carve their beauty more clearly. A history told by what is no longer. Did someone once stand on top of you and stare out across a lush plain or river? are her bones buried in that line of sediment?

———————

Time comes for us all. Eventually we face the dwindling moments.

You tell me you lived a simple life. You drove a truck. You provided for your family. You listened to the radio. You did your best.

———————

A few floors up a baby makes the first appeal, he cries, the first time he hears his own voice. The first time he shakes the air. A mother holds her baby, sweating, exhausted, a father stares, finding a new feeling stir in his chest, not something he has ever felt before. An unbelievable love, an unconditional love blooming in what had always felt like dry ground.

——————-

Why do we die this way? Clinging with tubes, and wires, and drips and lines, with ventilators and epinephrine to meager mortal moments? Why do we die clawing for mortality this way?

——————-

Is there such a thiing as a simple life?

I don’t think so. The number of inscrutible mechanisms that have to deploy themselves in the exact right time and place, the incredible synchrony of your life, the exquisite timing of the symphony of your bowels, your heaving chest defies he wildest engineer’s imagination. My job is largely appreciating the millions of ways things have gone right, for you to stand here, breathing. And as a cancer smolders away inside you, beyond our capacity to heal, I recognize this over and over again.

———————

this dying business, it is a heavy horror. it stoops low in the corner of our lives, ever present, like the door to an attic we know exists but have never seen. a monster of stupendous terror that we have grown accustomed to by virtue of its inevitability, and ubiquity. It seems wrong, that such a marvelous thing as a life should ever have an ending. Shouldn’t a good book just go on and on? But all our favorite things are this way, beginning, middle, end.

———

I speak to my mom on the phone, I saw a graph the other day, it outlined the amount of time we give to our loved ones over time. The headline was “You may have called your mom for the last time” or something terrible like that. I call my mom a lot. She jokes about death, she knows it hovers around the corner for all of us, she works in a hospital. “When I die, bury me with that Louis Vuitton purse.” Alright, mom.

magic

This is a story about magic.

This is the old fashioned kind of magic, the very old kind. The type of magic before we read about witches and wizards, before owls that could deliver letters, before anyone ever considered riding a broom or making a ring to rule them all.

It’s a primordial magic, the kind that stews in the background of our lives, the kind that if we really looked at it, we would probably lose our minds, like dividing by zero, or trying to understand the proportions of space between protons and electrons, between our galaxy and the pillars of creation, like trying to understand child birth or our mother’s love.

This is a combinatorial magic. A magic of ethics, science, laws, biology, physics. But magic is what it is, because it supercedes what our imagination can make of the facts. There was water, now there’s wine. And in that comma, a miracle. In the space between two states of being, an indefinable thing.

——————————

The first time I saw it, I almost missed the whole thing. But that’s the nature of magic, if you spend too much time trying to see it, you’ll miss it. I was 24, I was grasping for meaning. I went for an organ procurement with a relative stranger, we flew in a jet, like some sort of movie, to a different state. We retrieved an organ from a young man who had died of head trauma. I remember the moment of silence for his gifts. I remember seeing his wide open anatomy, the fearful, wonderful spaces where no eyes or hands had ever been except God’s and now ours, somehow.

I remember flying back. I remember the pilot greeting us with a couple of burgers from Applebee’s on the ride back, and I remember not having a concept of being tired at all. The transplant surgeon went to sleep on the plane.

I remember coming back and scrubbing in for the first time while the transplant surgeons put the liver in. I don’t recall the moment it happened, so much was happening, so fast, but I remember seeing the gray liver become rich, purple, and alive. How?

——————————

I spent three and a half years in a lab, based probably on just that night, trying to understand just one part of the mystery that is organ transplant. Just the very small sliver of the mystery, and what I found was that there’s just more wonderful mystery, every answer leads to wider array of questions. That’s the magic.

——————————

A few months ago, I sewed in my first kidney transplant. The clamps came off the blood vessels that allowed blood to go in and out of the organ, and it turned a purple and then pink as it came back too life. It was magic. And no one can convince me otherwise.

—————————-

Sometimes the miracle is not so straightforward. Sometimes there are twists, turns, there are setbacks, there are losses. Sometimes a heart stops during surgery, sometimes the body rejects the organ, sometimes you’re so weak after surgery you choke on your own vomit and nearly die. Sometimes the magic is mired in heartache and failure. That’s when you realize it’s magic.

———————

magic is not an excuse, it is not a lack of serious and disciplined investigation, it is not a panacea, it is not a shrug. it is the thing that happens when the sum is greater than the parts. When you look up at the ceiling and realize that the small blue square you were painting is part of a massive, glorious whole, a vista that a single mind couldn’t independently hold if it tried. Magic is not a scapegoat. It’s the respect you give to the unnamed fifth element, the unknowable ingredient. magic does not downplay or denegrate the hard work and sacrifice of the many minds and bodies that worked for the miracle.

————————-

Some Badasses

This is about some badasses I know.

They walk amongst you in the grocery stores, libraries, you may see them in coffee shops or more likely, bars, you may be sitting behind one right now in hot, sticky, Atlanta traffic. Eyes up!

They can get a 14 gauge IV in a hypotensive, tachycardic, essentially dead person, whose veins are more like wet tissue paper, rather than tubes of blood. They will sneak an NG tube and a foley in the patient in about 5 seconds between inubation and the CT scanner. You can’t even put your gloves on that quick.

They don’t wear capes, just stock blue scrubs, and sometimes bedazzled name badges. They have access to the trauma elevators that take you exactly where you need to go. You don’t even have access to the staff bathroom. Nor should you.

They can stop pain. Literally. They can make it stop. Your femur may look like a bad jigsaw puzzle, and your pelvis may be split in half, where your motorcycle tried to slam straight up through your body, and your chest may be caved in like you were made of play-doh when an industrial forklift tried to punch through you, but these people, they can make you feel like you’re floating on the Chattahoochee on a sunny Saturday. With fentanyl and ketamine. But still. They can do it. I’ve seen it.

They can take your clothes off before you can say your name, even if your name is just “Bob”, like Madonna, just the one word, “Bob”. They may do it with comically large shears, but still.

You may have uncontrollable diarrhea from c. diff, and you may be incontinent, but I know people who can put a clean femoral line dressing on you and keep it that way despite your uncooperative bowel and bladder. They can do it. I’ve seen it. They can keep it pristine all night with some sort of witchcraft that has not yet made it to the rest of the hospital system.

I know someone who can do chest compressions on you, and make your arterial line look like a normal pulsatile heart beat. They may ask someone else to open the pickle jars at home, but here, they will break your ribs to keep you alive. You never even suspected they could push so hard.

They work at night, during the day. They worry about if you can eat and if you’re ever going to make it to the OR. They want your pain controlled. They know your labs before I do most of the time. They mourn your broken body. They laugh when you say silly things after you get the drugs, before we try to fix you up. They talk to your family to help them understand what is actually happening, translating the medicalese we casually throw at you into something you’ll understand. We try. But they usually fix it for us.

These are the nurses and techs who work the trauma bay.

You find them in other places, but these undeniable badasses are the ones who taught me in the bay. They can smell fear on an intern. They call bullshit on the atttendings. You may have just killed someone, just shot someone, maybe just a block down the street, but now you’re in the bay, and sorry Dorothy, we’re not in Kansas anymore. You may have just stabbed someone in the face, but these nurses will look you dead in the eye and tell you that if you need to pee you’ll have to use the urinal or just hold it, but no you cannot walk to the bathroom rght now, and to keep your voice down. You may be a hardened criminal but these nurses will make you cry for your mother if you step out of line. I’ve seen it.

You may be bleeding in your chest, your belly, out of your open bilateral femur fractures, but i know someone who can dump blood in you faster than you can put the transfusion order in, or heat up a lean cuisine.

These badasses work in our trauma bay. Sometimes you’ll find them in the OR, burn unit or the ICU. They provide your hands on education, how to actually take care of the patient. You may know the krebs cycle but you don’t know the first thing about taking care of someone until you’ve been yelled at for not restarting a diet. That’s when your education really starts. You may know the parkland formula, but you haven’t learned a thing until you’ve been taught how to properly do wound care, and leave zero evidence of the mess. Honestly, you haven’t lived until you’ve seen someone get a peripheral IV line in a bleeding, diabetic, smoker, with heart failure, end-stage renal disease while you hold pressure on their bleeding fistula. Becoming a doctor is a lot of things, but the most unexpected gift is all of the teachers you find who don’t have academic titles, they just, you know, know how to take care of patients. They’ll show you, if you let them, that magic of caring for someone with your own two hands and a small measure of your humanity. In ten years, we’ll be re-writing the guidelines on how we treat traumatic brain injuries, but the wisdom, the healing you learn to administer by being there, with the family of a kid who suffered a devastating brain injury when he slipped off his motorcycle, that’s a special knowledge that won’t change, and might make all the difference.

———————

The word patient, comes from the latin word meaning “suffering”. Despite the advances in medical science, and maybe due to those advances, we have found ourselves wandering further and further from the patient, and closer and closer to scans, charts, labs, machines and computers. Who can blame us? We put out money where our mouth is. We throw billions of dollars at the computers. We should probably stare at these screens all day and night with our eyelids taped back to our skulls. Some of us probably do.

But the people who remain near the patient, those with the suffering up close, like boulders in a river of human trauma, they can teach you how to see a sick person, really see them, not just evaluate them. You need to do both. They can give you that priceless gift for free, maybe just for a small share of your heart.

———————-

“I’m worried about him.”

Get up. Go see them. Nothing will teach you how to spot a sick person like seeing one.

"Do you think they need a unit of blood.”

Give them blood.

“She’s in a lot of pain”

You haven’t put the orders in yet, so just sit down and do it.

“Can you talk to the family.”

Yes. A thousand times, yes.

“Don’t you dare cut that bra. I will cut you.”

Ah. Okay.

—————————-

Just some badasses I know, and am so thankful for.

The Shame

This is the shame.

It starts with you. It starts with the heat in your face when you forget. When it’s not the way they asked, or even if they didn’t ask, but it feels as though you should have known. It’s the same. This is the shame.

It works its way up when you realize you’ve been to college, medical school, damn, maybe you’ve even gotten a masters or for the really fool-hardy another doctorate, and you find you can’t staple a packet of papers the right way. You can’t line up the lab values the right way. The urine output is from the day before, not the last 24 hours. There is dissapointment, the team bends a little with these small stresses you put on it. The morning feels longer, doesn’t matter that you woke up at 4:00AM. What good is any of that if you can’t tell the difference between an X-ray taken this morning, and one taken yesterday. This is the shame.

It has a smell, the shame. It’s fear sweat. You can smell it when they ask you if the labs have been collected. Its got the metallic tang of failure in it. No you don’t know if the labs are collected. How can you know? Should you have collected them? The questions pile on more just questions marks under a dull roar of the blood rushing to your face, what blood vessel does that, makes that roaring sound that is the sound of the shame? You should know. But you don’t. This is the shame.

It has texture, the shame. It’s your slippery gloves that make it impossible to grab the stitch you’re trying to tie, it’s that ache in the small muscles of your palms, especally the one between your pinky and wrist, that is siezing up like it is holding onto this thread for dear life, why is that muscle even working? It has no business in tying this knot. It should relax. But it won’t. Your body even, your own body disavows you. The shame comes on full when your fingers slip and fail. You’ve tied your shoe laces three hundred and sixty five days a year for twenty eight years but you cannot tie now. This is the shame.

It has a tension, the shame. It’s your aching forearm, your aching back, it’s your aching arch of your aching flat sole of your forsaken flat foot. It’s the burning in your shoulders when they say “Pull a little more” it’s the numbness in your thumb when you are holding the gallbladder and you can’t understand why that is the only way to hold it but it makes your finger numb, but despite your age and your education you can’t cluster together the necessary neurons to figure out how to hold something so it won’t burn in your muscles or make your hands go numb. This is the shame.

It has a taste. The shame. It’s the bile acid taste in the back of your mouth when the patient dies, leaks, bleeds or spirals into a tachycardic, hypotensive, beeping, buzzing, inflammed, hypothermic hurricane of your own faults and mistakes. It’s the dry spit and salt taste when you say the words, “I should have done better.” Maybe someone else can do better. Better without you to send their family members to an early grave. This is the shame.

It has a sound. The shame. It’s the sigh, a short, heavy sigh of being discarded because you are unable and incompetent. The sound can change. As you float outside of your small one-man show into a slightly larger play. The sound is the heavy sarcasm that puts a bowling ball in the center of your guts. You realize you’ve been searching for ways to make this about you, but it’s not, and it never has been. The shame is you never saw that yourself. You always held up your failures as a mirror. But it’s a small window, a cracked and broken one, and you can see finally just beyond yourself, you can see everyone and everything trying and reaching for a little better, and here you are stumbling about in the dark like a drunk, looking for gold stars to put on a report card that’s no longer coming, when all you needed to do was to give a damn about anyone but yourself. This is the shame. The shame is, if you cared enough about anybody but yourself, you’d be doing the things, learning the things, reading the things to make sure you can help. This is the shame.

It has an end, the shame. It stops in the small puddle of the anxious sweat and tears you cried for yourself, the ones that were shed over your minor dramas. The shore is just beyond. You can step on that edge and out onto a bigger, scarier, more humbling vista. The large landscape of human suffering stretches out, some people so mired in their own delusional tragedies they couldn’t hope to be aware of the others. That is the real shame. The shame of self pity. The echoing loop of it. You can scramble to the edge of your self pity, and try to see the purposes that stretch out on either side of you forever. So many purposes. Can I help someone? No shame in that.

“Maybe I can be better than I was yesterday.” No shame in that.

“It’s not about me.”

————————-

I see them bludgeon each other with it. It’s hard to watch sometimes. They try to bury you in it, hoping that enough pain will fill that small pit of despair and you will, like a rat in that analogy, drowning, churn your guilt into something substantial until you climb out. But the saline you sweat and cry doesn’t solidify the same. You just drown. Now, I know there’s a better way, to acknowledge the shame without using it like a terrorist or a torturer. We try our best to beat someone with the shame, for a misdiagnosis, for a mistake, for a misstep, for a lack of knowledge. I sat through the self-flaggelating conference where we ritualistically punish ourselves and made a point out of a personal failure, or it seems, make a personal failure out of a point. I thought about the fact that the only voice I wished to hear was that of the dead and their family. I’ll never forget that. But it’s not the shame. It’s the empowerment that comes from knowing you could, you really could make it better. And there’s no shame in that. I don’t know why we use pain so commonly and primarily as a means of inflicting improvement. The sins of our fathers I suppose, that’s the shame.

First day

It’s day 1.

You don’t know where the bathroom is.

You’ve been to this hospital before. Shit, you thought you knew what you were doing on your Sub-I. You got a great rec. What the fuck is the dose of tylenol? Can you do 4 grams in a day? or is it 3? Shit shit shit. You put your order in, best guess.

The phone rings. Your heart rate is 150. Is that RVR or sinus tach? Fuck.

“Yes this is Dr. Moore,” You don’t sound sure though.

“Moore?”

“Yes, Moore.”

“Moore what?”

“No. that’s me I’m Moore”

“Moore what?”

“Are you trying to reach the trauma intern for team one?”

“Oh, no sorry wrong number.”

“Okay.” They already hung up.

Where the hell is the bathroom? You’re looking down the list of to-do’s the team signed out. There’s so many patients, you don’t remember anything they said during sign out. Who needed their urine output checked, again? Your checkbox is hovering between two different patients. Well, better check both their urine outputs then.

The phone rings.

“Yes this is Dr. Moore.”

“Oh yeah, I was trying to reach you.” It’s the same voice as last time.

“My patient is tachycardic, and has more pain -” The phone cuts out.

“Hello? Where are you calling from? Who is the patient?”. Theres a jumbled sound of static and beeping on the oher end, there’s another conversation going on in the background and you can’t hear.

“Hello?”

They’ve already hung up. Shit shit shit.

———-

it’s 3 am. You call the senior.

“Hi, i just got. a call this patients lactate is 5.1, what umm, what do you think I should do.”

“Well, why don’t you tetll me their story.”

“Right, well um, they’re a 40 year old, trauma, MVC from a week ago, they had a right colectomy, umm…” You rattle off their information.

“Alright, what do you want to do?” The senior asks.

Shit what is this a fucking quiz, why can’t they just help you. Stupid son of a-

“You’re a doctor now. You have to come up with a plan for this patient. So what do you want to do.”

You want to reach through the phone and slap them. This is not the time for pop quizzes, dammit, this is the time for answers and help and, and did he just say I was a doctor? What kind of sick joke…

“Um, well, I want to give him fluid?”

“Looks like he went to the OR with ortho for his pelvis a few hours ago.” The voice on the other end of the line says…leading question….?

Shit, you should have mentioned that.

“Oh yeah, that’s, that’s why we got labs.” You say kind of lamely.

“Well there’s no hemoglobin. So what do you want to do.”

And on and on, a conversation that feels equal parts embarassing and unhelpful. You check the labs, you give some fluid. The patient does fine.

———-

It’s 4am.

The phone rings.

“Yes, this is trauma one.”

“Hey Dr. Moore, It’s Dr. Jones.” Oh shit it’s the attending, have they figured out I’m an idiot?? Did I Kill someone?

“Yes Dr. Jones, Ma’am, how can I help?”

“Do you want to come help me do a diagnostic lap?”

The answer is obvious. No, you have to check on 30 more patients you don’t know, you still haven’t checked that urine output, But you want to be a surgeon right? Although you are seriously re-thinking it now.

“Yes ma’am, I’ll be right there,” You say, unenthusiastically.

“And Dr. Moore,” the tone is less friendly, “Don’t call me Ma’am” Shit, is she mad at you? But that’s how you were taught to address women senior to you. Shit. Have you managed to disgrace yourself before you even got to the OR? Shit shit shit.

“Um yes, Ma- I mean, yes Dr. Jones.” Shit shit shit.

——

It’s 7am. The sun is up. You survived. More importantly, so did your patients. You did your first case of residency. You smile. Maybe, maybe this won’t be so bad. You found the bathrooom too.

Informed Consent

“I was just swinging by to see if Ms. Campos was here.”

“That’s my mom, you could probably tell,” you reply with a wry smile. The resemblance is so obvious I wonder what your dad could have even looked like. You look the image of your mother, but brighter, with the bold pink letters on your black t-shirt announcing the EDM festival you went to last year, and highlighter yellow adidas folded up under you. If we hadn’t met here, now, I would imagine your life was a series of dance festivals interrupted only by the boredom of driving from one to the next.

“I figured, but you never assume, I’ve called daughters sisters, and sisters moms, and so on, but it’s nice to meet you,” I reciprocate the smile, pleasantries all around.

“So what did you want to talk to my mom about?”

“Well we are planning to pull her port out, she has this infection associated with it, it’s a short procedure we can do it here with some numbing medication.” I shrug easily. “Just wanted to talk to her about it and get the consent form signed.”

There’s an abnormally long pause.

Usually, you would nod, look thoughtful, maybe ask a few questions but usually not even that, usually you would just say something agreeable.

A second turns into a minute, but feels more like a decade before you speak.

“I can come back later when she gets back,” I say, trying to cover the unease.

“No. No that’s okay, she is coming back in just a second she went down to get some fresh air in that garden ya’ll have, she loves that place… But, can you tell me something?” Your face is very pensive, you’re sitting in the chair next to her bed, I can’t say for sure but you can’t be morre than 25, like your mom you’ve got a baby face, and your voice squeaks and twangs like an old slide guitar, the sound of sweet tea and tomato sandwiches. You’re from that deep-deep-south and your mom trucked up here because my boss was the only surgeon maybe anywhere willing to do her operation.

“What is the worst thing that could happen? When you take this port out?”

“Well,” I begin more awkward than I mean to be, “It’s really, honestly, a minor procedure, we have to cut the skin and sometimes the port is kind of scarred in so that takes a few minues to peel off, and then it’s sort of like pulling any line that your mom has had. In your mom’s case, when there’s infection, it comes out pretty easily. It’s just a matter of holding pressure and pulling. I’ve never had a complication from pulling one out, It’s possible for there to be something called an air embolus I suppose, or bleeding from where we are pulling the line,” I shrug “But i’ve never seen that, the more common-”

“I have.” you say quietly. I didn’t think you could squeeze any tighter into that chair but you have.

“Really? You’ve seen an air embolus?” I ask without a little bit of incredulity.

You’re not looking at me.

“I have a sister. A younger sister. When she was 19 she had to have a line put in her neck kinda like my mom has. She was healthy, but they said she needed this line in the emergency room. They didn’t say there were many risks and they said they did it all the time. We agreed you know, we’re from a small town,” Your eyes are full, your voice is thick. You shrug, “We just sort of said ‘Yeah, sure’.”

“Yeah," I say like an idiot, with a foreign horror growing inside me

“Anyway, they put this line in, and there was some sort of problem with the line or something, anyway they put it in the wrong place maybe, and a big bubble of air got in, and my sister had to go to emergency open heart surgery,” Now you’re crying, your face, the image of your mom’s, is looking at me with no shortage of tears running down them, your face couldn’t hide a single detail of that anguish. “So you know, now I ask, and I tell people to ask: what is the worst possible thing that could happen? Because I should have known better.” You say it with no malice, just a hard realism that doesn’t fit anywhere in the young, opimistic, unburdened face I saw just a few minutets ago.

“Yeah, of course, I appreciate you asking and, I am so sorry about your sister,” I manage to say trying to cross the gulf.

“My mom takes care of her, she needs a hundred percent help now you know, she needs someone to dress her, she was normal before, and they told us after her surgery she would be a vegetable you know, but she can sit at the dinner table and sometimes she surprises us, but my mom takes care of everything for her, well she did until she got so sick and needed to come here.” You give me a strained smile, the eyes are drying, you’re body is relaxing “So that’s why I want to know what the worst thing is that could happen, because I’ll be the one to take care of them if anything happens.” Your voice has lost all its warmth, carrying now a void, flat realism that doesn’t fit with your southern drawl, or your neon shoes. How could someone so small carry so much grief, I wonder. How do you bear up under it? I am crushed by it just standing near you, feel the weight of it pressing into our conversation.

“No, I understand. I mean, what we are planning to do, taking this port out, It’s pretty sraightforward.” I talk about the risks, I talk about the benefits, I talk about the possibilities, I assure you this will go a long way to helping her get better, you nod now.

We talk for a southern minute, you brighten slowly, you talk about the EDM festival you went to. You’re a manager at a retail store. You’re proud of your mom.

————

I remember my intern year, consenting a patient for the first time, and reading the legalese on the consent form. Death it says. Permanent brain damage. Paralysis. A dozen other horrifying things. Then a couple of lines for me to write the most relevant complications and risks, which I dutifully do: infection, bleeding, damage to surrounding structures. But I never think I’ll kill someone by pulling their port out. Anything can happen. Anytime. To anyone. And for them, it’s a case series of 1. Our language about risks, hazard, odds is all a bunch of statistical bullshit to that one person.

————

I had taken care of Ms. Campos for weeks, and she had never mentioned all of this. The port has been out for a few days. She looks better. The midline wound is healing. The bacteremia has resolved. Her fevers have stopped.

We never talk about the weight of responsibility that hangs on her narrow shoulders. We take for granted your benign smile, your tacit understanding, your implicit trust in us. We are the Big Ivory Tower Academic Center, with a capital “A”. The one the regional masses flock to for our technical wizardry and scientific know-how. There’s portraits of of old white guys in the hallways, that oil painting of significant size that emphasizes “This Guy did a Thing.” There’s posters of people in white coats with test tubes in their hands and glass flasks in obscurous behind them, with the subtitle “Game Changer”. I mean, the whole place inspires confidence. But your trust shames me. I know how fallible we are. For all the marble edifice, the floor to ceiling windows, and endowed chairs, we are just probing into the unknown offering our best guesses with our best attempts. Would that we could be worthy of your faith in us. But we are just the sum of our shortcomings. Small minds excavating at the edges of what we think we know. We do our best. No guarantees. But our posture says, “We guarantee it.”

——————

I sit half awake in Grand Rounds, I listen to one of the most respected surgeons I know tell us how, just 20 years ago, we used ot kill patients by flooding them with fluid until their bodies ballooned up like Michelin Men, and their blood turned into Kool-Aid and poured out of them. “That was how we used to take care of patients in hemorrhagic shock, until we learned better, now we give blood early…” He talks about massive transfusion, and trauma. My mind wanders back to Ms. Campos. I wonder if in 20 years I’ll think of the surgery we did, the saga we subjected her to, the burden we foisted onto those narrow shoulders already so full. Will I be proud of what we accomplished? Will i swallow back the bitter taste of guilt? We do our best. No guarantees.

Cold leg, warm heart.

You’re a survivor. I can read it in the way your skin sags from your bones, and your blood cultures grow almost pure bacteria like a bad lab experiment, and your heart just ticks away and you smile when I walk in the room.

“Mr. Verano! Good morning! How are you?!”

The medical student mutters to the other medical student, “Why does he always yell like that?”

Because you’re basically deaf. But you smile benignly. “It’s that time…” you say… You say that every morning. I have no idea if it is that time or not.

“You’ve still got a good pulse here!” I announce obnoxiously loud and then in a normal speaking voice, “Go ahead and take down those dressings, “ to the medical students.

One is disgusted. The other morbidly curious. They’ve never really seen your leg before, but they’ve seen wounds. Oh I made sure they saw some good ones. One of them, I can’t tell which one, moans quietly while they pull down your dressing revealing, honestly, some pretty good healthy beefy tissue.

“That looks good Mr. Verano, this thing is starting to heal,” to the med student, “Do you need to step out?”

“No… I think I’m fine.”

“That beefy red tissue is healthy, you should’ve seen it before his surgery, basically it was dry and yellowish black and more or less dead.”

“oh. That’s good.”

She has no idea. She is alarmed by the sound of my voice.

“I think I knew you in my old neighborhood,” you whisper. “You work at the grocery!” You tighten up your face which is a bundle of elastic that has lost it’s stretch, like sweat pants from the ‘80’s, sagging from the outlines of your skull, your skin, which is more liver spots, than that healthy tan you developed hanging out on the beach in Sarasota at your retirement community, is like some damaged papyrus that falls apart and wiggles away when we touch it.

“Close, we’re at a hospital. It’s Monday. You have bad blood flow to your foot, and we fixed it. You’re just a little confused, it’s okay.” So am I.

You look at me with a completely vacant stare, like a greek oracle, “This is it.”

“Alright Mr. Verano, We will see you later, I’m very happy with your leg.”

Outside the room the mediical students blink like they’re trying to forget the image of your foot, with its missing big toe, and beefy red wound across the side of your ankle.

“He had a nice pulse,” I explain, “that red wound, that’s healthy, overall this is a good progression for him.”

“He looks so sick.” One of them says

“Yeah, he is, he’s a 66 year old guy in a 90 year old’s body, he lived a hard life.” I spoke to your kids yesterday, they didn’t hide their anger or frustration.

I get it. They want you to get better. But no one can tell me what better looks like. From here, it looks liike your foot healing. Finally. From them, they want to see their Dad, as he was, 20 years ago, a white tanktop on, a cigarrete in his mouth, healthy pot-belly shaking with laughter, ambliing around the kitchen picking at Mom’s pre-dinner preparations and smiling innocently. Better is a matter of perspective. Today, your foot is healing. Last week, your foot was killing you. You’re delirious from being in the hospital. I can understand why your kids are mad. Better is a matter of perspective, but sometimes building a bridge from their perspective to mine feels impossible. I didn’t know you as you were. They don’t know you as you are. The tension between those visions is thin and tight, like a dream that could snap and recoil to either pole if anyone moves.

a small savage

“No, no, no, no, noooo…” your tiny voice cries softly.

I know, I know, I am scary, It’s hardly morning, I’m here to look at your belly, at your drain, I’m here to press on your belly, and I know that anguished squeal is all that you can muster right now.

“You’re such a big girl, “ remarks mom

“You’re doing so good,” I assure you,

We lift the tiny blanket, it can’t be bigger than the surface area of my chest split open. It’s a small blanket.

We place it just above your pelvis, hugging your tiny hips that look like the kind of fragile china my mom would never let me touch growing up.

“You’re such a big girl!” whispers your aunt from the corner of the room.

Your tiny hands tremble and lift the hem of your dress up to your chest

The wound across your abdomen, you wear it like a warrior’s scar, a tiny savage that tussled with some one fingered bengal tiger, and won.

Your body shakes, I know, I am scaring you, but you are a proud little warrior. This time you didn’t cry. This time you lifted your dress to show us your wound all by yourself.

Your perfect smile breaks out, even as tears spill down your face.

Your dad looks at me, “She’s so brave, she hadn’t done that before”

“She is.”

His eyes are filled up with tears, they sit in those craters and well up and sloppily sink through his beard.

Your tiny fists ball up the edges of your dress, your holding up against your perfect face, there’s not a single hair on your perfect head is there? Your fists are tight and angry like a brawler’s, you tiny tempest. Every morning I see you something wakes up, something that was buried, something fierce responds to your ferocity, something hard and hot and full of light, burns through the debris, it seems to radiate a hot anger and love at once, it’s that unbridled courage in your delicate fingers that pushed us away the first time we met.

You are my courageous little queen, a warrior princess. I can’t wait to say goodbye, and never see you here again.

Boston

I feel like we’re talking about our favorite kinds of bagels, but we are actually talking about ways to rearrange your insides.

“I actually had a good poop earlier if that makes any difference to ya,”

“Well that’s good,”

“That doesn’t really change much, eh? Are you from New York?”

I shake my head and shrug.
“Yeah actually, how did you guess? My accent’s pretty neutral I thought”

“Oh I could tell. Where do you get decent bagels around here?”

“You don’t”

You chuckle easily, we take turns making fun of Atlanta bagel shops.

“Don’t even get me started on the seafood. I miss Boston. Alright Doctor, well, I’ll see you tomorrow. Try your best to take care of this.”

Your voice carries that Boston accent that that steers wide of pronouncing “R” and ends as many words as possible with the sound a shrug would make if a shrug were a sound - “AH”. “Clam Chowdah”. “You Bettah”. And so on. It’s crisp the way the wind is coming in off Boston Harbor.

———————

I unzip your skin, your fat, your muscles, and open your viscera. It’s Christmas Eve-eve. My wife is wrapping presents. I’m opening your belly.

“Ah fuck.”

Across the table, the surgeon looks up for a half second, “Put your hand under his fascia here”

Your abdominal wall is plastered with rough pebbles, where it should be smooth. Cancer, like barnacles clinging to the side of a ship.

“Yeah, same on my side.”

We silently run the loops of your intestines over our hands and reach down into your pelvis. It’s a horrible matted ball down there in the corner where it should be loose, easy, and compliant. It should smoothly move across my finger tips, but this cancer has socked your intestines into a knotted mess, like a hard rubber ball that’s melting and cooling in the corner of your belly over and over again, turning the corners of your belly into a congealed wad.

“Let’s find something we can put together here, how far down on the small bowel can we get?” He wonders aloud.

“Clear off the transverse colon there.”

“Yeah that sits nice”

We start to sew your large intestine to your small intestine, so that food doesn’t get stuck in the malignant traffic jam that has replaced your intestines.

————————————

“Last night was fine, I’m farting, you wouldn’t believe the stench in here you must be farting too,” you chuckle easily. I laugh too.

”How did the food go?”

We trade news like parishioners seeing each other in the grocery store, meals are good, my wife is fine, thank you for asking.

———————————-

Sometimes I imagine you sitting in a Back Bay restaurant enjoying a beer and a deli sandwich, with your wife, complaining about Belichick. I imagine you laughing and relaxing. Maybe that was before. Maybe it’s next month. I hope we got you there.

Trauma

Your femur is broken in a way that makes your leg hang at an unnatural angle, the bone erupts up, through the skin. They call these “distracting” injuries, these obvious, painful, almost exaggerated injuries that could steal our attention away from other more insidious, more deadly injuries you may have suffered.

But that isn’t the issue here. Your spirit has already left your body.

“Time for the secondary, Dave”

“Yep”

“Can someone roll while I take a look at her back?”

“Yep”

You were young, you were healthy as far as I can tell, fit even. Your arms have the outlines of muscles that see regular, active use - did you play a high school sport? There, along your flank, just below the curve of your rib cage is a small hole, I can’t even fit the tip of my pinky into it. That’s where a bullet either entered or exited your body. That is where a small metal ball left your body, most likely, after it ripped open one of the large chambers of your heart, and tore you away from your family, your friends.
Did you go to prom this year?
Did you have a dog?
Did you do senior skip day at your school?

It’s been a long month of this.

As my co-resident put it, “I cannot keep watching young black boys and girls die.”

There are these plastic stretchers, dozens, leaning up against the wall outside the hospital, like rental surf boards. I walk by them on my way into work every morning. I wonder to myself, every morning, how much death did these boards convey into us. Just one? Five? Fifteen, just last night? These boards could have been anything. They could have been melted down and used for kiddy pools. They could have been the plastic in your straw for you to sip through, the tray your meal comes on, the casing on the lights overhead, the pen I’m holding as I write down each of your injuries, the ways in which your body was broken.

These plastic boards are sometimes covered in blood, just before someone gets a chance to scrub them down. But some things you cannot wash away. These plastic surf board stretchers look like those life-savers life guards wear around their shoulders on TV. They could have been one of those. They still can be. Do they ever get tired of carrying in corpses? Your fragile body came in on one of those. Your body agonized on one of those, for minutes, probably. Before the blood that was trying to get to your brain poured out in a warm puddle around your broken heart.

There on the left side of your chest, just to the left of middle, is another wound. Small. My little pinky finger wouldn’t even fit into it.

I look down at your arm pits, your arms, your hands, your fingers, your pinkies. You are broken beyond our repair. I wonder how. I wonder at your beauty, the beauty of your irreplaceable brain, your fingers that held your mother’s hand when you were a baby, the careful architecture of your wrist and arms that will never hold the people you loved. I run my hand over your cold belly, soft, dead.

“No other obvious traumatic injuries to the back, buttocks, posterior legs”

Your spirit has departed your body, and now this shell echoes a longing in me, a small hollow in my heart, that I will keep you in. I wonder how we come to this place, where we can discard each other like trash, like used coffee filters, like disposable gloves. Maybe your killer should be forced to perform the secondary exam of your corpse. Maybe they should be forced to go to medical school and learn the thousands of mysterious and wonderful ways your body coalesces into a living, breathing, walking whole, a human living, a human being. Maybe the only justice is the knowledge of good and evil.

How can you be properly haunted until you begin to understand the miracle that was the life, the breathing body, the sinewy, vascular, muscled, organic wholeness that gave rise to the thinking, feeling, moving, wanting, desiring creature.

Maybe the knowledge will produce the appropriate grief and repentance. We should grieve your tendons. we should wear grey mourning clothes and raise a cry in public over your viscera, your precious kidneys, we should wail with abandon at the intersections over your liver. We should mourn like the psalmist over your cold toes.