Light Heart, Dark Tea

Dark, blue, sterile. You gingerly unwrap the tightly sealed package and the thin sheets come apart slowly, neat and elegantly balanced on a wheeled metal tray. You touch only the outsides as you pull on gloves; Snap, snap! Powder and latex cover your hands, too long at the fingertips, but you push them down, then ignore them. You glance up; the patient breathes rapidly, looks away; periodic cries from the monitor remind you that it's probably not working again, but you look anyway, hesitate. Back to the patient; jugular notch, three fingers down, nipple line. 4th intercostal space, just anterior to the midaxillary line... is that it? You palpate the ribs, push hard, run fingers along their smooth, dense bodies, rigid underneath the leathery skin. Is this right? Is it here? You pierce the skin with a thin needle, anesthetic seeping under the skin, fuffing it up like an enormous goose-bump. The skin swells, the patient moans, you pull back. Small scalpel blade, the length of a thumb, thin and razor-sharp. You hold it like a butter knife, loose gloved fingers pressing tightly against metal. Right here? You breathe, you cut. Pale, pink tissue gives way under darkest brown... you run the blade along slowly, smoothly, then press harder. Once centimeter... two... four. Crimson drops obscure the view, but that's it, the blade is nearly through. "Forceps!" You're handed a needle driver. There are no forceps. You breathe again and push the blunt metal hard against the incision, pushing through, pushing further through. The patient moans... more anesthesia? No, he's supposed to scream. You push again, then remove the driver and feel with a gloved finger... there is only muscle, so much of it, so thick, hard, nearly inpenetrabale. You push again, harder this time, putting your entire body weight into a trembling hand. You feel as though you're going to fall into his chest, fall into the tiny cavity made larger by the brutal dissection, and still, you're not through, there's more muscle. Deep breath, push again. And then, ah!! You're in, your wrist collapses against his chest as the blunt dissector finally punches through; there is blood, dark, deep, running over you, over the bed, onto the already darkened floor. Quickly, reach a finger in... clots, strings, ribs... you feel hard pulsations reverberating through the lung, barely palpable at your fingertip... it is partially collapsed, and there's blood, so much blood. You pull back, and a thick plastic tube replaces the digit; you release the clamp and blood is allowed to run through, bubbling at the base of the collector. Crouching down, mesmorized by the swinging indicator, you watch the water seal closely. You're in, you're through. Several sutures in, and you're on to the next patient... another chest tube, another ABG, another line. They come through like soldiers in an inexplicable war without a front line, leaving their scent, parts of themselves. Blood, sweat, saline, everything everywhere. You come home to wash but it's still there as you try to sleep... there are dreams of blood, dreams of dark raptures circling overhead. We are like scanvegers, competing for procedures over prematurely slaughtered flesh. We joke, drink coffee, retreat but always come back to chaos. This is emergency medicine, this is trauma. This is real... it is the most real thing I have ever done.

The days are long because they are quieter; the nights run by in a flash of needles and scalpels, splints, drips, and stretchers. I am working nearly every day... tonight will be my ninth shift in less than two weeks and the weekend is yet to come. Sometimes it really is like a war zone and you wonder how people find the money for drugs, weapons... there is so much of it, there seems to be almost nothing else. There are the patients that make you laugh... there was a car accident victim on Saturday night who had suffered a TIA whle driving; we couldn't clear his C-spine right away and so he had to lay on a stretcher for hours, large orange headblocks tightly strapped to his chin and forehead. In a delerium, he would continuously sit up, entirely compromising the immobilization, looking around with a bizzare resemblance to an enormous teletubby. It wasn't funny, but yet it was hysterical... in the middle of the night, i wished for my camera as much as I wished for a faster radiology service. There was a man with a "broken penis" who I was lucky enough to suture... he was stoned out of his mind, and all the better. I think of the patient whose chest x-ray showed possible bowel in his chest, cringe at the battle over whether he would be allowed a CAT scan... back home we CT everyone; here, it is a rare luxury. I have begun to hoard supplies... a small vial of antiseptic cream is tucked into my pocket, several ABG tubes stuffed into another... there is always a shortage of something, monitors breaking, gloves for tourniquets and dirty plastic instead of biohazard bags. It has become a joke - lazy nurses, incompetent technicians, medical students who disappear and cabinets that are never stocked. I ask the residents how they deal and they reply with weary smiles that they know no other way... but then, I do, and that stays with me. Unstable patient? Directly to the OR? No, there is only one OR, and it's booked straight through... just how unstable is he? A young woman was hit by a bus, run over as she was crossing behind it; The stringy, pulpy muscles of her left leg reminded me of cadaver lab as I held it for bandaging, and my stomach turned. Six hours and the vessels are gone, all muscle compartments turned grey, necrotic... when you wake up, you will not have a leg, and your life will be forever changed... i'm sorry, there was only one OR, they know no other way. I do.

They say that there are no atheists in foxholes, but either I am yet to be fully entrenched or "they" are wrong. I don't see god in this work, and I don't see god in the situations that makes it so plentiful. I see predjudice, bitterness, stigma and greed spilling over. I spoke to a patient as I was suturing him, a 37 year old man pushed off a train. Yes, it happens all the time. He has a daughter and works six days a week to make forty dollars. I hesitantly approach two refugees from the Congo, and they eagerly tell me about their dead fathers, about being illegals. I say that I hope we can help, I hope they will be healed, will get asylum. They say it is in God's hands and smile patiently, wearily, but still smile. I look around but I don't see God in these hallways. A petite, white 75 year old woman was turned away by the nurses because she needed a referral first... a referral from an inner city clinic where she could not go because she is old, and she is white. Racism? Realism. I would treat her, and I would treat a little old black lady just the same. But the nurses scowl, speak Zulu, and we turn away... white doctors, asian doctors, not black and not them. Us and Them. Is there racism in my country, a resident asks me. I'm not sure what to say... I shrug and reply there is injustice everywhere. So many patients, so much suffering, and hope? There is hope. I'm looking for it. Elizabeth is still barely responsive, moaning gently to pain but otherwise restless on her startched ICU sheets. I wonder what her morphine dreams look like. I continue to check on her, keep watching the respirator, keep waiting for God to decide.

I am working tonight. I drink dark Rooibos tea and try to lighten my mood, lighen my heart. Perhaps we can make a difference, even if it's just bandaids. If God is indeed here, then I hope he will lend a hand instead of only watching from the sidelines.