print previewback BRUCE KILSTEIN
The Recipe For Making Blood
For the life of all flesh is the blood thereof; whosoever eateth it shall be cut off.
Leviticus 17:14
And so I conclude that blood lives and is nourished of itself.
William Harvey, Anatomical Account of the Motion of the Heart and Blood, 1628
The call came early and began as all calls do: Sorry to bother you. Nobody was really ever sorry to bother you; in fact, they were glad and relieved to be making their problems yours. Intensive Care on the phone with a patient’s falling blood pressure. Every night on call, Dr. Eliot Sanders had an opportunity to wonder why he went into medicine. During the workday, the hospital was a living organism, pulsing with the beating energy of outpatients arriving for lab tests and X-rays, deliveries of babies and flowers and supplies, surgeons performing elective surgery, technicians and nurses busy tending inpatients; there are lectures, consultations, and prayers. Come nightfall, the heartbeat slows, and the building drains itself of the routine flow of the day. Visitors disperse and leave the sick to their silent suffering. Machines hum in quiet departments. Eliot made his way from the basement room where they stashed the residents with the extra mops and boxes of masks, up a narrow flight of stairs and across the vacant hospital lobby to the elevators. Elevator thoughts: causes of hypotension include dehydration, drugs, cardiac events, chronic anemia, sepsis, stroke, acute blood loss.
The younger residents hoped for quiet shifts. Left alone with your inexperience, nights could become terrifying. You lived with the decisions made without supervision, criticized in hindsight at conferences held in the daylight. But this was where you learned. When an attending physician tells you what to do in a given situation, you do it, but you may not remember why. When you figure something out in the lonely darkness, even if it’s what didn’t work, you are imprinted with the experience forever. Now in his third year, Eliot preferred to stay busy. Surgeons are people of action. Sitting suspended in a shabby on-call room avoiding the bad coffee, waiting, to him, was worse than a busy eight hours full of emergencies. Eliot’s favorite surgical aphorism: A chance to cut is a chance to cure.
The elevator doors opened and injected him into the quiet, ninth-floor corridor. He padded silently on paper-covered sneakers to the ICU, turning over his list of possibilities as to what could be the cause of the patient’s problem. He faced a second set of doors to the ICU. A plaque with a quote from Clara Barton read: The door that nobody else will go in seems always to swing open for me. There were days when Eliot wondered if a quote from Dante would have been better suited to the entrance. He used his ID badge to open this new set of doors. The lights were dimmed to allow the conscious patients to attempt to fall asleep.
Eliot joined a nurse named Clare, face lit from below by the green glow of a computer. Eliot had not seen Clare before. He knew all the regular nurses on the day shift. Who had reliable information, who you could joke with, who you could go out with and who you could not. Night shift people changed all the time: budget cuts, staffing shortages, work visa laws. Clare sat next to a pile of printouts, a clipboard, a pen on a string, and a half-consumed carton of the hospital juice labeled “orange” that had the bitter taste of grapefruit and fear. Nobody ever finished them. She offered one to Eliot. He declined.
She explained that the patient was a thirty-year-old woman who had been hit by a trash truck while putting out some last-minute recycling before heading to church. “Her blood pressure has dropped to seventy-nine over forty and her heart rate is 130.”
She was going into shock. “What was her last hematocrit?” Eliot asked.
“Her hemoglobin was 7.0 and hematocrit was thirty-two an hour ago,” Clare said. She was young. There was concern in her voice.
“What’s her name?”
“What?”
“What’s the patient’s name?”
“Oh.” She checked her clipboard. “Mobley. Henrietta Mobley.”
Eliot motioned her to join him at the patient’s bedside. He turned on the lights to the room but still had trouble seeing Henrietta. The truck had shattered her pelvis. The orthopedic surgeons had temporarily stabilized the bones by installing an external fixation unit. The lower half of her body was encased in a lattice of metal bars. The urologists had done their best to repair her bladder which, full at the time of impact, had burst. It would have been messy surgery. Eliot would have enjoyed sewing like mad as blood and urine spilled across the pelvis. The repairs done were left intentionally incomplete. Fix what you can and get the unstable patient off the table before she bled to death. Once the bleeding stopped, and, barring other complications, they could go back and complete their reconstructions. But such an injury often created massive blood loss. Blood that would continue to ooze for days. Drains had been placed to siphon off the leaking urine. IVs and monitor leads coiled in all directions, lines on a map where all roads led away. Her legs were encased in inflatable boots that squeezed the veins to return blood to the body before it pooled into clots, which could then break away into fatal emboli. The pain would have been unbearable and so Henrietta was kept sedated. A ventilator sighed in the corner, filling her lungs through a clear plastic tube inserted in her throat.
Lost in a maze of life-sustaining apparatus lurked a human being. It was all too easy to see the patient as a thing: a disease or an injury, a cancer or an infection, fractures or a failed heart. Sometimes this view was insensitive and wrong. Sometimes, when working to save a life, you put everything else out of your head in order to do your job. Eliot always made sure to know his patients’ names, to remind himself that there was a person under the disease. The monitors beeped, the ventilator and boots panted for breath like runners on last laps. The TV was on for some reason and CNN droned unwatched on a unit bolted in the upper corner of the room. Eliot turned off the sound on the TV and monitors.
“Ms. Mobley?” he said near the patient’s ear. Her head had swelled like a melon from the massive amount of IV fluids she had received. She had become something she would not recognize in a mirror, her body a distorted version of the person who had started her day. “I’m Dr. Sanders.” He doubted she could hear him. He took his stethoscope from his coat pocket and listened to her lungs. Rales, a crunchy sound like twisting hair near your ear, indicated that fluid was beginning to collect in her chest as well. The fluids she had received were necessary to buoy her blood pressure, but they had begun to leak from her vasculature into her tissues. She was drowning from the inside out. She needed blood. “Let’s crossmatch her for four units of packed cells.” He reached for Henrietta’s arm to offer a comforting squeeze. There was no immediate confirmation of his order from Clare. His hand touched a paper bracelet, a fluorescent warning, and he realized why.
“Her faith does not permit transfusions,” Clare said, tapping her pen impatiently on her clipboard like a waitress waiting for a new order after telling the customer they were out of the special.
Eliot had wondered why there hadn’t been a unit of blood already hanging there. He turned the monitor sound back on so any alarms could be heard outside the room. He left CNN off and returned to the desk. Any moment, Clare would ask him what he wanted to do. Why he loved surgery: you could fix things. Cut out tumors, remove kidney stones and bullets and burst appendices. You brought all your skill to bear on a situation that demanded results. You demanded them of yourself. Like a baseball player hitting a two-strike pitch or a diamond cutter with a raw stone, you often only had one chance to get it right. To perform. And when it worked it was as beautiful as the gleam of a faceted gem or a towering home-run drive over the left field wall. The danger: you began to think that you could fix everything.
In some ways, the actual procedures and operations were the easy part. In many situations, a kind of muscle memory kicked in and you let your training take over. Your hands held the scalpel and made incisions the same way, your fingers tied the practiced knots of a thousand sutures. The hard things were often the decisions to be made. When to operate and when to watch? You sifted the symptoms and test results to make sure the diagnosis was correct. And even after you had read the textbooks and the journals you realized that the answers were sometimes not to be found there. William Osler said: Medicine was learned at the bedside and not in the classroom. See and then reason, compare and control. In that order. But not everything could be controlled.
“What do you want to do?” Clare asked.
Here’s what was likely going to happen: Henrietta’s body was trying to compensate for her bleeding by clamping down arteries, sacrificing the circulation to her arms and legs and kidneys to keep blood flowing to her heart and brain. But soon, if blood was not given, there wouldn’t be enough pressure or blood cells to carry oxygen to any of her organs. In the meantime, she would lie suspended between life and death. Eliot was stuck in a situation where he had a treatment that he was forbidden to use. Caught between action and standing by while his patient, somebody’s sister or mother or friend, expired, he asked, “Have any family members been by?”
“Somebody was here during the day shift to tell us not to give her a transfusion. There’s no printed directive on the chart,” Clare said.
It was too easy to respond with anger. Outrage that pieces of paper or notes on a computer screen dictated the flow of blood. Outrage that a religion would prohibit the preservation of life. Frustration to be in a situation where you were expected to act, to do something, but were expected to operate with tied hands. The band on Henrietta’s wrist was a paper handcuff. Often, it seemed, you lived in a world where people were never expected to die. It has to be someone’s fault for not doing something or for doing the wrong thing. Nobody taught doctors that they had to save everyone but there was always a floating expectation, maybe self-imposed, maybe from external pressures, that you were somehow inadequate, liable, for inevitable circumstances. Nobody was at the bedside while his patient was in critical condition. Family, lawyers, clergy, community leaders, reporters, and politicians would magically appear to point fingers when she was gone. Eliot hoped that on some level, and it was actually a comfort, to think that Henrietta might, in her faith, accept the tragedy as God’s will. There were situations where patients had accepted blood transfusions in spite of religious doctrine when nobody was looking. Eliot could not imagine waking up Henrietta to ask her; putting that kind of pressure on someone, inflicting such pain, would be antithetical to every medical doctrine. She had been robbed of enough of her humanity.
Clare was tapping her clipboard. He fought the urge to snatch it away from her. The real clock told him that he still had hours to go until morning relief. He knew colleagues who would do everything they could to keep a patient alive through a difficult night just to avoid the paperwork and awkward phone calls that accompanied death. An idea: call Moona. He asked Clare to please leave him alone for a moment and he checked the hospital directory.
Hospitals were full of human resources that lurked in hidden corners: pathologists in morgues, radiologists in dark reading rooms tucked behind MRI scanners, lab and X-ray technicians elusive in their movements, pharmacists in lonely basements counting pills. Good residents found and networked with these people who could expedite reports and tests, provide advice on medication doses, locate lost equipment or wedge patients into crowded surgical schedules. They all had special talents and often felt overlooked and underappreciated. Develop relationships, take an interest, and they were happy to make your life easier. Moona Dave was in a special category. Eliot had never met her and did not know her official title. She seemed to haunt the hospital labs at night and answered any of the extensions he dialed down there: cytology, hematology, blood bank, chemistry. He did not know if she was young or old, or what nationality her name signified. She had a deep voice that he found sexy.
Residents lived in a kind of limbo, as much prisoners of the hospital as the patients. They were graduate doctors but rarely spent time outside the hospital, sometimes pulling thirty-six-hour shifts. They were neither in the real world nor out of it, sometimes neither fully awake nor asleep, drifting medical revenants, until they could steal a nap or a few restorative hours at home. Stuck inside an institution, anything could turn into a fantasy. In physics, there is a thought experiment called Schrodinger’s Cat. A cat is in a box and gas is injected into the box. The cat either lives or dies. Until you open the box, the cat is neither dead nor alive; quantum physics holds that it exists in both states until it is observed. Once you open the box and look in, an entire universe of possibility collapses. Henrietta was in the box, neither alive nor dead; Eliot was in the box, caught between action and inability. Eliot enjoyed keeping Moona in a cloud of quantum expectations: sometimes she was a Hawaiian beauty, sometimes a tall Middle Eastern woman with dark eye makeup who peered over a surgical mask, and sometimes she was a lot like his old high school librarian, Mrs. Gladwick, with intimidating, thick glasses and a limp. All equally erotic in the right circumstances. He dialed the blood bank.
She picked up on the first ring. “Blood bank, Moona Dave.”
Eliot wondered if the same thing would happen if he dialed the extension for Chemistry while he kept her on hold. “Hi, Moona.”
She recognized his voice. “Eliot Sanders. To what do I owe the pleasure?”
“I need to make blood.”
“We have some already made, in several varieties,” she said. “There is Type A, B . . . and my favorite all-purpose brand, O negative.”
“Yes, I know, but if you were going to start from scratch, construct blood without using red cells . . .”
“Are you feeling okay, Eliot? Would you like to come down here?”
People rarely took the time to see how doctors were feeling. Moona was one of the few who did. Did he detect a hint of an accent? “No, to be honest, not really. But I have this patient in ICU . . .”
“Name?”
He hoped he hadn’t offended Moona by ignoring her offer. “Henrietta. Henrietta Mobley.” He could hear the clack of keys as Moona accessed her computer. Librarian Moona materialized in his imagination; he saw the reflection of Henrietta’s electronic medical record scrolling down her glasses.
Recognition on the other end of the line. “Oh, I see. She can’t have whole blood or packed red cells. Well, at least they drew a sample for crossmatching anyway. Is she still bleeding?”
Probably. “Yes.”
The question was important because the body naturally wanted to plug all the leaking veins, arteries, and tissues. To do this, an entire cascade of clotting agents and cells had to be activated. Blood vessels contract and platelets wedge themselves into bleeding sites like plugs in a leaky boat. A protein mesh, like tar for the boat hull, then forms, gluing the clot in place. But, for this to happen, about thirteen different clotting factors had to act in concert. When they worked, it was an intricate symphony and whether you believed it was endowed by a Creator or just random natural selection, the evolved process over billions of years of trial and error, you had to be awestruck by the interplay. Change one gene, alter a single clotting factor—like factor VIII in hemophilia, for instance—and the whole thing breaks down. In Henrietta’s case, the continued massive bleed would use up almost all of the clotting factors before her body could make more. In a matter of hours, her system would be overwhelmed. She would drown in her own blood if her heart did not give out first.
“Fresh frozen plasma,” Eliot said.
“Put in the order and I’ll thaw some out. But isn’t that kind of like giving a whole blood component?”
Eliot now pictured Moona as a supermarket shopper, selecting the best items for a family dinner, squeezing fruits and vegetables, sniffing packages of chicken, placing the choice items in her basket and returning others. The plasma, the watery part of the blood, was rich in clotting factors. He was not sure of all the details about the various religious prohibitions. He could feel a tension headache begin and a vague wave of nausea rolled over him. He glanced down at the acidic juice cup but thought better.
Moona said, “Cryoprecipitate will give you the clotting factors and it’s not like it’s sourced right from a whole blood product.”
“Like orange juice from concentrate.” It made a strange sense.
“She probably needs colloids to keep the fluids in circulation,” Moona continued. “I’ll bet she’s already blown up like a balloon.”
Eliot motioned for Clare to return so that she could see what he was ordering. “Albumin.” Henrietta had been given liters of saline to replace the volume of lost blood. This helped her maintain her blood pressure temporarily, but the large blood cells, in addition to carrying oxygen, also acted as a kind of magnet, and through this force of oncotic attraction, kept fluids within the circulation. This was why the fluid was pooling in her lungs. The albumin, a protein of relatively big particles, the stuff of egg whites, would help keep the fluids from escaping. He logged the orders in.
Clare was tapping furiously and now shaking her head.
“What’s wrong?” Eliot asked her.
“You can’t give this without the patient’s permission.”
He ignored the comment momentarily. To Moona, “Vitamin K. We can’t give her platelets. We could give iron too, but I’m hesitant to use it in IV form right away, too many reactions.” He ordered the vitamin, a necessary link in the chain; the iron would have to wait for later, if there was a later. Back to Clare, “We can’t ask her permission and there is no one listed on the chart as power of attorney.” He flipped virtual pages of the patient’s records, scanning for clues, for electronic sanctions of authority that he knew did not exist there. Under “Next Of Kin,” there was someone listed as “Brother Josiah.” No phone number. No address. Was this a real brother or a church brother? He didn’t have time—Henrietta didn’t have the time—to figure this out.
“Well count me out,” Clare said. “I’m not losing my license over this.”
Eliot thought: Fine. She’s more worried about herself than saving her patient. Maybe she wasn’t wrong. During the recent pandemic, Eliot had seen nurses bravely put themselves at risk for the benefit of those in their care. People they didn’t know. People who would never remember their names. People who would rarely thank them. A strange thing to be willing to put your health in harm’s way, but not your job. Advice to young doctors: In a crisis the first pulse to take is your own. He couldn’t remember where he had read that. It was surprisingly easy to stay calm when you had to react immediately to a situation, like a gunshot to the heart, when there was no time to pause to reflect or do otherwise. This situation, this blunt trauma, a slow crush bearing down with the weight of a garbage truck, was different. There was no reaching for a knife or for suture to sew penetrated things back together. No putting out a slick, gloved hand and feeling the reassuring slap of an instrument. No blood pooled at your feet. Time ticked. Pencils tapped while you dispensed medicine from a chair, computer, and telephone. There would be criticism and consequences no matter what you did, no matter how you justified or documented your thoughts and actions. All would be words on a screen or page or gravestone. His teachers had taught him the importance of taking control. He fought for control of this situation. Sometimes the best thing, the hardest thing for any surgeon to accept, was to sit on your hands and do nothing while the night bled away.
Clare loomed over him. She seemed to want to be counted out but still hovered around to remain in the loop. He wasn’t going to let her. “I’ll take care of things, thanks,” he said. He asked Moona to courier up whatever she had ready and went to sit by Henrietta’s side. As long as no new emergencies popped up, he could handle the minor duties and dispatch orders from his phone. Things had an eerie way of staying calm elsewhere in the hospital when you needed them to.
The room was a quiet, windowless box. With the monitors and television off, there was nothing but the sound of his own breathing and the hiss of the ventilator as oxygen snaked through tubes.
Henrietta knew nothing about the person taking care of her. Taking control. What would she say if she knew that Eliot was secretly glad there were no windows to the outside world? From this upper floor, above the death dealt on the Camden streets, there were lovely views of the Delaware River shining black against the blue arc of the Benjamin Franklin Bridge, lit by the backdrop of the Philadelphia skyline. How his gaze had become jaded, how he had become unable to see the cityscape for the familiar flight patterns of the trauma helicopters. On hot summer nights you stood on the roof, ignoring the city, and scanning for the landing lights as they circled wide and then hovered above the hospital helipad, waiting for a turn to disgorge their loads. What would she say if she knew the trauma team wore no underwear on nights on call, the blood sometimes so profuse as to soak through vinyl gowns and scrubs and ruin a good pair of BVDs? Or how, if the patient had been drinking, the blood alcohol level could be so high that you could taste the gin and juice that aerosolized through your mask, so sometimes you wore two.
What would Henrietta hope that Eliot knew about her? There was not much Eliot could surmise from a broken body in a hospital gown. She wore no wedding ring, had no tattoos. He knew she was a woman of faith, and maybe the line on her neck was the ghost of a gold cross, or locket containing a prayer or photo of a loved one. Whatever had been there was removed so that a large-bore IV could be placed in her jugular vein, just behind the graceful muscle in her long neck where the necklace would cross. Maybe she would tell him how her neighborhood had become infiltrated by gangs, of which many were the gunshot victims he treated on those hot July nights; how her neighborhood Congregation of God stood its ground like a bridge to safety, how prayer and faith were the only defenses left. Or maybe she was the nasty woman who shooed children off her stoop and refused to chat with neighbors or give out Halloween candy. He preferred to think she was not like the latter, but there was no way to know. She was unable to speak for herself and a voice was something Eliot could not transfuse.
Eliot paced. He couldn’t sit, couldn’t abide feeling suspended between now and what would happen.
A rattle of wheels on the tile floor in the hall brought him relief. An orderly wheeled in a cart loaded with reinforcements. He helped unpack boxes of auxiliary IV tubing, metal poles with looping hooks, an infusion pump and warming device, and the wobbly, cold bags from Moona’s freezer.
“Here’s a note for you, doc,” the orderly said, handing him a slip.
Eliot peered at the orderly’s ID badge. “Thanks, Matthew. There might be more down there for you to bring up.” He almost felt that he should be giving him a tip like a pizza delivery man.
The orderly squeaked away with his cart and Eliot read: Here are the first ingredients for your recipe for making blood—M.
Eliot set up the poles and attached the pump and warmer to them with clamps. A forest of machinery had sprouted up around Henrietta, making her seem so small and distant in the clutter. He wound the viney tubing through the apparatus and attached the bags, full of yellow suspensions of floating frozen proteins meant to facilitate clotting. He punched in settings for flow rate and a temperature to heat the thawing fluids. He watched the slow drip from the IVs. He envisioned the feeling of the warm installation entering her veins, like slipping into a soothing bath. Easing a straining heart. Maybe he was only comforting himself. He was now both nurse and doctor, but, as he dutifully typed the record of treatment into the computer terminal, he couldn’t help feeling more like a data entry technician than a surgeon. He pressed ENTER and there was not much more to do now than hope. If he was a person of faith he could pray. He would have to have faith in his skill even in these times when he knew the wall of limits was coming up fast. Surgical aphorism: All bleeding stops . . . eventually.
Henrietta held her own for a while. Eliot watched, checking and rechecking her vital signs to keep himself busy, as if the next reading would be the next hopeful sign. He felt himself getting wobbly. His head hurt and his mouth was dry. He pried his dehydrated body away for a moment and walked down the hall to get a bottle of water from the machine in the empty waiting room. He took a large swig, draining half the fluid, and rummaged through his coat pockets that he kept loaded for long nights. The left pocket held his stethoscope, a few reference guides, patient lists for rounds, a roll of tape, note cards, and his phone. From the right, amongst the peanut butter crackers, Life Savers, and spare pair of socks, he found his emergency apple and two of the generic Tylenol from the candy dish the residents kept in the lounge which they told the medical students was full of Valium. He had been trying to limit his caffeine, the drug to which all health care workers were addicted, to mornings so as to be able to charge into the day. Drinking coffee at night kept sleep at bay when those rare opportunities presented themselves, and the accumulated effects produced palpitations during tense situations such as now. Still, he longed for just a half cup. Sign of addiction: he was comforted just having a cup with him, an object as a warm totem, a friend in a lonely moment. He would carry a coffee with him on rounds, not drinking it but often forgetting where he had left it before entering a patient’s room. He would refill a new cup and carry the fetish object to his next case. The night janitors could probably trace the course of his day from the trail of paper cups.
Waiting rooms were depressing places when full, lonely when empty. He sank into a chair of cracked, blue vinyl and waited for the natural sugar and water to start working. He took from his left pocket his Sweeney’s Good Transfusion Practice and flipped the pages. He knew there was no section on what to do when you couldn’t follow the advice in the guidebook, but he scanned it anyway, as if some secret could be mined from a buried footnote or appendix. His phone rang. He closed the book which contained nothing that he or Moona had not thought of and tossed the apple core and empty bottle in the trash.
“Dr. Sanders,” he answered, trying to reassure himself of his title.
“Eliot,” Moona said cheerfully. “Did you get my package? How’s your patient?”
He appreciated her asking about a patient and not about his project or his progress or “the bleeder” or “the Holy Roller in ICU.”
“I wouldn’t say she’s stable, but I can’t say that she’s any worse,” he said.
“It’s hard to get much worse when you start out awful, I suppose. And how are you holding up, young doctor?”
Young doctor. Did that imply that Moona was much older than Eliot, or was she just being cute? You can’t tell about age from just a voice. Actually, there were times he had run into OR staff out in the wild, in the real world outside the hospital, who would stop and say hello. Eliot must have seemed silly not recognizing them—and it wasn’t just because they were presented out of context, he realized that there were some people that he worked with every day that he had never seen without scrubs, a hat and a mask on. You could construct an impression of what you thought someone looked like from only seeing their eyes—Melanie has short, curly, black hair and a pointy nose—and so it was a surprise, when she actually appeared at the Cherry Hill Mall, with long blonde hair and a pierced nostril and a drop of Starbucks drooping from the metal stud. It was also strange seeing healthy people when you were used to being around the sick and injured most of the time. He saw his own reflection in the window of The Gap and wasn’t sure that he recognized himself in street clothes.
“Thank you for asking, Moona. I’m staying hydrated and staying positive. It’s all I can do.”
“Nights are long.”
Did this mean that she worked the day shift somewhere? Maybe she had two jobs, a single mother supporting two kids or grandchildren. Maybe she was going to med school during the day or was a paramedic on an ambulance crew.
“I have the vitamin K ready,” she pronounced.
Like a librarian informing him that his book order had arrived. Librarians, grandmothers . . . why not underwear models? Maybe she played bass in a Fleetwood Mac cover band, dressed in leather and lace like Stevie Nicks. He dragged himself out of the crackling blue chair. He wandered by the nurses’ station, Clare eyeing him sideways. He smiled a sarcastic smile which he hoped passed as the equivalent of giving her the finger.
“I was thinking,” Moona continued.
What he expected: Maybe we could go out to breakfast sometime after one of these long nights.
Maybe better, he thought, there was a bar down the street, The Cubicle Lounge, that catered to factory workers coming off the night shift. Like something left over from the Second World War, they still had pony glasses of Pabst Blue Ribbon on tap for fifty cents and a bowl of hard-boiled eggs and opened at 5:30 a.m. Some of the residents had become regulars.
What she said: “How about tranexamic acid?”
A great suggestion; tranexamic acid blocked the enzymes that broke down the fibrin scaffolding of clots and sometimes slowed bleeding. It could clog the arteries in Henrietta’s heart if she had coronary artery disease, but it was a chance he would have to take. He was happy to have something to take a chance on. “That would be lovely.”
But she wasn’t finished thinking outside the box. She seemed as eager as Eliot was to find some solution to a problem that didn’t have one.
“I know the military is experimenting with artificial blood; we could call Fort Dix. And also, there’s solvent-detergent plasma. Each batch is pooled from something like six hundred donors and washed, so it wouldn’t be like she was getting a transfusion from a single donor.”
“I’m sure the military isn’t going to lend out experimental solutions.” But, then again, he thought, they did send their trauma teams to train in Camden, the closest domestic war zone in which they could practice. Quid pro quo. “In the morning, we might make some calls. Maybe Robert Wood Johnson has some studies going. But, if I remember, even ‘artificial’ blood is still hemoglobin-based, so we have the same issues with what Henrietta, or her faith, would allow.”
“What religion is she, by the way?”
That was a good question.
Eliot had assumed that Henrietta was a Jehovah’s Witness, but actually, he didn’t know.
He reentered her room and put Moona on speaker despite Clare listening in. She was likely to wake the administrator on call at any moment to complain no matter what Eliot did. He began obsessively rechecking all the lab data, as if some minute fluctuation would be the clue to a cure or harbinger of failure.
In the chart, under Advanced Directives, there was just a note that said: Refusal of transfusion based on religious exemption. A general statement that may have just as well read, You know, those people. Catholics were easy as vampires, they were always transubstantiating, changing water into wine and wine into blood. Transfusions seemed par for the course. Perhaps Henrietta was a Christian Scientist? Or a Janist? If you believed in reincarnation, then maybe it didn’t matter if you died on a non-special Tuesday night in Camden. Blood was different things to different people, which he respected. He could very well just have accepted that premise and gone back to the basement and caught a few hours’ sleep. But he knew that if he did there would be no sleep, caffeine or not, and that he would just squirm in bed, staring at the familiar cracks in the ceiling he had been watching widen these past three years, and feel terrible.
“I’m not really sure what denomination she is a part of, Moona,” he answered. And then, “When’s the last time you had a Pabst Blue Ribbon?”
Clare, lurking in the doorway, looked up from the notes she was making and made a show of walking away.
A hinted smile in the voice from the wilderness down in the labs, “I’m sure that I’ve never had a Pabst Blue Ribbon.”
Did that mean she was Muslim? Or only drank wine? Or was she one of those beer snobs who exclusively drank limited hipster craft ales from the Pacific Northwest? Recovering alcoholic? “Okay, then make it a shot of your tranexamic acid and another bag of albumin as a chaser.”
“I’ll put it on your tab.” She clicked off.
He was chasing his tail. The urine output from Henrietta’s catheter had slowed to a trickle, a sure sign that her kidneys were failing. Eliot felt that he was failing, that there was something else he could be doing. And no matter how he rationalized that there was nothing he could do, feeling helpless was not why he had chosen medicine. And at times like these, you asked yourself what your reasoning could possibly have been to enter a career where you were defined by an impossible expectation of always succeeding. Wasn’t this a sure recipe for failure? Weren’t situations like these traps? Pits into which if you fell you might never climb out?
In college he had loved reading stories and writing essays, but when he showed an aptitude for science, his professors encouraged him to apply to medical school. Maybe this was just their way of saying that he was not a very good writer. He remembered reading a story where a college student searching for a career path ruled out medicine because he didn’t possess the necessary emotional detachment. An interesting notion: to succeed in a field where you cared for people, you had to have the ability not to care. What bullshit. The author didn’t know what he was writing about. But neither was it the crap about a calling that people felt compelled to spout during their med school interviews as if they were applying for the priesthood. Medicine was no more a religion than refrigerator repair. There were plenty of false idols to worship, but, ultimately, you had to believe in yourself, even if that meant taking every bad outcome, every death, personally. At least in surgery, you had the best chance of seeing the immediate results of the skills you brought to bear. He couldn’t see how people went into oncology or psychiatry, fields with built-in failure or such slow progress as to measure success in terms of years rather than the minutes or hours that flew by during an operation.
But tonight was not one of those times that you pulled someone off a helicopter with a gunshot to the chest. Where you took a blade and sliced through the muscles and spread the ribs in seconds and put your finger in the punctured ventricle, stabbing for it quickly as it beat wildly, and began sewing the hole in a heart, still on the hospital roof because, as the blood pooling in your socks was a reminder, there wasn’t time to do anything else. You worked quickly and tried not to sew your finger into the heart. The adrenaline of those moments carried you through the next thirty hours of your shift until you finally were allowed to go home and collapse for an afternoon before you returned and did it again. Motto on the trauma team lapel pin: Bringing knives to gunfights since 1973.
There was no knife or gun in this fight. There was no quivering heart acting as a moving target. As the next few hours ticked by, it was only Eliot and Henrietta and deliveries from Moona. There were evil stares from Clare and electronic paperwork. Moments when Henrietta seemed to rally, and a point where her heart stopped. He shocked it back into action.
He checked his watch. It would be sunrise soon. Locked in his box, he could not see it, but he knew the lights of the city would go out, leaving the shining river to return to its dead slate color. No helicopters would use the dark reflective water like a road to guide them in. They would be temporarily grounded: the drunk drivers had all crashed by now or swerved home after last call; the gangbangers who had survived the evening had gone home to sleep and reload weapons; and the morning rush with its new set of traumas and the dawn hours—so popular for suicides and heart attacks—had yet to begin. There would be trash trucks roaming the empty streets soon.
A key stuck in the computer as if telling him to wait, to pause with this gap in the night, to resist the finality of reducing a patient to a set of coded orders and, ultimately, to notes on the time of death—a summary to be printed out and read at the monthly Morbidity and Mortality Board: a conference that took place on a high level of the hospital, where you wore a tie and pressed shirt and fresh white coat free of apples and wrinkles and drugs and stains. Where your actions were judged in the white light of day, where you were prodded and punished or pardoned but never praised. And Henrietta’s were just as dead, and you lived with it.
He returned to the bedside and watched the heart monitor as the beats elongated and stretched and strained. He had no prayer but hoped that the part of Henrietta, the part with the voice that maybe sang songs of praise in the church choir, had left her the moment that she was hit by the truck and that this exercise was just futile window dressing like something at the mall, The Bone and Body Shop. He was out of ideas and all he could think to do now, all that was left, was to squeeze Henrietta’s hand, just below the paper bracelet.
He left the ICU. Clare might very well call him back soon, to say that Henrietta’s heart had stopped again and ask about CPR. He would tell her to go ahead, knock yourself out. He would take his time returning. Or she would report an improvement in vital signs and lab levels and proudly sign her patient out to the incoming shift of nurses. He went down the hall and into the stairway. He hesitated and then started his way up toward the door to the roof, to get some air and watch the river. 