Dirty Hands

Jordan Carson 2005



Pager beeping and flashing.  Gunshot wounds—pectoral and lower leg.  Ambulance en route from south barrios.  Gunshot wounds, always the barrios.  Me just having sat down in the doctors' lounge.  Patient critical.  Patient name Rosario Jimenez.  Patient should make it if goes under knife at arrival.  Coffee still too hot to drink, cup left full on table.  Me grabbing my lab coat on the way out.   


St. Luke Hospital was the only trauma-one hospital in the city.  All severe traumas came here.  I was on call in the orthopedic wing, up on the fifth floor.  Few traumas go to the ortho rooms, but one of the bullets shattered Rosario Jimenez's tibia, requiring an orthopedic surgeon. 

I had just poured a cup of coffee in the doctors' lounge, after making my round in the recovery room.  I was complaining to Patel, one of the ortho surgeons, about how the coffee in the lounge was worse than gas station coffee.  The news anchor was saying that the death toll in Sri Lanka was up over 100,000 from the tsunamis and rising.  The front page of the paper lying on the table had a big picture of the first lion cub ever conceived and born at the local zoo.  I spilled a few drops of coffee on the paper when my pager went off and startled me.

I phoned the tech and told him to have 100 cc's ready of anything we could possibly need for a trauma.  We couldn't be too careful they had told me during residency—that people would sue for anything these days, and that if a body ends up in the basement with a toe tag on account of drugs, oxygen, or the lack of any of these, it is my fault. 


Jimenez still conscious.  Me meeting the stretcher in the hall.  The hall connected the ambulance drop-off to the ER.  Blood soaking through the crisp linen sheet.  Blood at his legs and near his shoulder.  Jimenez looking to be early thirties.  No, 28 chart saying.  Me asking questions while jogging alongside the stretcher.  Last time you ate?  Any medications?  The banging of the doors slamming open automatically every twenty yards.  Me noticing the track marks on his arms.  Shiny, sinewy, raised, running at angles and crisscrossing each other over veins.  Pink against his earthen skin.

            Was there heroin in his system?  If yes I must use alternate medicine.  Never done that before.  Worth the risk?  If I miscalculate, he dies.  Simply.  Finally.

            I bent my head down as close to the bloody sheet as I dared.

"Mr. Jimenez, this is very important," I began loudly and slowly, enunciating carefully as possible as I jogged along, "Mr. Jimenez, have you used heroin in the last two days?"

            His face contorted with pain as he rolled his head slowly and definitely side to side.  I couldn't tell if he heard me.  I leaned my head down closer to his, and repeated my question.

            "No," he said through gritted teeth.

            "Are you sure?  If you don't tell me the truth you could die from the anesthetic," I said.  I repeated the question.  He shook his head and arched his back in pain.  I was not sure if he was telling the truth.

            These were the things that weren't taught, couldn't be taught.  No medical school book I had read said anything about decisions like this.  There was only the Hippocratic Oath that I took the day I officially became a doctor.  I will apply all measures which are required.  I will remember that there is art to medicine as well as science.  I decided he was lying.  Yet, I will not be ashamed to say "I know not."  Did I know?  There was not time to decide whether or not I knew.  With traces of heroin probably in his bloodstream, I had to use an alternate, riskier anesthetic.  I knew the procedure.  I knew it exactly.  But I had never done it unassisted before.  There had to be a first time for everything.

Team finally reaching emergency room.  Sheet even bloodier than at unloading.  Me grabbing morphine from tech.  Too much scar tissue making it difficult finding a good vein.  No wonder he looked older.   Nurse pulling red sheet off to prep.  Nurses cutting shirt to reach wound, cleaning off dried blood.  Seeing wounds—small caliber handgun wounds, ash-colored from the burned powder, nickel-sized hole, not real to me, looking just like slides in med-school classroom.  Seeing tattoos.  Tattoos on neck, shoulders, and chest, greenish color black ink becomes after while.  Bullet through tattoo on right pectoral muscle, near shoulder.  Other bullet through anterior side of the left leg, shattering tibia. 

The tattoo on his chest was of the Virgin Mary, kneeling with an elaborate aureole encircling her head.  The bullet that hit his chest had punctured the aureole.

            "Another one at the wrong place at the wrong time.  Caught by stray bullets in a cross-fire," the EMT said. 


            We had just cut skin.  Pulse-ox was normal.  The patient's face was still.  His eyes were taped shut.  His stomach rose and fell easily now under the anesthetic, making a slight rustling sound in the blue, papery, sterile sheets.  I was calm and composed.  You must continue to be calm, always.  This is your work.  A good doctor remains objective.  Being emotionally involved is fatal to the doctor's focus and potentially the patient.  I told myself all of these things.  I had not been practicing long enough to ingrain them into my subconscious.   

            We were all scrubbed in and sterile.  Two doctors were operating at once to keep the surgery as short as possible.  There were nine pairs of hands in the room.  Two surgeons and two scrub nurses, getting their gloved hands bloody, one overseeing nurse, two retractor holders, Jimenez, hands limp under the sheets, and me, gloveless, simply charged to watch the monitors and administer drugs.  Jones was working on the chest.  Patel, the orthopedic, was working on the tibia.  The oldies station played softly under the clinking of instruments and beeps from the monitors.  Jones and Patel were talking football as they operated.   

            "You think anyone's strong enough to end the Patriots' reign this year?  Hand me a Kelly and put a longer tip on this cauterizer.  I think Brady is unstoppable," Patel said.

            "The Eagles probably have the best shot," Jones said.

            Notice how they stay calm.  Talking football keeps emotion at bay. 

I glanced at the monitor just as the bars spiked.  The pulse-ox started beeping rapidly and loudly.

Death unexpectedly peeked her ugly black head through the door.  Everything leveled out onto one common plane.  There was no longer doctor and patient, two separate entities.  There was only crisis.

            The spiking bars on the monitors and the screaming electronic beeps were like the first rain drops falling from the heights and crashing on the skin of a pond, making little explosions everywhere and turning the pond into one big gyration.  Operating room 37 erupted.  Surgical instruments clanged onto the tiled floor.  Trained reactions took over.  There was no time to think or feel.  Our allegiance to sterility was abandoned.  Jones yelled at the tech to get the crash cart from the hall.  My eyes swept his body furtively for indication of the cause. 


His face was still.  His eyes were taped shut.  Tubes protruded from his mouth.  The blue sterile sheets, now contaminated, no longer made the slight rustling sound that came from the respiratory rise and fall of the stomach.  Rosario Jimenez—drug addict from the barrio, statistic, patient, not to be missed by many, in the wrong place at the wrong time—now dead on my table.  I stared now, not at Rosario Jimenez, but at death, silent and unmitigated, not the slides in lecture, separate and objective, not a body in a coffin, perfumed and dressed, but death, bloody and raw.  The stillness and powerlessness of Rosario Jimenez's dead body emanated an emptiness, into which fell all of the structure and sequence of my world.


I stood in the hall outside OR 37, looking out the fifth floor window at the street below.  The sun had just slipped behind the tall downtown office buildings, making them black against the shining light outlining them.  Evening traffic was thick—brake lights glowed like thousands of cigarettes in the dusk, all the way to where the interstate disappeared into the horizon.  The hallway was empty, except for me and the bed that was to have taken Rosario Jimenez to the recovery room.  I heard the Doppler effect of a plane as it crossed the window with lights blinking, descending, heading for airport ten miles to the north. 

I let my head fall onto my chest.  Again the oath—If it is given me to save a life, all thanks.  But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty.  I looked at my name embroidered on my coat over my left pectoral muscle.  Stephen P. Janikowski, M.D., it read, in bright blue thread on the white cotton.  I remembered back to when I received the coat, to when I could finally call myself doctor.  This coat had since seen days, years, blood, births, and death since that first time I put it on.  It still fit well, though.


            "Yeah?"  I turned my head to the right to see Jones reach out to put his hand on my shoulder.  My face must have betrayed my anguish.  Jones' face softened.      

"We have to finish the write-up," Jones said gently.

            "Okay Paul.  I'll be right in," I said.

            Jones turned to walk back into the OR.  I turned back to the window.  I heard his footsteps, loud in the hallway.

            "Paul?"  The footsteps ceased and his clogs squeaked on the floor as he turned around.

            I turned toward him with a face that asked everything.  



            "It happens."

            "Yeah."  I watched him walk back into the OR.  I turned back to the window. 


It was getting dark enough that all I could see in the window was my reflection under the fluorescent lights and that of the scrub sink behind me.  If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter.  May I always act so as to preserve the finest traditions of my calling and may I long experience the joy healing those who seek my help.