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Informed Consent

By Sandra L. Glahn

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The ringing phone jarred Jeremy out of a deep sleep. “Yes.” It was more a groan than a question.

“Sorry to disturb you, Dr. Cramer,” the head nurse said.

“What is it, Dev?”

“We need you in the ER.”

He sat up and turned on the Call Room light. “What’s up?”

“Bus crash.”

He sighed. “Be right there.”

Jeremy hung up and looked at the clock. 10:08 P.M. Only one hour of sleep in the past day. This residency is killing me.

With a couple of gulps, he drained the half cup of cold coffee on the nightstand and tossed the Styrofoam in the trash on his way out the door. Shoving a stick of gum into his mouth to mask the nasty taste, he exited the room and jogged down the hall to the ER. As he went, he ran his fingers through tangled brown hair and retied the drawstring that passed for a belt on his scrubs.

Devin Garrigues stood waiting at her station. A tall, slender black woman from Antigua or Aruba—Jeremy could never remember which—she was at least ten years his senior.

“What’s the story?” he asked.

She pointed up. When he drew closer, she said, “Helo’s due in a minute or so.” They strode toward the roof elevators and Devin explained, “Bus in the lake near Fossil Bends.”

Jeremy felt a cold surge. “Submersions?”

Devin nodded and entered the code to call the elevator. “Seven adults, nine kids.”

“All fourteen coming here?”

She shook her head. “No. And seven plus nine’s sixteen—sorry, man.” She spoke in the easy tones of an islander, even when she was in a hurry. “I let you sleep as long as I could.” The door opened and they boarded. Devin lowered her voice. “We have two incoming—mother and daughter.”

“Injuries?”

“Not sure. But they were under for five to ten minutes.”

Jeremy whistled.

“Right—slim chance,” she said. “Kid’s about eleven. Mom’s late thirties—one of the only two adults they haven’t already pronounced dead. Dad died along with four other adults and four kids.”

Jeremy’s stomach tightened.

At 10:12 the stench of helicopter fuel came at them in wind-pulses that blew back their hair. A pilot and two EMTs threw open the doors. Leaving the mother to Devin by default, Jeremy instinctively raced toward the little girl. He knew something of the terror she’d just lived through, and he had to help her if he could.

One of the EMTs yelled over the roar of the engine: “Female child—pulse slow and thready, weak at sixty. Body temp down to ninety-six. Pupils fixed and dilated when we got there. Started CPR. The woman—lost pulse en route. We did external compressions most of the way here. Body temp down to ninety-five.”

Not good, Jeremy thought. His patient was in a coma and unresponsive to light. Jeremy raced the little ashen-faced blonde into an ER room where three nurses stood ready to assist. He pulled the curtains and took over compressing the chest while a nurse ventilated the child with the oxygen mask from the helicopter. Another nurse hooked the girl up to the EKG pads already in place.

“Cut her out of these clothes. Get some heat on her,” Jeremy ordered. The musty smell evoked memories he had no intention of revisiting. He watched as a nurse with bandage scissors cut off the girl’s wet pants and shirt. Then she replaced the helicopter blankets with heated ones.

Jeremy glanced up at the heart monitor. Not a great rate, he thought. At least there was a beat. He looked at the wet-haired girl’s pale face. Her round nose reminded him of Ravi—another memory he didn’t want to think about. Jeremy bit his lip.

Someone pulled back the curtain, and Jeremy looked up to see the stethoscope-yoked attending, Nate Barlow, a pediatric intensivist. Jeremy didn’t know him well, but pediatrics wasn’t Jeremy’s specialty, so the sight of Barlow’s face brought relief.

Jeremy filled Barlow in on the girl’s status, and Barlow took charge. “I need a complete blood cell count and serum electrolytes. Let’s get a pulse oximeter on this kid. Keep the blankets and warmed IV fluids coming. And we need an ET—STAT.”

He took over the chest compressions and watched as a nurse removed the helicopter’s oxygen mask. Then he put a laryngoscope and inserted an endotracheal tube through the girl’s mouth and down into the large airway to the lungs.

Jeremy shot a look at the clock—10:18 P.M. He slid a laryngoscope into the patient’s mouth to visualize the vocal cords. The water on the patient’s lungs made her cords frothy, so it was hard to see. After placing a tube into her windpipe, he slid it through the space between the cords. To the other end he hooked up an Anbu bag for manual breathing and gave it a couple of squeezes to make sure the lungs inflated. Then he took his stethoscope and listened. When he realized he’d intubated the girl’s stomach, he cursed.

“Blowing up the stomach, Doctor?”

Jeremy couldn’t tell if Barlow was impatient or amused. “Give me some suction,” Jeremy said. He waited for the nurse to assist and took another look. It was much clearer this time, and the tube slid right in. He listened again, this time to the welcome sound of both lungs filling with air. “There. Got it.”

“Good job,” Barlow said.

Jeremy glanced over and, seeing that Barlow’s smile was genuine, felt his confidence returning. He eyeballed the monitor. The girl’s heart rate was improving. A nurse swiped an alcohol prep pad across a spot on the child’s arm and the sharp smell of alcohol replaced the soggy-clothing odor that permeated the room. The nurse stuck a vein, and drew blood. Then she hooked the IV to the same needle. The pediatric urinary catheter revealed no blood in the urine—a good sign.

Jeremy checked the pulse oximeter on the girl’s chipped-polish finger. “We’re at ninety-one now,” he said, referring to the blood oxygen level. “Up from the low eighties.” He glanced at her face. Was it wishful thinking, or was the color in her cheeks improving?

The girl stirred, and two of the nurses hurried to tie her arms with cloth bindings so she couldn’t pull out her IV. When her temperature reached ninety-seven, Jeremy and Barlow exchanged smiles. The petite girl thrashed about, struggling without success to break free. She opened her green eyes. At 10:31 she made her first sound—a moan—and continued to struggle.

One of the nurses rested a hand on the girl’s arm. The other nurse leaned down to speak in her ear. “It’ll be all right, honey. You’re doing fine. You’re in the hospital. We’ll take good care of you.” The girl shivered. She looked around and her eyes grew so wide Jeremy could see the whites completely surrounding the irises. With her growing awareness of her surroundings, her fear increased. Jeremy recognized in her a terror he had once felt and would never forget.

“Can you understand me?” Barlow asked her. She gave him a timid nod. “You can’t talk because of a tube in your throat that’s helping you breathe. I’ll bet you want it out.” She nodded vigorously. Barlow looked over at Jeremy. They would need to check her muscle strength first.

The moment Jeremy took her hand, his paternal instinct kicked in and he had to will himself to stay focused on her medical need. “Squeeze hard for me,” he said. She had a good grip. “Great job.” When she relaxed, he didn’t let go.
Barlow turned to the tech, who was wheeling in a portable x-ray machine. “We need to rule out neck injuries before we remove the ET tube.” The tech shot a C-spine and rushed off to get the films developed.

Time, which had rushed by, now seemed to loiter as everyone waited for the tech. Jeremy’s eyes wandered from the gray streaks in Barlow’s otherwise brown hair to a stack of Q-tips, spilled on the floor in the rush. He walked over to pick them up and caught his reflection in the metal canister—his short hair, round face, tired brown eyes—and saw something in his own features that reminded him of his dad.

At the thought of his father, memories he’d tried to suppress flooded into his consciousness. Icy water. The sight of a head bobbing down the river. The fright of waking up alone in a hospital. He wondered if he could have prevented that accident. Forcing himself out of his reverie, he gazed down at the patient.

Eleven years old, alone, where no one knew her name, in a hospital without a father and probably without a mother or maybe without even anyone else in the world. He wanted desperately to protect her from the pain. Jeremy had lost both of his own parents—his mother died right before he married Angie. And his second-born—Ravi—had died, too. Jeremy shuddered when he considered the future this girl would face. He knew only too well the sadness and grief—and especially the guilt—she would bear.

He leaned close to whisper. “Scary, isn’t it?” She focused on his face and nodded slightly. “I’d be scared, too,” he said, “but you’re going to be fine.”
The tech returned with the radiologist, who hung the pictures on a view box and switched on the light. “Neck looks fine,” the radiologist told Barlow.

Barlow studied the x-rays for himself and then leaned toward the girl. “Can you lift your head off the pillow?” She let go of Jeremy and raised herself up. “Good.”

Barlow looked in Jeremy’s direction, signaling for him to take off the AMBU bag that was helping the girl breathe. Then Barlow spoke to her again. “Take a couple of good, deep breaths for me. Okay?” She complied. “Good. Another?”

After she breathed again, she closed her eyes and seemed to drift off. Jeremy deflated the cuff and slid out the tube. “Another,” Barlow insisted. She coughed. “Again, please.” She took another breath, this time deeper, followed by more coughing.

“It hurts! Daddy, it hurts!” Jeremy realized she didn’t know her father was dead, and the revelation sent a jolt through him like an electrical current. She lay with her eyes still closed, but the volume in her voice increased. “Daddy! Don’t let go!”

Jeremy swallowed hard and looked away. When he did, he saw Devin poking her head through an opening in the curtain. “How’s the mom?” he whispered.
Devin glanced at the girl then back at Jeremy. She pursed her lips, shook her head, and mouthed, “Gone.”

“Moments that change your life forever,” Jeremy thought. It was one of those phrases the ER staff tossed around as they steadied themselves to break news to families. When you know your words will crush them, you feel no urge to rush. You rehearse—at least the more compassionate doctors do— selecting every phrase with care, preparing to break news and hearts gently.

The girl opened her eyes again and looked around. “It hurts,” she whispered.

“Where?” Barlow asked.

Her gaze came to rest on Devin. “It hurts . . .”

“I know, sweetie,” Devin said, stepping inside. She moved closer to the girl and rubbed her arm. Devin cocked her head and locked her deep-set eyes on the child. “We’ll get you feeling better as fast as we can. What’s your name, honey?”

“It hurts!”

“That’s a funny name,” Devin teased in a voice that bordered on baby talk.

Jeremy admired how Devin, with her twenty years’ experience, worked her charms on patients, drawing from a seemingly unlimited cache.

“What hurts?” Barlow asked. The girl didn’t answer.

Devin stroked the small cheek with an index finger. “I have a little girl who’s just about your size and she’s very, very brave—just like you.”

“Amy,” the girl said.

“Your name’s Amy?” Devin asked.

“Uh-huh. Amy Black.”

Devin brushed tresses from the girl’s cheek and looped them behind her ear. “How old are you, Amy?”

Amy coughed hard. “Ten-and-a-half.”

She’s lucky to be alive, Jeremy thought. Yet so unlucky. Devin rested a hand on the girl’s shoulder and Jeremy took her hand again. He could feel her trembling.
Devin soothed with her unique brand of vocal anesthesia. “We know you’re hurting, so we’ll give you some medicine to help that real soon, little missy. Where does it hurt? You can tell it all to Nurse Devin. What happened?”

“My leg.” The girl let go and pointed to her right side.

Jeremy pulled back the blanket to have a close look. A small patch of semi-dried blood covered the inside of her right leg. Amy spoke slowly. “I thought I was gonna die. I don’t know how to swim. Not really.” She coughed hard.

“I’ll bet that was very scary then.” Devin’s brown eyes exuded empathy.

Amy nodded. “The bus was sinking. Dad kicked out the window so me and Mom could get out.”

“Were you in pain then?”

“When we crashed, something banged my leg. And then I drunk a ton of water. It tasted dis-gusting!”

The sweet smell of Betadine filled the room, as a nurse cleaned the wound. The blood on the leg disappeared, revealing a laceration. Jeremy caught the attention of Barlow, who had been focusing on the girl’s words, and pointed to the injury. Barlow nodded and told the tech, “I need an x-ray.”

“I’m only up to intermediate in swimming,” Amy continued. “I never had to keep my head up that long before.” Sometimes knowing how to swim doesn’t help, Jeremy thought.

“How long were you under?” Devin asked.

“I dunno. Maybe three hours.” The team members exchanged glances and suppressed smiles. “Dad got me and Mom out of the bus and up where we could try to breathe. He was helping us, but we got tired.”

As he imagined the helpless parent, Jeremy felt a rush of heat. Suddenly he was short of breath. He turned his head away, trying to shake the image of his own father’s struggle.

“Dad was under us,” she continued. “He pushed me and Mom up above the water. But then he let go.”

Then he let go. Jeremy wanted to step out and catch some air, but he was trapped.

“That must have been so scary,” Devin said.

“Yeah, that was the scariest of all. But after that it was like—it got pretty—kind of purple. And then . . . I don’t remember.”

Jeremy glanced at the heart monitor once again. As Amy’s heartbeat slowly returned to normal, so did his.

* * *

By midnight Jeremy had treated five kids and all of them looked as though they were going to make it. Neither of the adults survived. He recalled what he’d learned from experience and later in med school—that in cold-water submersions, kids fared better than adults. Far better. Adults could make it only a couple of minutes, tops. But kids? They could survive after more than ten minutes under the surface if the water was cold. He wondered why. Textbooks attributed it to the resiliency of youth, but he wondered—as he had many times since med school—what factors actually made youngsters more resilient.

On his way to the morgue, Jeremy stopped by Devin’s station. “How’s Amy?” he asked.

Devin looked up, concern lining her dark forehead. “Physically she’ll be okay. But. . .” She shook her head.

“I know what you mean,” Jeremy said.

“Social services got us a counselor who specializes in pediatric trauma. They sent her to see Amy after the docs told her. Her mom’s sister is on her way. Sad.”

Jeremy couldn’t imagine losing both parents at once. One at a time was bad enough. “Her leg’s all right, then?”

“A little banged-up, but no breaks. She may be asleep now with the help of some Stadol.”

“What room’s she in?”

“703.”

Jeremy made a mental note and leaned on the counter. “What do we know about the rest of the victims?”

“Not much. But they transported all the bodies here for autopsy. Morgue has its hands full.”

Typical for a research hospital, Jeremy thought. “Ward X” always filled up when multiple-death accidents occurred. The demand for autopsies rose, especially if some of the victims donated their bodies to science.

“Listen, I’ll be down in the morgue if you need me.”

Devin’s eyes widened. “Why down there?”

“I want to ask the coroner pathologist for samples on all the victims.”

“Samples?”

Jeremy hesitated, but saw no harm in telling Devin. “Blood. Spinal fluid. Urine. And I want them marked for cause of death—which ones from trauma, which drowned.” Jeremy had a hunch that some chemical factor or something genetic—some physiological reason—accounted for why kids handled submersions better.

Devin stared at him. “What’re you looking for now?”

“Just something I’m curious about. But I’m tired and not thinking straight, so it may be hare-brained.”

“C’mon, tell me, man.”

He shook his head. “I don’t want to risk you mocking me tomorrow when I wake up and it makes no sense.”

“You mean the part where I say ‘Hey, braindead flatliner, you can’t even add! What were you thinking?’”

“Right.”

Devin shot him a wicked smile. “You do have a point.”

Jeremy went to the elevator banks and reached out for the down button, but he changed his mind and pressed up. When the doors opened, he got on and punched 7.

All the way to Room 703, he resisted the urge to turn back. He handled patient care just fine when it came to ordering blood work and diagnosing diseases, but when it came to actually caring, to empathy, he usually left that to the patients’ families. Or to nurses like Devin. He rarely made casual visits, but tonight he felt compelled. He figured he’d find her asleep, but he had to check on her. Reaching her room, he gave the door a tap.

“Yes?” The voice of a grown-up female came from the other side.

He cracked the door wide enough to look in. Amy lay staring out the window, as if to disconnect herself from the woman whom Jeremy recognized as a member of the hospital’s psychiatric staff. She was patting Amy’s arm.

Jeremy couldn’t blame Amy. He wouldn’t have wanted to be with a stranger, either. But then he reminded himself that he was a stranger, too. A moment of insecurity held him back until Amy gave him a slight smile and said, “Hi.” He hadn’t been sure she would recognize him from the ER—she’d been so out of it—but she seemed to know who he was.

“Okay if I come in?” he asked.

“Uh-huh,” Amy said. Her eyes followed him as he came over to the side of her bed and stood with his hands folded.

The counselor gestured toward the chart, but Jeremy shook his head. “I’m just here to tell Amy how sorry I am.” The woman nodded, got up, and slipped outside.

Amy blew her nose and wiped her eyes. “Did you hear my mom and dad are . . . ?”

Jeremy sat on the side of the bed, remembering how that felt. “Yeah,” he said. “I heard. There’s nothing I can do, but I wanted to tell you I’m sorry.”
The silence felt awkward. “My dad drowned, too, when I was about your age.”

Jeremy reached for her hand but Amy grabbed him and clung to him wailing. He patted her back as she cried and cried, digging her nails into his arms. He wrapped her in a hug as he often did with his own kids and though she got snot all over the front of his scrubs, he didn’t care. She choked out, “It’s not true!” Jeremy knew she would spend her life thinking of what she might have done to save her parents, and he wished he could help her.

“I know it’s awful, sweetie,” he said.

“Will you . . . ?” she asked something, but it was too garbled for him to understand.

He leaned back so he could see her thin lips as she spoke. “What?”

“Will you stay until Aunt Julie gets here?” Her wide eyes pleaded.

“Certainly,” he said. He squeezed her hand. It could be hours and he was already running on two hours’ sleep, but how could he say no?

Amy leaned against him again. “I want my daddy,” she said through muffled sobs. I know what you mean, he thought.

Her sobbing tapered off followed by short bursts of sporadic breathing. Eventually she lay back down. When he saw that her eyes were more shut than open, he slid over to the phone and pressed the morgue’s number. He asked them to start collecting samples immediately.

Within the hour Amy’s aunt showed up. Jeremy expressed his condolences, briefed her, and excused himself. Then he slipped out of the room and headed straight for the morgue.

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