At first I thought it was a rock, but as I got closer I could see that it was a good- sized snapping turtle. Its upper shell was muddy, dark brown, featureless as a worn stone. Its shell alone might have measured over a foot. Long neck, legs, tail, didn’t seem to all fit in the shell.
It was on the wrong side of the street from the pond.
“It needs to go to the pond,” I said to Jonathan, my husband.
“Leave it alone,” he said.
I got behind it, studied it. The neck was long, the beak sharp. I picked it up with both hands, grabbing it just behind the middle of the shell. Lifted it up about six inches. It was heavier than it looked. The hind legs raked forward at me, the neck swiveled back, the jaws snapped. This turtle had a really bad attitude. I dropped it gently back down on the newly cut grass.
“It’ll get run over,” I said.
“Not in this town,” he said. “Nobody would run over a turtle.”
“I could get a box. Put it in the box and take it to the pond.”
“Let it be. When I was a kid, my best friend got bit by a snapper. They had to go to the ER and have the turtle sedated before it would let go.”
So I did. But later that night, I wondered about the turtle. Once, long ago, as I was jogging on a dirt road in another town in a faraway state, I had passed a box turtle inching its way to the shoulder. It was less than a foot from the grassy verge, so I’d run on ahead. Seconds later I heard the turtle implode with a hollow thwuck! and watched a pickup truck recede into the distance. That driver would have had to deliberately swerve to crush the turtle.
In that other time and place, people would sometimes toss empty beer cans at me as I ran. Now we live in a town where drivers will hit the brakes to avoid hitting a squirrel, but I heard that sound again as I nestled close to my husband in the night.
I was on call the next day and it was busy. By 3 pm, we had already done two appendectomies and admitted several other patients, including a severely burned woman, to the surgical service. The second appendix popped up into our field of view like a Jack-in-the-box, red and grinning. We made short work of taking it out. Tim, my junior resident, and I were in high good humor at the end of the case.
“The day’s young,” he said.
“Happy hunting,” I replied. A ritualistic exchange.
After talking to the appy’s family, I finally had a chance to sit alone in the hospital cafeteria and scarf down a cheeseburger. At a large table next to me, a family sat waiting for news. Their conversation drifted in and out of my consciousness.
An old guy with a John Deere cap was just saying, “I went to get a tractor, asked how much it cost. They said depends what you need it for. I was just telling Bill, Bill might not agree, everything’s a racket. That’s the way it is.”
“By the time you pay the 6% on that tractor it’s 60 thousand, is what it is,” a younger woman said. The guy next to her—maybe he was Bill?—nodded.
I wondered who wasn’t at that table. Could it be the woman with the major burn whom we’d stabilized and admitted to the Burn Unit? Was it the pregnant lady with gallstones who was waiting for us to decide if she needed surgery today, despite the second life in her womb? Unlikely. I didn’t recognize any of these folks. Lots of crises were slowly unfolding in the hospital, not just the ones I’d witnessed in today’s on-call activities.
“She’ll probably go home tomorrow, doc said,” John Deere went on. “They just need to give her a pint or two of blood.”
“She’s going to need help for a while. We’ll give you a hand.”
My pager went off.
“Dr Abernathy?” I was struck by how very young Tim, sounded.
“We just got this consult, a 70-year-old woman with belly pain for a couple of days and now she’s GI bleeding. I walked into the room and she’s in full arrest, they’re doing CPR, code team’s there, the whole thing. She’s been bleeding from this ulcer for a couple of days. I don’t think they realized it because she had her hip pinned four days ago, they just figured the ‘crit drop was due to that.”
“I’m on my way.”
The Orthopaedic Unit was two pavilions over and four floors up. I stuffed my cheeks with the rest of my cheeseburger, stepped into “Old Faithful,” the elevator that’s always waiting, doors open, on the ground floor. But this time, Old Faithful jerked, went up a couple of feet, shimmied, shuddered, and stopped cold.
I tried the door open button. Nothing. I kicked the door—nothing. Jumped up and down on the floor. Nothing. I crouched down to reach the red button, placed near the floor in case you’re knocked down in an emergency.
Security answered right away. My cheeks were still full of cheeseburger, but they managed to understand what I was trying to say.
“We’ll get someone right over there, ma’am.”
Up on Orthopaedics, Tim was waiting for help to come charging over the hill—well, he’d have a bit of a wait. Should I call the ward? Page him? They’d all be occupied with the code. I decided to wait until I knew how long it was going to be. Meanwhile, they were going to wonder where the hell I was.
I heard a voice from outside. The doors wrenched apart a couple of inches, and an eye appeared—“ Hel-lo! You OK, Doc?” I grabbed the doors with both hands to keep them from shutting. I had a professor once who said, never use your hands—your hands are your livelihood. Use your feet, your head, even, but not your hands. But I thrust both hands into that narrow metal gap without a second thought and heaved. Nothing happened.
“Doc, we’re going to have to send for the tech. It may be a while. You OK?”
“Sure. But I was on my way to a Code Blue…” A big pair of hands appeared in the gap about two feet below mine.
“Stand back, away from the door, Doc.” I slid my hands out, hugged them to my chest, and stepped back. The doors sprang open. The elevator was stalled about two feet above floor level. I leapt down.
“Thanks!” I ran to the stairwell.
It was easy to find the patient—a clot of people spilled out of the room and into the nurses’ station. I elbowed my way into the room, like water flowing into the spaces between people. Tim stood at the head of the bed, a bloody laryngoscope in his hand, lips set in grim satisfaction. A respiratory therapist attached a ventilator to the endotracheal tube. At the EKG machine, a medical resident watched for a rhythm. The line on the cardiac monitor wavered lazily.
The hospital bed had been stripped for action—pillows, sheets, and blankets removed. Spread-eagled under the harsh fluorescent lights, a frail white-haired woman lay exposed, her hospital gown askew. Blood poured from her nasogastric tube, gushed from her mouth, and puddled on the bedsheets before flowing onto the floor.
“I called the OR. They’re ready for us to take her up,” said Tim. I knew he was hankering to get his hands into that belly, find the bleeder, put in a stitch, save the day. The clarity of action, of surgery, what we do every day, began to seduce me too. I looked at the patient.
The old woman lay motionless, not responding to CPR or to the intern struggling to draw a blood gas from the big artery in the groin. Blood ran into her through two large-bore IV lines, but it gushed out of her onto the floor even faster.
Tim went on. “The blood bank has ten units of packed cells, four units of plasma, and they’re getting platelets together. We can’t find the family, but Orthopaedics wrote a note already; you can write a note and we’ll have a two-physician emergency consent.”
A sense of futility and violation struck me. How do we bring this to a close? She’ll never survive, she’s already gone. No chance to operate, no chance to scope her, or angio her, or try any one of a couple tricks I knew could have stopped the bleeding. It was just too late. She’d bled out. Tim stared at me, waiting. I just stared back.
“It’s probably her gastroduodenal artery. Quick duodenotomy, put in a stitch, she stops bleeding,” Tim said.
“Yes, it probably is,” I said. Tim straightened up a bit.
The Orthopaedic senior resident sidled up to me. I’d worked traumas with him before. “Who’s your attending?” I asked him.
“Have you called him?”
“Yes. He says the patient didn’t want any heroic measures. Patient has a living will on file in her chart.”
I realized I was the only attending physician in the room. Frenzied activity all around.
The EKG remained flat line. I looked at the Orthopaedic resident, “What do you think we should do?”
“I don’t know. This patient didn’t want this. I talked with her when she came in for surgery.”
“The fact is, even if she had wanted the full court press, there are no more options. She’s simply bled out.” I stepped forward. “How long have you been at it?”
The medical chief checked his watch. “45 minutes.”
“And what’s the EKG?” I knew the answer, but the ritual had to be honored. Every participant had to feel that everything had been done right.
“I’m calling it. What’s the time?”
The team peeled away, leaving the intern and nurses to fill out the paperwork. I shepherded Tim and the rest of my team to a quiet spot across from the nurses’ station. Tim stared down at his hands. A muscle in his jaw twitched.
“Sorry it took me so long to get here. I got stuck in the elevator, why you should always take the stairs… looks like y’all did everything you could. They were just way behind the eight-ball. She never would have survived surgery.”
“We just got the big lines in. Got her tubed. Blood going in. OR ready.”
I looked past Tim, through the open conference room door. A family huddled outside the old woman’s room. I thought I glimpsed a John Deere cap.
“Get the family in a room. I’ll go talk to them,” I said to the nurse. “It probably was her gastroduodenal. Doesn’t matter. We wouldn’t have gotten her off the table.”
The set of Tim’s jaw cried you don’t know that! But all he said was, “If they had just picked up on her ‘crit drop this morning.”
“She’d just had hip surgery. Probably thought it was due to that. There was no reason to think she was GI bleeding. Anything else going on?”
Tim stared at me for a long instant, and then he looked down. Shrank a little into his scrub suit. He pulled a gold chain out of the neck of his scrub shirt and fingered his wedding ring, looked at it.
“I was just going down to the ER to check in,” he said.
“Change your scrubs and clean the blood off your shoes, first.”
I stood up abruptly and followed one of the nurses to a small conference room where the family waited. The nurse introduced me to that very same family I’d heard discussing the price of tractors, and speculating that “she” would go home tomorrow. The husband was wearing the John Deere cap. To his left, sat a grown son and his wife, and to his right, sat the woman’s sister. None of them were crying.
“Where the hell’s Doctor Freed-ell?” said the son.
“Doctor Friedl’s on his way,” said the nurse.
I introduced myself. Took off my surgical cap, so they could see my grey hair, knowing that it would look almost white under the hospital fluorescent lights.
“I’m Doctor Abernathy, the general surgery faculty on call,” I said. I turned to speak directly to the husband. “Your wife was bleeding from her stomach. Probably from an ulcer. That’s the reason she was having pain in her belly. Then it started bleeding really fast. These ulcers eat away through the wall of the stomach. The ulcer probably ate its way into one of the big blood vessels nearby. There was nothing we could do.”
“I want to hear it from Freed-ell. He’s the one operated on her. He said she’d go home tomorrow,” the son said. I passed the box of Kleenex to his wife. The husband sat silent, just looking at me.
“Told us she just needed a pint or two of blood,” the husband said.
“Said she’d go home tomorrow.”
I slowly went back over the situation again and again. Waiting for that moment of comprehension. Finally, the husband took off his John Deere cap.
“She hated me wearing this inside,” he said. “I told her, keeps my head warm.” He threw the cap suddenly past my left shoulder, just missing the trash can in the corner of the room. “Been married 49 years. What am I to do?”
Perhaps if there had been a daughter there, instead of a son, the daughter might have put her arm around him. But there was only his son, his daughter-in-law, and his wife’s sister, and they all sat stolidly. He leaned forward, putting his face in his hands, and a few hairs on his nearly-bald head gleamed silver. There was a groove in the skin of his scalp where the cap had rested.
I sat quietly with them until the chaplain arrived.
It was late when I finally got home, and Jonathan was sitting up in bed reading one of my books about natural history. He set it aside when I opened the bedroom door.
“Do you know what it says here? A fully-grown snapping turtle can take your finger off. There is no safe way to pick up a snapper. Pick one up too far back, the sharp claws of the hind legs get you. Too far front, the beak gets you. Pick one up by the tail, it can injure the turtle.”
I leaned over and kissed him. Took a deep breath and sat down on the bed beside him. Thought for a moment about telling him about the John Deere cap, but it was late and I was so very tired. I took a deep breath and bent forward, ready for a second kiss.
“That so?” I said simply. I’d forgotten about the turtle. I wondered if it made it back to the pond.
“They travel miles away from their home pond to lay their eggs. And you know what? Once they bite, only the sound of thunder makes them let go.”
* * * * *