Like a waiter reciting how the evening specials are prepared, a man in uniform announces, so that the eight of us can hear, that you are probably a man in your fifties, that you were struck by a car, that your body was dragged over asphalt for half a city block, and that your face was found against a curb. Like a glaze, blood runs down your face. The man hands me your oxygen mask, warning, “Be careful,” because it is slippery, because it is your breath. I place an ultrasound probe on your chest and find that your heart is beating quickly, thrashing, then calms down, then stops completely.
A surgeon wielding a scalpel elbows herself between us and gouges a hole in your chest, which I should have thought to do. Another surgeon with a stainless steel mallet chisels through your breastbone, exposing your lungs to the air as they collapse and inflate like a giant gill, like a bellows, like anything except a living person. He chisels just exactly the way a sculptor would chisel, and with the same tools, your sternum giving the resistance of stone. Before they finish, before I learn your name, you are wheeled into the operating room for another round of violence, this time more controlled, where you will be rearranged and edited, mostly by cutting, into a version of yourself that might survive. I am told later, for example, that your spleen, having shattered into a dozen pieces, will be excised.
Emergency Medicine doctors are usually handy, but I am still in training, visiting a new hospital, and I am blanking. Instead of following you to the operating room, I stay behind to tend to the next patient rolling in, who turns out to be the driver who rammed into you. A police officer tells me that your friend chased him after the accident, then stabbed him. The officer verifies this while holding back a grin, as if to say, no really, this is all true.
The R Adams Cowley Shock Trauma Center is connected physically to the University of Maryland Medical Center by an atrium with a high, glass ceiling – the innards of the hallway are also exposed, but only to the sky. Indoor trees grow beside the elevators, and what once served as an outer flank of the historic hospital building has been repurposed into a side wall of an interior passage. In the Trauma Resuscitation Unit, the heart of what’s colloquially known as Shock Trauma, handmade snowflakes fashioned out of folded pieces of paper dangle by paperclips as though they were weather. One of the snowflakes is carved from an unused diaper. In this branch of the medical complex, there’s no clear separation between inside and out.
This is my second time in Baltimore. During my first visit, back in 2015, the city appeared in national headlines when police officers arrested a Black man named Freddie Gray for possessing an illegal “switchblade” that was later deemed to be a lawful pocketknife. In police custody, Gray suffered spinal cord injuries, fell into a coma, and ended up here, at Shock Trauma. Six officers were charged with murder; three were acquitted; charges on the remaining officers were dropped. At the time, I was studying the basic sciences required to apply to medical school, and while I crammed for physics, homicides per capita skyrocketed to a record high for the city. Many of those victims also landed at Shock Trauma, and I began to dream of what it must be like to train here. A love of learning is required to become a doctor, and medicine often involves bloodshed. In the beginning of our careers, some of us crave it.
Now, in 2021, it’s Christmas season, when people shoot and stab each other less frequently than in the summer. I’m back in Baltimore as a visiting second-year resident-physician from my home training program in Brooklyn, where even on our worst days we see less butchery. Today, I hear from the nurses that you have beaten the odds for now: you survived the operating room, though we still haven’t learned your name. In the meantime, there are other patients to see, and I take over the care of an elderly woman who fell in her home and could not get up. She tells me that without food or water, she called 911 by dragging herself over a length of carpet to reach her phone, a feat that took her two days. I am instructed by an imposing senior surgeon to immediately send her home as soon as her x-rays return, as long as they are normal. Her thighs have rug burns.
If I had been the first physician to see her when she arrived, I might have ordered a few more tests than the surgeon did, just to evaluate the toll of dehydration on her kidneys. I tell this to the nurse, who encourages me to run the tests anyway, though it will prolong her stay – the woman, she says, deserves to know about the health of her organs. But those were not the surgeon’s orders, and the treatment, I decide, would be the same either way: she’ll have to drink more water until her kidneys recuperate. Besides, the surgeon needs to free up beds; at any moment, patients with graver injuries could arrive. No one has time to ask this woman if she can again stomach the sight of her carpet, if she feels safe anymore in her own bedroom. Discharging her to her home is a form of triage, and triage is a necessary, if violent, form of abstraction.
Not satisfied, the nurse presses me to defy the hierarchy. To drive her point home, she leans toward me and whispers, “Did you hear that Desmond Tutu died today? He said something that always stuck with me. He said, ‘I make you and you make me.’ We can’t change how others see a patient, but we can see each patient as a person. We, you know we,” she says, implying me and her and not the surgeon, “can treat them differently.” I nod, and she feels that I’ve agreed with her, but as she walks away, I think of your opened chest, your lungs, your spleen. As a doctor, I lance, stitch, intubate, and drug. What does it mean to do these to a person? How exactly is a person made?
R Adams Cowley, who made Shock Trauma, later made his name by advocating for an emergency transport system that broke with tradition and ferried patients not to the nearest generic medical facility but rather to the nearest hospital with the resources to provide definitive care. In 1969, he was the first to propose the use of military helicopters for this kind of transport so that those living in the farthest-flung reaches of the state of Maryland could gain access to the most advanced life-saving treatments in Baltimore. To drum up support for this vision, Cowley had to wait until the right person became critically injured. After a car accident nearly killed a friend of the governor’s, the state began to allocate funds.
Nowadays, physicians from all over the East Coast and Canada, including those in the armed forces, spend some time at Shock Trauma for two reasons. First, it embodies the gold standard of treatment for traumatic injuries. Second, conditions in Baltimore at times approximate a war. Though New York City has eight times the population of Baltimore, it sees fewer total gunshot wounds and stabbings. Thanks to its carnage, Baltimore is one of the few places where trainees can reliably witness enough violence in a single month to match years of experience in their home institutions. We doctors flock to Baltimore to practice slicing a thorax like a wedding cake.
Colleagues from Brooklyn who sojourned here before me warned me about this month. Some found it too sad to see, in the flesh, so much tragedy in the lives of young men, mostly Black. Little is offered to trainees in the way of grief counseling (it’s assumed we know what we’re signing up for), and the relocation to another city means that most visitors must leave their families and friends behind. Thanks to the resurgence of Covid-19 in the form of the Omicron variant, my wife is able to work remotely and has joined me in Baltimore. Even still, it’s hard for me to relate to her what my days at the hospital are like, the quotidian nature of ghastly injuries. Occasionally, when I begin telling her a story, she’s horrified at the set-up, before I even reach my point. At other times, in an over-calibration, she assumes I’ve become inured to things that long preoccupy me.
At the Baltimore apartment we are renting for the month, my wife finds it difficult to sleep alone when I work 24-hour shifts, and she becomes obsessed with Carl Sagan again, watching episodes of Cosmos before bed to keep her company. On one of my days off, she asks me to explain the fourth dimension. We find a video from 1980 in which Sagan holds a glass cube under a lamp and says that the flat shadow it casts on his desk is a two-dimensional representation of a three-dimensional object. To creatures that resided in a two-dimensional world, the passage of a falling apple through the plane of their existence would confound all comprehension – an object would seem to appear out of nowhere, grow, then disappear. He then displays an odd three-dimensional object that he says is designed to represent the “shadow” of a four-dimensional cube. It is hard to picture; in a sense, it is impossible to understand, locked as we are in three-dimensional minds. But, he says, that doesn’t make it untrue. I wonder what an understanding of the fourth dimension would explain to us that now seems so uncertain. Would it explain memories, premonitions, or what it means to be a person? When I return to the hospital the next day, I find out that you have died.
When his body was alive, Sagan liked to say that we, all of us, are “star stuff,” that our bodies are comprised of recycled atoms from ancient, exploded stars. So is a chair, I think. So is a knife. His point is that we are connected materially to the primordial reaches of the universe, though that does not explain why we humans should be special.
No one gets special treatment in trauma. No matter how a person is wounded, the medical assessment of a trauma follows an algorithm that sticks to the alphabet. It starts with A. A is for airway – can air reach the lungs? B stands for breathing – are the lungs themselves working? C covers circulation – does the patient have pulses, or is the patient hemorrhaging? The mnemonic keeps us on task and reminds us of our priorities, from most to least deadly: asphyxia kills faster than blood loss. But it also helps to ground us when we find ourselves paralyzed by the agony of visible human suffering; when in doubt, we can always fall back on a kindergarten song. In plastic gowns and face shields, we run patients down the conveyor belt of this algorithm, attaching wires and tubes, stripping patients nearly naked, and occasionally palpating their anuses to inspect for neurological damage. Everyone is processed in the same way.
Not all traumas are severe, and in the Trauma Resuscitation Unit, hours can pass without action. I work with four other Emergency Medicine trainees from Maryland, Pennsylvania, and New York. Three of them spend their downtime making origami frogs, dragons, and for the most ambitious, unicorns. Near the nurses’ computers, a small library consists of paperback novels, a medical dictionary, and the King James Bible. Perhaps because it is late December, I’m seeing more religion around the hospital. Each morning, as I enter the lobby, a Southeast Asian man in a suit greets me with, “God bless you, sir.” As I walk past him one morning, I overhear a woman ask him why he doesn’t just say hello, and before she can finish her question, he interjects, “I say ‘God bless you’ to everyone, no matter who you are.” I convince myself that this man applied for this job in order to bless as many people as possible – and not just church-goers, but also the unlucky souls who pass through hospital buildings, including those who drift into Emergency Departments after homeless shelters close.
In my downtime, I leaf through the nurses’ Bible. “What is man, that thou art mindful of him?” Psalm 8 asks. The creation of the moon and the stars took less than God’s hands, the psalmist writes. Just his “fingers” were enough. And then there’s us, mere humans. How do we compare? What does it mean to be made in God’s image, “crowned with glory and honor,” allotted dominion over all the fish of the sea, then stripped naked in a trauma bay by hospital staff who grow annoyed when your objections slow them down? Quiet shifts are often boring; in my boredom, am I treating patients like people? The time would pass more quickly with action, but action is violence. It occurs to me that perhaps the right thing to do is to pray fervently every moment that no patients will arrive, that no calamities befall anyone, that our ward remain empty, that I have come to Baltimore to learn nothing. I should pray for people as nuns pray for the passage through purgatory of souls they never encountered.
In the atrium, a chapel remains open for prayer, and this, in itself, makes me want to pray out of gratitude for the institutional recognition that sometimes we just need a moment. Au Bon Pain, the sandwich shop, is also open 24/7, and the staff there are always kind to me, never begrudging me a warm meal, though it means more work for them at a late hour. I’m not religious, but this seems like a better, less solemn place to pray for my patients, the kind of place where the families of our patients are actually likely to be found.
At 2am, my pager alarms. A police officer has been shot in the back of the head while sitting in her patrol car. She arrives unresponsive. Other police officers arrive. The mayor arrives. My pager alarms again. A middle-aged woman in her forties is arriving by chopper from a distant, rural county because she fell down a flight of stairs. This is Cowley’s dream. I meet them at the rooftop helipad, and the cacophony of the rotors is unbelievably loud, so much louder than on television. I hear nothing until we reach the elevator. Finally, I can make out her words from her position on the stretcher: in tears, she is apologizing, saying she’s fine. She is mortified by the fuss.
A man rolls in next, older than most of the other patients I’ve seen. He’s been shot so many times – in the neck, chest, shoulder, abdomen, legs, through-and-through his scrotum – that we count the wounds twice to reconcile the number. Even so, we find injuries later that escaped our first and second glances. He speaks only a few words, about how he can’t take the pain. I pet him, tell him we’ll take the pain away, then drug him. He has a Le Fort fracture, which makes it a challenge to insert a breathing tube. (René Le Fort, the fin-de-siècle French surgeon, spent years of his life bashing in the faces of cadavers with kicks, metal shafts, wooden clubs, and marble tables. After shattering their heads, he sawed them in half front-to-back, boiled off the soft tissues of the face, and carefully documented the way that skulls fall apart.)
The older man needs a tube placed in an artery. I am good at this, as far as residents can be, but every time I perform this skill my heart races, and I sweat profusely. A part of me is grateful that the man is unconscious, because, though I am trained, I still fret that patients will think I am a fraud and discern how many times I have missed. Before an audience of every other nurse and doctor, I crouch over the patient’s right arm like a tailor. I extend his wrist and tape it down to a table. His pulse is strong. His pulse is so strong. I thank God on his behalf that his heart is good. I aim a needle into his pulse and thread a plastic tube into it. I stitch it into his own skin as if he’s a doll, so that if, in his delirium, he tugs on it accidentally, the excruciating pain of trying to remove it will prevent him from hemorrhaging.
I follow his stretcher to the operating room and scrub in. The surgeons remove segments of bowel like people digging through a box of mittens to find two that match. They hand me the dead colon in a steel bowl. I think of the Orthodox Jewish man from Chicago who sued a hospital for cremating his amputated limb instead of preserving it for burial. In Slow Man, the novel by J.M. Coetzee, a cyclist struck by a car refuses to replace his lost leg with a prosthesis. The loss overwhelms his life, takes on a bodily weight, and becomes a part of him, a new appendage. He becomes “a half-man, an after-man, like an after-image; the ghost of a man.”
That night, incredibly, multiple family members of a single patient call our team for updates on the course of her recovery. Each of them separately has woken up from a similar dream, dreamt at around the same time: that the patient appeared to them and asked them to let her go. She dies the next day. The police officer dies, too, the first female officer in Baltimore to be shot and killed on duty.
When we grow inured to violence, what becomes of us? When patients arrive with exposed bones, I notice various members of the hospital staff trying to peek, and I recognize the same tendency in myself. Since becoming a doctor, the guilt of that enthusiasm has by now become a well-worn, broken-in feeling. But this is not the dream I thought it would be in 2015, during all those murders when I was learning physics. I still think of you and wonder what it means for you to exist in my mind; whether it represents a small fraction of your ability to exist elsewhere; whether, like stars, you remain visible at a distance, long after you’ve ceased to exist; whether, like Sagan, you could comfort a sleepless wife who, at the moment you uttered some beautiful thought, had not yet been born; whether my grief for you has extended beyond my conscious thoughts of you; whether this is what Desmond Tutu meant, that you are part of what has made me.
Adam Lalley is an emergency medicine physician. His writing has appeared in Plough, The McNeese Review, The Healing Muse, STAT, The Diplomat, and Intima. He is a winner of the Michael E. DeBakey Poetry Award and the William Carlos Williams Poetry Competition.