His North Star

"As an Emergency Doctor, there are seven things you should know.

"Number one—you'll kill someone one day. It's going to happen. You'll often need to make critical decisions with no patient history to guide you. You'll make the right call most times. But a few times, you won't and you'll lose the patient. When that happens, learn what you can from the situation, forgive yourself and move on. You will kill someone. Accept it now and you'll handle it better when the time comes.

"Number two—half of what comes through the door aren't legitimate emergencies. What'll make you efficient is being unapologetic about priorities. If some idiot limps in with a sprained ankle and whines that he hasn't been treated while cardiac arrest cases are pouring in at the same time, tell that limping bastard to shut up, sit the hell down and wait.

"Number three—people are weird. They perform acts you'd never dream of, and insert unthinkable objects into orifices where such objects should never be inserted. After a week in this ER, nothing will ever surprise you again.

"Number four—spring is suicide season. The assumption is that suicide peaks in winter, because of holidays and the weather. That's bull. Suicide rates are lowest in winter. People kill themselves in April and May, with the sun shining and flowers blooming.

"Number five—burnout is real. If it hits you hard enough to affect your mental health, don't try to power through. That's a great way to endanger your patients. If you're about to crash, let me know. I'll see that you get a break as soon as scheduling allows.

"Number six—you'll be sued at least once before you're 50.

"And number seven—you'll save lives on every shift. That's why you'll enjoy this job as much as you'll detest it. Questions?"

This was the opening speech of Dr Elizabeth Elgar, an ER Attending physician, to the 8 new residents under her supervision.

The residents were between ages 27 and 29. All had done pre-med courses, attended medical school, gotten their M.D.s, completed their internships and a year's residency in Internal Medicine.

Although it was their first day of Emergency Medicine, it was their second year of residency overall. The first year in Internal Medicine was mandatory for their program. They were in for three years of Emergency Medicine residency before they'd be full-fledged Attendings.

Nathan Bellamy, 27 years old, was among this crop of residents who stood listening to Dr Elizabeth Elgar's speech.

Nathan had no illusions. He had a damn good idea what this job involved—he'd already been a doctor for 2 years. Yet with a streak of the hope that had always sprung eternal in him, he let himself believe Dr Elgar was exaggerating. Just slightly, to drive her points home.

As the weeks of his residency passed, Nathan found she hadn't exaggerated at all.

But it wasn't until April 1982, two-and-a-half years later, that her speech hit home for him.

*****

Author's Disclaimers: Suicide is a major theme in this story. If you find this theme distressing, please don't read further.
There are Emergency Room scenes and I haven't shied from details. If you're easily queasy, beware.
If you enjoy reading about brutal punishments heaped on women who stray, this story isn't for you. Any comment glorifying violence or containing hateful slurs will be deleted.
This story is long. The pace is unhurried. The writing is descriptive. These are features, not bugs. If you prefer wham-bam stories, you're not the target audience here.

*****

PART ONE: THE KID
"I sometimes lie awake in the sawdust, dreaming I'm in a suit of light." Buddy Mondlock, The Kid.

New York, April 1982

*

Delta Lake was to one side of him. To his other side were trees on an elevated ridge.

Dr Nathan Bellamy was at the wheel of his AMC Eagle, driving to the place he'd worked at for the last 4 years; Delta Lake Hospital. It was a Level I trauma center in upstate New York. In the city of Rome at the foothills of the Adirondacks. The hospital was a convenient 3 miles from the Lake Delta Fire Department, and a bearable 10 miles from his apartment.

He worked 12-hour shifts; morning, afternoon or night. Whenever his shift began in the morning, he always stopped at a certain inn for breakfast. It wasn't much of a detour from his route. He turned left before the dam and followed the road for a mile until he reached Rossini's Inn.

He'd done that this morning.

Giorgio Rossini owned the inn. His wife had handled the running of things, but chronic kidney failure had claimed her two years ago. When Giorgio became widowed, his daughter from a first marriage had moved from Buffalo to help him. Emma Rossini, with a recent degree in Business Admin, had been in the position to seamlessly pick up where her stepmother had left off.

Giorgio ruled the kitchen. Emma ruled everything else.

That morning, Nathan drove to Rossini's Inn, walked into the breakfast parlor and parked himself at an empty table. A waiter had come, poured him coffee, and taken his order.

As he'd sat drinking it and waiting for his breakfast, Emma had come in from the garden, crossing the breakfast parlor towards the kitchen; probably going to speak with her father about something. When she'd spotted Nathan, she'd walked over to his table. "Good day to you, Dr Bellamy."

Nathan had given her a ceremonial nod. Overly formal greetings were their personal joke. "And a good day to you, Miss Rossini. I trust you're in good health."

"I am indeed in good health, thank you Doctor. And yourself?"

"I too am in good health."

Emma laughed. She cut a slender, long-legged figure as she leaned her hip against his table. Her black hair was sheared to her angular chin, but her lace dress lent her a feminine air. "The waiter's taken your order?"

"Yeah."

"Good. I'll go hurry him up if he's taking too long. Will we see you the rest of this week?"

"Probably not." Nathan brought his coffee cup to his lips, holding her brown eyes over the rim as he drank. "I've got two late shifts, then I'm off a couple days until Friday. I'll use the break to go see my folks in Binghamton."

"I'm glad to hear that. It's been months since you visited your parents." Emma straightened. "Because you're being a good boy, you get a reward. I'll throw in a honey muffin on the house."

Nathan grinned. "A free muffin? I feel blessed."

Emma laughed again; a rich yet light sound. "As you damn well should. Dad's honey muffins are the best in a 300-mile radius. I'll tell him you're here. If he gets a minute, he'll come say hi. We'll see you sometime next week?"

"Definitely. Have a great day, Em."

"I sure will. And you too." Emma flashed him another smile before she stepped away from his table and headed for the kitchen.

Nathan watched her go.

His breakfast came a couple minutes later, brought to his table by Giorgio himself. With his free muffin in a doggy bag, he went on his way. He arrived at Delta Lake Hospital in time to start his 8:30am. shift at the Emergency Department.

In some hospitals, ER doctors at the end of their shifts signed any remaining patients over to the doctors starting their shifts—which was great for the outgoing doctors. In other hospitals, ER doctors stayed until all their patients were either admitted or discharged—which was great for the incoming doctors.

Delta Lake Hospital was the former. As soon as Nathan changed into his scrubs and white coat, three patients were signed over to him. This was despite that 9 other doctors were currently working shifts and the whiteboard at the nurse's workstation had several names waiting.

Clearly, it had been busy overnight.

Nathan's first patient was an elderly man whose grandson brought him in because he'd suddenly begun having seizures. Nathan examined the elderly man, took a history, gave him an anticonvulsant, sent him down for an EEG, and referred him to the Neurological Intensive Care Unit.

His second patient was a younger guy with second-degree burns on both legs. Nathan treated the burns and had him discharged.

His third patient was a middle-aged woman. There was a corn cob lodged up her ass. When he asked her how the corn got there, she flushed crimson and looked away.

"I was walking around the house and I fell on it," she muttered.

Nathan looked at her expressionlessly. "You were walking around your house as usual, then you suddenly tripped and fell on a corn cob, causing it to become wedged in your anus?"

The woman flushed redder yet. "I, um, yes." Still refusing to meet his eye, she added, "I...I've tried everything. I even tried a laxative, but it didn't work. It's...um, well, it's too big for me to poo it out."

"I see," was Nathan's deadpan reply.

There was a nurse in the consulting room with them. The nurse's eyes were dancing with amusement, but she managed to suppress an outright smile.

"I'll send you for an X-ray of your rectum," Nathan continued to the patient. "I'll need to know the corn's depth before I try extracting it."

He sent her for the X-ray. An hour later, he pried the stinking, shit-covered corn out of her dilated anus using biopsy forceps.

When she thanked him, he replied: "Glad I could help, but understand that this was the best possible outcome. Objects in the rectum can cause complications, like inflammation or infected perforations. Those can be fatal." Keeping his straight face, he added: "If I were you, I'd be more careful while walking around my house. Don't trip and fall on any more corn cobs."

"Of course," she muttered.

Nathan nodded. "If you head back to the waiting room, the nurse will meet you there."

The instant the crimson-faced woman stepped out, the nurse burst out laughing. She laughed and laughed, bent double. "I have a damn fine prank to play on my husband tonight. I'll grill some corn cobs for dinner, wait till he's munching away, and tell him this story."

Nathan allowed himself a smile. "You'd do that to an innocent guy? You're a cold woman."

The nurse laughed merrily on. "He's not innocent. Yesterday, he didn't wash the dishes when I asked him to. He's brought this punishment on himself."

"Before you go punish him, you think you could finish up with this patient? Schedule her for a follow-up sigmoidoscopy, keep her in Observation for a few hours, then discharge her."

"Sure thing."

His next patient was no laughing matter. She was a car accident victim. An ambulance brought her in, but she was awake and alert. A quick examination assured Nathan she had no major head injuries, but when he listened to her chest, he knew what the problem was. Her heartbeat was too fast, her breathing was too quick, and the skin over her left ribs was bruised.

As Nathan listened to her chest, he tapped for hollow sounds. With each tap, she winced. He examined her face, assessing the level of her pain and noting her bluish pallor. "On a scale of 1 to 10, how bad is the pain?" he asked.

"Nine," she whimpered. "It's like a stabbing pain." Her eyes welled. Her voice wobbled. "It hurts worse when I breathe."

"Don't be afraid. You'll be fine." Nathan straightened, pulling his stethoscope out of his ears. His suspicion was pneumothorax—that her ribs had broken, punctured one lung, and collapsed it.

But he didn't say so yet. There was no point scaring her more than she already was. He said, "Let's get you sent for a CT scan, okay? That way we'll know exactly what we're up against. A nurse will stay with you."

He was correct; when the CT scan came back, it showed a collapsed left lung with fractures severe enough to need surgery. With an intern and a nurse assisting him, Nathan intubated her to drain the air in her chest, then he paged a Trauma Surgeon. As soon as he'd briefed the surgeon, she was on her way to the Operating Room.

Without skipping a beat, Nathan moved onto the next name on the whiteboard; a toddler with a widespread purple rash and running a 105-degree temperature. Bacterial meningitis. After treating the toddler, he took a short lunch break then moved on to the next patient.

Nathan continued at this pace of controlled chaos until evening.

By 6:00pm., he was stitching up a guy who'd been bitten while breaking up a dogfight. The wound was deep, jagged and spurting fresh blood, so the sutures took a painstakingly long time. A nurse was there, assisting him by cutting the suture after he made each knot.

The patient watched Nathan uneasily the entire time. At last he said: "Look, doc, you don't really got to report this to Animal Control, do you? He's my dog. I know him. He's vaccinated. I've shown you his certificate. He's not aggressive either. It was my own damn fault for sticking my arm between two fighting dogs. He shouldn't get punished because I was stupid. Do me a favor and don't report this."

Nathan glanced up from his stitching. The request irritated him. In the first place, it was his medical license on the line if he didn't make the report. In the second place, the long hours were starting to wear his patience thin. "I'm bound by law to report all animal bites."

"But he isn't dangerous."

"That's not the point. Our priority is your safety and the safety of others. When I make the report, they'll double-check the vaccination certificate and observe your dog under quarantine for a few days. If it's sick, you'll come back here for rabies shots. If not, you're all clear. Either way, this bite is bad enough that a black mark will be put against your dog, but if this is the first time it's bitten anyone, and you prove it didn't attack you without provocation, it probably won't be put down."

The patient scowled, but didn't argue further.

Nathan finished the suturing and turned to the nurse assisting him. "You can start the discharge process," he said to her.

He went to phone Animal Control, but he'd barely taken one step out into the busy corridor when he saw a Triage Nurse striding his way. Worry was written on her face. She began speaking before she reached him.

"Dr Bellamy! Thank goodness. You're the only doctor not busy right now. A patient just came in. Male. Age 18. Purposely swallowed sodium hypochlorite pills. He left a suicide note. His elder sister got home early, caught him and called an ambulance. He doesn't know how many pills he took, but this is the bottle." She handed Nathan a small plastic jar.

The bite-happy dog was immediately shelved lower on Nathan's priority list. He scanned the pill bottle's ingredients in a matter of seconds. The pills were industrial strength, each with 1.7mg sodium hypochlorite. The pH was 11.4.

The bottle was almost empty. Even if it'd been only a quarter full, this was a case of massive toxicity.

"Shit," Nathan muttered under his breath.

He went with the Triage Nurse, taking brisk strides down the corridor. He hadn't lost a patient today. It was a couple hours until his shift was over, and he prayed he'd go this whole shift without any deaths.

Despite the icy discomfort clawing up his spine, and that the analytical side of his mind was working at 1000 miles per hour, Nathan spoke coolly. "He's alert?" he asked the nurse.

"Barely conscious," the nurse replied. "Vomiting blood and can hardly speak."

They stopped at a door. Nathan glanced at the chart to check the patient's name, then he shoved the door open, nodding to the Triage Nurse in dismissal. She returned to the nurse's workstation. He went into the patient's room.

The combined stench of blood, shit, vomit and chlorine punched Nathan in the gut the instant he opened the door. Despite that, he didn't outwardly flinch. He went inside, shutting the door behind him. In the room were two nurses, an orderly, and the teenage kid.

The kid had a bucketful of vomit beside him. The vomit was liberally laced with fresh blood. He lay half-upright, sagging on the bed. He'd shit himself, the back of his jeans stained with the feces. He looked up with empty blue eyes as Nathan stepped inside.

The emotionlessness in the kid's eyes gripped Nathan's spine like an icy fist. This kid had chosen an excruciatingly painful way of killing himself, yet there was nothing in his expression. No pain. No fear. No regret. No sadness. Nothing.

Nathan stepped towards him, assessing. This was sodium hypochlorite toxicity alright. He was sure of it even without a blood electrolyte panel. The stench of bleach oozed from the kid. The bloody vomit meant that his stomach and intestines were perforated. His eyes were red and watery; irritation. There were black marks inside his lip; his mucosal membranes were corroded.

"Jason Holst?" Nathan asked.

"Y-ssss," the kid replied. His speech was slurred and his voice was thin—the tissues of his vocal cords had begun to necrotize.

But at least he was conscious and responsive. It was just possible he might survive what he'd done to himself.

"I'm Dr Bellamy," Nathan said. "And we're going to fix this." He rubbed his hands with alcohol. As he put on sterile gloves, he fired a question to the nurses. "You've taken his blood pressure?"

"Yes," one nurse answered. "He's at 79/51."

Nathan swore under his breath again—that blood pressure was way too low for his liking. He stepped up to the kid's bedside, suppressing nausea as the reek of shit and vomit intensified. "Jason," he said, bending to meet the kid's eyes. "I need you to answer a couple questions for me. Help me out, okay? How many of those pills did you swallow?"

Jason's body jerked, wracked by a violent fit of dry heaving that almost made Nathan wince. "I d'nn kno..." he hissed when the fit allowed him to speak.

As the kid spoke, Nathan examined the inside of his mouth. His gums and tongue also were black with corrosion. Wetness dripped down his chin; hypersalivation.

"Did you swallow a handful?" Nathan persisted.

The kid stared into Nathan's eyes. "T'w h'n'fl'ss."

"Two handfuls?"

The kid nodded in confirmation.

"Did you take anything else?" Nathan asked. "Painkillers? Stimulants? Depressants? Alcohol? Weed? Hallucinogens? Anything?"

The kid shook his head repeatedly. "N-n-noth'n." Sucking in a sharp breath, he grabbed the bucket and retched into it, expelling more blood than vomit. Then, seeming spent for the moment, he collapsed on the bed, wheezing.

Nathan picked up the bucket to examine its contents. The color was deep copper. The consistency was thin and lumpy. He set the bucket down and turned to one nurse. "Take arterial blood. Rush it to the lab. Do whatever you need to push the results out ASAP. I want gases and a full electrolyte panel." To the other nurse he said, "We'll intubate him."

While the first nurse drew blood from the kid's wrist, the second nurse prepped for intubation. It took all of a minute for the first nurse to swab, draw, cap and label. With the blood sample in hand, she burst from the room. The second nurse was gloved. She'd laid the equipment out and was putting pressure on the draw site at the kid's wrist.

The kid lay sprawled on the bed. He hadn't even seemed to notice that his blood had been drawn. He was unmoving, his breaths growing shallower.

Before intubating him, Nathan tried to get a response. "Jason," he said, touching the kid's cheek.

The kid's eyelids flickered. He looked up at Nathan dazedly, but otherwise didn't respond. His eyes closed again.

"Jason," Nathan said again, authoritatively.

There was still no response from the kid. His eyes stayed closed. His body was lax. He was unconscious.

Nathan turned to the nurse and nodded.

That one nod was all the communication they needed. They repositioned the kid flat on his back. His throat was already relaxed, so the nurse opened his mouth wider, keeping his tongue down while Nathan guided the laryngoscope into his trachea. He inserted the tube. Once it was in, he inflated the balloon and listened to the kid's chest.