Chapter 2: Permissive Hypotension
For twenty-one days, Whitaker presented every patient he saw to somebody who wasn't Robby.
Collins staffed him that first Monday. Mohan on Tuesday, McKay on Wednesday, Collins again through the weekend. When Trauma One lit up, Robby's voice came across the floor calling for Santos, for King, for whoever was closest, and Whitaker was never closest anymore. When he asked to put a central line in a septic woman in six, Collins gave it to him and stood at his elbow and told him, very nicely, that it was good. Robby passed the door twice and didn't look in.
Whitaker had worked out how it was being done by the end of the first week. By the end of the second he had worked out why, or thought he had, and spent several nights lying awake in his apartment deciding he'd made it up.
The fleece hung on the back of the chair by his door. He had washed it twice. Every morning he looked at it on his way out and told himself he'd forgotten it.
On the twenty-second day, a nineteen-year-old named Tyler Brandt came in at twenty to four in the afternoon with what his roommate said was the flu.
"I told him to come in yesterday," the roommate said. He was a skinny kid in a Panthers hoodie, holding Tyler's phone as well as his own. "He said it was just the flu. Everybody on our floor has it."
The department was boarding again, two deep in every hallway. Tyler's stretcher was wedged between the supply alcove and a drunk man who sang. He had a temperature of 103.6 and a heart rate of 134, and his pressure was ninety-four over fifty-six, which in a nineteen-year-old was fine until it wasn't. His hands, when Whitaker took his pulse, were cold to the wrist.
"My legs," Tyler said. "My legs really hurt. Is that normal?"
"Where?"
"Everywhere. Like, the bones."
Whitaker crouched to push up the cuff of his sweatpants, and Tyler rolled half onto his side and vomited, thin and yellow, over the rail. Some of it hit Whitaker's sleeve. Tyler gagged and couldn't clear it, so Whitaker grabbed the suction off the wall, cleared his mouth with the Yankauer, and held him on his side until he could breathe. Whitaker wasn't wearing a mask. Nobody in the hallway was, yet.
When Tyler could breathe again, Whitaker went back to the leg.
There were spots on the ankle. Small and flat, the purple of a ballpoint pen, scattered up the shin as if somebody had flicked a brush at him. Whitaker looked at them for a second. Then he took a clear plastic cup off the supply cart and pressed its bottom hard against the skin.
The spots didn't fade.
"Samira," he said, and heard his voice come out much too calm. "Can you look at this?"
Mohan looked. Her face did the thing it did when a differential collapsed down to one line. "Masks. Everybody near him. Get him into four, I don't care who's in four." She was already pulling a mask over her own face, and she tossed one at Whitaker. "Ceftriaxone, two grams, now."
"Cultures first?"
"Draw them while you hang it. Don't wait on anything."
He didn't wait. He drew two sets of blood cultures, one from a fresh stick and one from the IV he'd started twenty minutes earlier, then hung the antibiotic himself and watched it run, while Mohan got a second line and the nurse cleared four of a man with a sprained wrist. By the time they rolled Tyler into the room the spots had reached his knees. Some of them had run together into blotches the size of a thumbprint, dark at the center.
His pressure was seventy-eight over forty.
"Call Robby," Mohan said.
Robby came in gowned and masked thirty seconds later, and for one second, over the top of the mask, his eyes went to Whitaker. Then they went to the legs.
"How long since the antibiotic?"
"Six minutes," Whitaker said. "Two grams of ceftriaxone. Cultures drawn first. He's had a liter."
"Good. Give him another. Start norepi through the peripheral for now, and I want a central line in the next ten minutes." Robby was at the bedside, a hand on Tyler's forehead. "Tyler, I'm Dr. Robinavitch. You've got an infection in your blood. We're giving you strong medicine and we're staying right here."
"I want my mom," Tyler said.
"She's coming," said the roommate from the doorway, where somebody was trying to get him to leave. "Ty, she's coming. She's on 22."
Two hours from Altoona in good weather. It had been snowing since noon.
The next hour went the way the bad ones went, every step correct and none of them enough. Robby put the central line in himself. The norepinephrine went up and up, and they added vasopressin. The lactate came back at 8.9. The platelets came back at forty-one, then twenty-eight, and blood began to ooze around the IV sites and along his gums. The purple climbed past his knees and up his thighs, and it came out on his hands, the fingertips going dusky and then black. Tyler asked for his mom, then asked what day it was, then stopped asking anything, and Robby intubated him before the confusion turned into something worse.
"Hydrocortisone, a hundred," Robby said. "Start epi."
At ten to six the monitor still showed a rhythm and Whitaker couldn't find a pulse.
"PEA," Robby said. "Start compressions."
Whitaker was closest. He climbed onto the step stool, locked his hands, and pushed. Tyler had a runner's chest, narrow, and on the fourth compression something gave under the heel of Whitaker's hand with a soft crackle he felt in his own teeth. He kept going. Two minutes. Pulse check. Epinephrine. King took over, then Whitaker again. At twelve minutes Robby's fingers found a carotid pulse, thin and quick, and for nine minutes Tyler Brandt was alive again, with a pressure of sixty and his hands turning black on the sheet.
Then he wasn't.
They worked him for another twenty-eight minutes. Whitaker did compressions until his shoulders burned, traded off, did them again. Somewhere past the half-hour mark Robby stopped calling for drugs.
"I'm going to call it," he said. "Anybody have a reason I shouldn't?"
Nobody had a reason. Whitaker's hands were still moving.
"Whitaker." Robby's voice, close. "Stop."
He stopped. His arms didn't seem to know what to do next, so he left them where they were, hands flat on the boy's broken sternum, until Robby reached over and lifted them off by the wrists and set them down at his sides.
"Time of death, eighteen thirty-nine," Robby said.
The medical examiner's office wanted the tubes left in, so Whitaker couldn't take them out. He could tidy them. He retaped the breathing tube so it sat straight at the corner of Tyler's mouth, and he folded the sheet down at the chest and laid Tyler's hands on top of it, though the hands were the worst part and he almost tucked them under. He found the sock that had come off during the line and put it back on.
Then he sat in the chair beside the bed, because the roommate had been sent to the family room and the parents were somewhere on Route 22 in the snow, and it didn't seem right to leave Tyler in here with the monitor off and nobody.
He didn't hear the door. He heard the curtain rings slide, and then Robby was standing beside the chair with a paper cup of water in one hand and a single white pill in the other.
"Cipro," Robby said. "Five hundred milligrams. You suctioned him without a mask."
"Everybody in that hallway—"
"Everybody in that hallway is getting a dose. The roommate's getting a dose. County health is going to call his whole dorm floor." He held out his hand. "Take it, Whitaker."
Whitaker took it. The water was lukewarm and tasted of paper.
Robby didn't leave. He stood with his hip against the arm of the chair and looked at Tyler for a while, at the black fingertips, at the sock. Then his hand came to rest on the back of Whitaker's neck.
It was a warm, heavy hand, and it didn't do anything. It just stayed there, the palm against the top of his spine and the fingers curled around the side of his neck below the ear, the way you'd hold a calf steady in a chute so it couldn't hurt itself. Whitaker felt his whole body lean toward it. He let his head drop a little, and the hand took the weight.
"We had the antibiotic in under thirty minutes from the door," he said to the floor.
"Twenty-six. I looked."
"I should've seen it sooner. His hands were cold."
"His hands were cold and he had the flu, in a building full of the flu." Robby's thumb moved once at his hairline, then stopped. "You saw it. You saw it in a hallway with a drunk singing next to you, and you put a cup on it, and you didn't wait. Some people get the bad version. He got it."
"His mom's going to walk in here in two hours."
"I'll be here when she does."
"So will I."
The hand on his neck went still in a different way. "You don't have to do that."
"I know I don't have to," Whitaker said. He lifted his head to look up at Robby, and the hand moved with him but didn't let go. "Nobody has to do anything. I'm going to."
Robby looked down at him for a long moment. Whatever he wanted to say, he didn't say it. His fingers tightened once at the back of Whitaker's neck, and then he took his hand away and went out through the curtain, and Whitaker sat with the cold where it had been.
The Brandts got there at a quarter to nine, white-faced, snow in Mr. Brandt's beard. Robby told them in the family room, sitting down, using the word died the way he always did, and Whitaker stood by the door. When Mrs. Brandt asked who had been with her son, Robby said, "Dr. Whitaker. He's the one who found it. He didn't leave him." She held Whitaker's hands in both of hers for a long time afterward, and he let her.
By ten the snow had shut down half the bus lines and Robby's motorcycle was a white hump in the staff lot.
"Call room on four," Robby said at the end of the hallway. "Two bunks. Nobody's going to fight us for it tonight."
"You're sleeping here?"
"I'm not riding in that. And you live across the river." Robby was already walking. "I've slept in worse places than a call room."
The call room had a sink, a chair, a bunk bed with plastic-covered mattresses and a smell of industrial laundry, and a window that looked at the wall of the parking garage. Robby took the top bunk without discussing it. Whitaker lay on the bottom one in his scrubs with the scratchy blanket pulled up to his chin and looked at the sag in the mattress above him, where Robby's weight was.
The building hummed. A radiator ticked under the window. Someone walked past in the corridor in squeaking clogs.
"Do you still hear them?" Whitaker said into the dark. "The parents. After."
The mattress above him creaked. "Yes."
"All of them?"
"Enough of them." A pause. "You never stop hearing them. You just stop being surprised that you do."
Whitaker thought about that. "When I was eleven I sat up all night in the barn with a calf that had scours. I had it in my lap. I kept getting electrolytes into it with a bottle. It died around five, and then I had to go catch the bus." He looked at the springs over his head. "I sat in social studies smelling like the barn, and nobody knew why I was like that, and I didn't know how to tell them."
The radiator ticked. When Robby spoke again his voice was lower. "What did you do?"
"Fed the rest of them when I got home. They were still hungry."
Robby made a sound that might have been a laugh. Whitaker lay and listened to him breathe, and when the quiet had gone on long enough that the question seemed to have been in the room all along, he asked it.
"Why did you take me off your patients?"
Nothing came down from the top bunk. Then Robby's breathing changed. It went slow and even, slower and more even than it had been all night, and a little too careful about it.
Whitaker had worked enough night shifts to know what a man pretending to sleep sounded like. He lay on his back and stared up at the dark shape of the mattress and didn't say anything else, and neither of them slept.
At twenty to four, Robby's voice came down out of the dark, perfectly awake.
"You hungry?"
Marnie's had been open twenty-four hours a day since before either of them was born, and it looked it. The booths were red vinyl patched with red tape. The coffee came in thick white mugs that never got empty, because the waitress, a woman with her reading glasses on a beaded chain, came around with the pot every time you looked at her. Outside the window the snow came down at a slant through the streetlight and buried the cars along the curb.
Whitaker ordered pancakes. Robby ordered eggs he didn't eat.
"Twenty-one days," Whitaker said, when the waitress had gone.
Robby looked up from his coffee.
"Collins, Mohan, McKay, Collins, Collins, Mohan. Every trauma, you called somebody else. I counted." He kept his voice level. "Collins told me last week you'd asked her to staff me. She thought you were doing me a favor. She thought you were giving me a break."
"I was."
"I don't want a break."
"It's not about what you want. It's about—" Robby set down the mug. "I write your evaluations. I sign off your procedures. When the committee sits down in the spring to decide whether you get to keep doing this, I'm in that room. Do you understand what that is?"
"Yes."
"I don't think you do."
"I'm twenty-eight," Whitaker said. "I'm not a kid somebody left at your desk. I've had my arm inside a cow up to the shoulder. I just did compressions on a nineteen-year-old until his ribs went. You don't get to decide what's too much for me." He heard his voice crack on the last word and didn't stop. "You can tell me no. That's yours. But you don't get to make me not see it. You don't get to move me down the hall and call it looking out for me."
The waitress came around with the pot. They both held still while she filled their mugs, and she looked from one of them to the other and went away again without a word.
Robby turned his mug in a slow circle on the table.
"I'm fifty years old," he said at last, very low.
"I know how old you are."
"I've been doing this since you were in kindergarten."
"I know."
"Then you know why I—" He stopped. His jaw worked. He looked out the window at the snow.
Whitaker waited. He'd learned the waiting from Robby, from watching him sit with patients who were about to tell him the true thing.
But Robby didn't tell him. He took out his wallet and put two twenties on the table, which was too much for eggs and pancakes, and stood up.
"Come on," he said. "It's almost five."
They walked back up the hill without talking. The snow had gone wet and heavy, and it clung. At the ambulance bay the sodium lights turned everything orange. The doors were shut against the weather, and for once the bay was empty, no rigs, the concrete under the overhang dark with melted slush. Whitaker stopped under the overhang. Robby stopped with him.
"You're wearing my jacket," Robby said.
He was. He'd taken it off the chair yesterday morning without telling himself anything at all. "I keep meaning to give it back."
"Keep it."
"Put me back on your patients," Whitaker said. "Or tell me why. One or the other."
"You know why."
"I want to hear you say it."
Robby looked at him for a long time. Snow had caught in Whitaker's hair; he could feel it melting at his temples. Robby lifted a hand and brushed it off his shoulder, slowly, and then off his collar, and the hand didn't leave. It stayed curled at the zipper of the fleece, the knuckles resting against the side of Whitaker's throat, where his pulse was going hard enough to count.
"Dennis," Robby said.