by Brent King

I put the first picture on the bulletin board when Tim died. I put his picture up in the staff lounge after one of the ER docs at Metropolitan let me know he died in their ICU.

I’ll admit I didn’t always like Tim. He could be a dick. But I’m sure he had untreated mental illness and he used the fentanyl and the cocaine as medicine, something to help him handle the world in a way he couldn’t without it, and I tried to forgive him for his outbursts and threats.

The last time I saw Tim, he came to the ER after he shot up into his groin. He had long ago used up the easy veins. Now it took an ultrasound probe to find the veins buried deep in muscle, dark spots that collapsed with pressure in the greyscale pattern on the screen.

He came because he had a “lump” at the injection site. I finally got him to pull his pants down, after I offered the usual bribe, turkey sandwich and a fruit cup, and I saw it immediately, an arterial pseudoaneurysm as big and red as a fresh plum. He missed the vein and damaged the wall of the artery. I touched it as gently as I could, and felt the blood pulsing through my gloves before he shoved my hand away.

“That fuckin’ hurts, man.”

“Look, Tim,” I said, hoping to scare him just enough to make him take it seriously, “you’ve got a weak spot in the wall of your femoral artery. It could rupture at any moment. If it does you’ll bleed out in a few minutes. I need to get an ultrasound of it and get the vascular surgeons to see you. I think you’re going to need an operation.”

“Just give me something for the fuckin’ pain,” he said, “and I want another san-which.”

I knew I couldn’t give Tim a sandwich. The surgeons were going to be mad enough about the first one, but I knew him well enough to know it wasn’t the time to explain or argue. That could wait until we figured out what to do. But Tim had a new nurse that day, and she didn’t know him, hadn’t learned how to redirect him when he started making demands. So, when he asked for ginger ale and she told him, in a matter-of-fact way, that we didn’t have any, he said “Fuck you, bitch.” He tore off his hospital gown and threw it at her. Then he stormed out of the ER, cursing us all the way to the door.

I was afraid he would die in some abandoned row house on a dirty mattress half hidden in the dim light of the candle he used to cook the fix, the remaining layer of the wall of his artery parting under the pressure of the speedball, the other users around him too wasted to help. But that isn’t how it happened. When he went to Metropolitan a few days later, the skin over the pseudoaneurysm was hot and there were red streaks down the length of his leg. He had a fever and was talking nonsense. He died a few days later. Sepsis. 

I found his picture in our electronic health record and pinned it up next to all of the announcements for the staff; another lost soul we couldn’t save. 

Then, I heard Sophie died after an overdose. That hit me pretty hard. In January, EMS brought her into the ER after a friend found her unconscious in an alley. When we cut her clothes off, they were stiff, and I could feel my trauma shears grinding through a thin layer of ice. Her core temperature, when we finally got a reading from the thermometer in her rectum, was eighty-three degrees. She looked pitiful, a cold, emaciated wreck of a body with ulcers and craters, some scabbed and some open all along her legs and her left arm from skin popping when she couldn’t find a vein. 

Tina and I were working together that day. She got the intubation equipment together while I started working on a central line and the nurses started CPR and then got the Lucas set up to compress Sophie’s chest. I knew it was Sophie lying on that gurney and briefly I thought of all the times we’d seen her in the department; tried to get her into rehab, but I pushed all of that down deep and focused on the steps of getting the line and on keeping my breathing steady.

At one point, one of the nurses looked up to Tina and said, “Dr. Howard, let us know when you want us to pause the Lucas so you can intubate.”

“There’s no need,” Tina said, “the tube’s already in.”

I hadn’t worked with Tina in a while. She didn’t do as many shifts now that she was the medical director, and I had forgotten just how good she was.

We worked for hours to get her stable enough to go to the ICU, and even then, I was sure she was going to die. I was shocked when I heard she walked out of the hospital a few weeks later. I hoped that her near-death experience might finally send her to rehab, but the fentanyl won. It almost always wins. So, her picture went up beside Tim’s.

On the day we resuscitated Sophie, after they wheeled her up to the unit, I congratulated Tina on being named Medical Director. She laughed and said, “Condolences might be more appropriate. Before I took this job, I would finish a shift, go home and have dinner with Theresa and Niko. After we got Niko to bed, Theresa and I could have a glass of wine and watch some silly TV show. Now I get done with a shift, go back to the office and work for an hour. Then I go home for dinner. When we get Niko to bed, I spend another hour catching up on emails and …”

She stopped in mid-sentence and looked at me. “Mind if I change the subject for a minute? Look, Phil, I know you applied for the job, too. I don’t want things to get weird between us. If we need to talk about it, we should.”

I couldn’t tell her that I felt ignored, hurt, and betrayed. So, I told her that the committee had made a good choice and left it at that.

That shift had a strange ending. Just before sign- out, Big Michael was placed in a room. He was a huge man who had fallen through the cracks of whatever “system” there is supposed to be to take care of people who can’t care for themselves. He probably functioned at the level of a five-year-old. He also had congestive heart failure that had gotten worse with each passing year. He lived in the park and survived on handouts either freely given or strong-armed, and scraps scavenged from picnic tables and trash cans. He never got the care he needed, except when he was with us. 

Since he was basically a child in a giant’s body, if he got angry or upset he could be terrifying and dangerous. And that day, he got upset. The tech distributing the meal trays accidentally gave Michael the wrong one. Like any kid, he had strong likes and dislikes. Whatever was on that tray wasn’t to his liking.

We heard the metallic crash of the tray against the wall, and the poor tech ran out of the room, screaming, hands covering the top of her head. We rushed to the door but kept our distance and told the unit secretary to call security, stat. 

Michael was pacing the room, pulling the supplies out of the baskets on the walls and throwing them on the floor. But his heart, his feeble, failing heart, could only be pushed so far. Before security could respond, he was leaning over the stretcher, gasping. Tina and I were trying to figure out what to do next. We needed to help Michael. He was in respiratory distress but getting close to him was still risky.

Then Tina did something crazy and amazing and incredibly brave. She pulled a glove from a box on the counter and blew it up like a balloon. Then she grabbed a magic marker from the secretary’s desk and drew a face on the thumb and feathers on the rest so it looked like a chicken. She walked into the room holding the glove. “Look, Michael, I have something for you. If you get into bed and let us give you some oxygen, you can have it.”

Michael looked up at Tina then heaved himself into the bed. He let the nurse put the nasal cannula in his nose. The he held out his hands for the glove. 

An hour later, after he was stable, I took a picture of Michael. In the picture, he is standing between Tina and one of the nurses. He is smiling, showing a missing front tooth and holding the blue chicken glove like a trophy. 

“How did you think of the glove? That was brilliant,” I asked Tina as we finished the shift.

“Oh, our pediatrician used to do that to get Niko to cooperate with doctor visits. I figured in might work with Michael. You mind sending that to me?”

“Sure.” I texted the picture to her phone.

My motives for putting the pictures up in the lounge were complicated. Yeah, I felt bad about Tim and Sophie and all of the others who had died. I mean, I assume they must have had families somewhere, but we never saw them. When Tim and Sophie came to the ED, they were alone.

But there was something else. Not being selected Medical Director hurt, and I was pretty sure that the pictures were going to get someone’s attention and maybe cause a stir up in “Mahogany Hall.” That felt like a little rebellion on my part, a little quiet payback for the insult. So, I went into the lounge when no one was around and tacked the pictures up in a blank spot next to the colored graphs and charts that showed how we were doing with our “metrics”—the things for which we are held accountable by regulators and administrators. The board was largely ignored by the people coming into the lounge for their cups of mud-thick coffee. Still, it wasn’t a huge surprise when Tina caught me near the end of a shift and asked if I could stop by the office when I was done.

The ED office complex was an architectural afterthought, so Tina’s office was tiny. We sat down at the small, round conference table, the only piece of furniture that would fit in the office besides her desk. Tina had a habit of twisting a strand of hair around her finger when she was nervous, and as we took our seats, I could see that she had a lock wound tightly around her middle finger.

“So, Phil, this is about the pictures in the staff lounge. Frankly, I never noticed them until Carol called me to ask about them. I guess one of the Assistant Vice-Presidents was in the lounge the other day and saw the pictures and asked Carol about them. She hadn’t seen them either, but when she went into the lounge and noticed that they were pictures of Sophie and Tim, she started asking about them. One of the nurses told her you might know how they got there?”

“Is there a problem with the pictures?” I asked, guessing and, in fact, hoping that they had irritated someone.

“Well, I think that the AVP had some concerns about privacy issues, and the Assistant Nurse Manager thought putting pictures of dead patients on the bulletin board was kind of, well, creepy. Can I assume that you put the pictures there, or at least know who did?”

“I think I might have an idea who it is.” I didn’t say more.

“So, you aren’t going to tell me.” It was a statement more than a question. She twisted the strand of hair so tightly that the finger turned red, then white. “OK, Phil.”

There was an edge to her voice that hadn’t been there before. I could tell I was frustrating her and hoped she couldn’t see that I was enjoying it.

“Just so you know, if the AVP tells Carol to take the pictures down, then they will be taken down, and, in the meantime, for your own good and to save what little is left of my sanity, I’d appreciate it if you or whoever is putting the pictures up, would stop.” She pointed to the stack of papers in her In Basket and said, “I’m still feeling my way in this job, and as you can see, I have plenty to do even without the God knows how many emails.” She pointed her thumb over her shoulder toward the computer on her desk. I’d appreciate not having one more thing to deal with.”

After that meeting, I knew I was going to put up another picture, and, sadly, the opportunity came sooner than I expected.

Tawayne Brock, aka ‘Li’l T,’ had been born with a tiny, useless nub for a left ventricle. It’s called hypoplastic left heart syndrome. A generation ago, once the diagnosis was made, a neonatologist or an obstetrician would have sat the parents down and, as we sometimes say, “hung black crepe.”

There was no cure, no surgery: it was a death sentence. Then a cardiac surgeon named William Norwood created a marvel of anatomic and physiologic engineering that made it possible to survive hypoplastic left heart syndrome, but it was by no means easy. It required a series of three operations, with time between for the child to grow enough to allow the next one to work, before completing the process, and even those like Li’l T who make it through all three surgeries, don’t have a “normal” heart. They have a heart that has been rebuilt with baffles and conduits, some made from the patient’s own blood vessels which are sacrificed and repurposed to force blood to flow where nature intended.

It is a fragile heart and one that will someday fail, leaving the patient on a waiting list for a heart transplant. In Li’l T’s case, as his reconditioned heart betrayed him, so did his family. He spent more time in the ER, and his family came to visit less often. They were, I suppose, tired after twenty years of doctors’ appointments and surgeries, tired of steeling themselves when it was time for the next operation, knowing that, as they watched his gurney roll through the double doors to the operating room, he might come out a corpse.

When he came to the ER, he was usually complaining of chest pain, and, usually we found nothing, which led some to believe that he came to us when things weren’t going so well at home. When he died, he was in the ER, and we only knew it happened when we heard the monitor alarm. We did what we usually do but his heart was too far gone. I was careful to put Li’l T’s picture up when the lounge was empty.

After I put it up, I got called into another meeting with Tina and got pretty much the same advice but this time with a veiled threat. “You know, Phil, have you ever thought about why I was named Medical Director and you were eliminated in the first round? Have you considered the fact that people might get tired of you being a rebel and a contrarian and that maybe one day you’re going to take it too far? I know you are a good emergency physician, and I respect your clinical abilities, but Phil, there are plenty of good ER doctors out there who are less difficult. Candidly, I don’t care so much about a bunch of pictures on the bulletin board in the staff lounge, and I even kind of appreciate the sentiment—honoring people who most of the world prefers to just ignore. But, despite my complaints, I do like my job and I want to keep it. So, if the administration tells me to care about the pictures, then I have to care, and if they tell me to take them down, I’m going to.”

With my job threatened, I stopped. I never pretended to be willing to risk my job for what I saw as a rebellious prank and I figured I would just go into the lounge one day and find the pictures gone, so I was surprised to look at the board and see a new picture, one I hadn’t put there. Someone had also put the pictures in a neat row and used pre-cut letters to write “In Memory” in somber blue above them. 

I noticed that Mr. Blevins hadn’t been to the hospital in a couple of weeks. That was unusual for him, and when I mentioned it to one of the nurses, she told me he died on a city bus. 

Mr. Blevins was a Vietnam vet with shoulder-length silver hair. He had survived two tours as a part of a LRRP team and come home without a scratch, but diabetes had cost him his left leg and his kidneys. He came to the hospital only for dialysis and only when he felt like it.

He pulled himself along in his wheelchair with his one good leg, cursed at anyone who got in his way and generally made a nuisance of himself, so he’d been kicked out of most of the local dialysis centers. 

While most of the staff generally hated to see his name on the track board, he and I had forged a kind of truce that held most of the time. Perhaps it was because I saw through him and knew that he was just a scared and bitter old man with untreated PTSD. He had left the better part of himself in the mud of a jungle thousands of miles and five decades away. I knew he was alone and felt ill used. I never coddled him, I treated him with respect and gave him the straight facts, so he mostly tolerated me.

He had waited too long for dialysis and collapsed on the bus two stops from the hospital. 

When I saw his picture on the board and the way it and the others were arranged, I felt guilty and stupid and immature. I wasn’t just honoring Tim or Sophie or Li’l T, though that was part of it. I was also using them to make some kind of half-assed statement protesting against my so called “unfair” treatment on account of my injured pride. Some better person had taken my selfish act and turned it into a real memorial.

Of course, Tina didn’t see it that way. I had just finished a night shift when her assistant called to ask if I could “please” stop by her office before I left the hospital. When I entered, before I could even sit down, she greeted me with, “Damn it, Phil, really? Do you just have to be a rebellious pain in the ass all of the time?”

I played dumb. “What now?”

“Please don’t insult my intelligence. There are more pictures on the board.”

“Well, I didn’t put them there.”

“Then who is doing this, Phil? I need to know so I can address it.”

“Honestly, I don’t know who put the picture up. I just saw it myself last night.”

“Do you know what got the last nurse manager fired, Phil? A bunch of the nurses went to a conference a few years back and they came home with T-shirts that said, ‘I’m here to save your ass, not kiss it.’ This was back when patient satisfaction was first being considered as a metric that could be used to rate hospitals. Someone from the administration saw those T-shirts and went insane. The nurse manager was told in no uncertain terms to put a stop to it and she tried. Of course, the whole thing eventually blew over, but not before the nurse manager and a couple of the ringleaders were fired. I don’t want this thing to turn into another one of those. So, if you know who is putting the pictures up, you would be doing them and yourself a favor if you told them to stop. I’m not losing my job over this and I don’t want you to lose yours either.”

That was it for me. I let the angry part of me come to the surface and smother my better judgement. “Okay, you know what, Tina? I did put Tim’s picture up and Sophie’s and Li’l T’s. I did it mostly because I was pissed off about not being named medical director and maybe partly because I thought it was sad that they died alone with nobody around except us, and to us, it’s just another day in the ED. But I didn’t put Mr. Blevins’s picture up, and I don’t know who did, but whoever it was, they did it for the right reasons and I respect that. If I get labeled a ‘ringleader’ and fired for starting something good, even if I did it for mostly selfish reasons, so be it.” And I walked out of the office.

Someone put Micky’s picture on the board. We only saw Micky sporadically. He would come to us for a week or two usually so drunk that he had to be helped into one of the frayed faux leather chairs in our waiting room. Then he would disappear for a while. Sometimes he went to other hospitals and sometimes he did some time in jail for whatever petty crime he had to do to buy the cheap vodka that he drank by the fifth, every day. Jail gave him some time to dry out, and the jail doctors would get him on a detox program. But there must have been a demon he was trying to drown because the day he was released, I’m pretty sure he walked out of the gates of the jail and went right to the corner store for a bottle.

He was slowly killing his liver, and over the last few months he’d come in with a belly full of fluid—ascites, one sign of a liver’s last gasp. The last couple of times I had seen Mickey, he was starting to get the yellow color that comes with advanced liver disease, and on his last visit to us, he had so much fluid in his abdomen that he could hardly breathe. We put the ultrasound probe on his belly, and we could see his intestines floating like snakes in a specimen jar. We passed a catheter into his abdomen and pulled off four liters of fluid, one after the other, yellow fluid streaming into vacuum bottles. 

Mickey died of an infection in his abdomen at a hospital across town, or so the nurses told me.

So, on it went. New pictures went up despite admonishments from Tina and Carol. By that time, Tina was barely speaking to me, and Carol hardly acknowledged my existence, anyway. She hated the fact that my favorite nurses were the ones she saw as rebels and troublemakers.

Finally, Tina and Carol called a mandatory meeting of all available staff. A few days later, doctors, nurse, and techs, some looking ready to fall asleep on their feet. crowded into the staff lounge. The tables and chairs had been shoved into the hallway to make room, and still people were left standing outside the door, leaning in to hear. I noticed the Assistant Vice President standing in the back. I couldn’t help but feel that the look on her face was one of satisfaction and victory. 

Carol started the meeting. Pointing to the board she said, “I know you … we … took care of these people …”

When she said that, a few coughs and snorts could be heard around the room and the nurse next to me whispered, “Bullshit. Carol never gets her hands dirty. She might chip a nail.”

Carol was either oblivious or ignored it. She continued, “It is right that we remember them, but, for reasons we have explained, we think this board is a bad idea and these pictures really need to come down. Furthermore …”

“Excuse me,” someone said from the open doorway. “Why is that board a bad idea?”

Carol turned to face the person who had challenged her, her face red and her eyes narrow. “Well,” she said tensely, then she faltered. She stammered “W-well, er …”

The nurse next to me whispered again, “Holy shit, it’s the CNO.”

“Who?” I whispered back.

“The fucking Chief Nursing Officer, like Carol’s boss’s boss! Hell, she’s even the AVP’s boss. She reports straight to the CEO.”

The crowd parted to let the CNO through. When she reached the front of the room, Carol moved aside, ceding the floor to her boss, then stood, hunch-shouldered next to Tina who was standing in a corner, eyes fixed on me.

The CNO looked at the board for a minute, then turned back to us. “I think this is touching,” she said. She pointed to the pictures. “I know many of these people were not always easy to care for, and I’m proud that you not only did your best for them when they were alive but found a way to remember them when they died. Perhaps Carol and I can find a way to keep this going.”

That pretty much ended the meeting, and it did nothing for my standing with Carol or Tina. On the few occasions when we encountered each other, Carol walked by as if I was another stretcher or IV pole in the hallway. As for Tina, she was professional but hardly friendly. 

The following week, I wasn’t supposed to be in the hospital, but a colleague needed help with a suturing lab for medical students. I was recruited to keep them from stabbing themselves with sharp needles and scalpels as they created and then fixed lacerations on preserved pig’s feet. On my way to the simulation center, I passed through the ER. I saw Tina standing outside of one of the rooms. Her yellow gown and gloves were crusted with dried blood. She was looking down at the floor and shaking her head. When I got close enough to see into the room, I knew it couldn’t be good. 

An ER room after a resuscitation tells a story. Blood pooling on the floor, pieces of plastic equipment dropped in haste, used gloves and gowns tossed aside and scattered. The more of these things there are, the harder the struggle to save a life and the more likely the struggle was in vain. The debris on the floor along with a thick arm hanging from beneath a sheet covering the rest of the body was all the information I needed to understand why, when Tina looked up at me, she pulled one glove off and then the other and slammed them into the trash can. Then she ripped her gown off and did the same. “Fuck!” she said.

I had never seen Tina so frustrated after a resuscitation. Even when things didn’t go perfectly, she remained collected and poised. There was something different about this one.

“Tina, what happened?”

She pointed to the room. “It’s Big Michael,” she said. “EMS said they got a call about someone sick in the park. He was still breathing when he got here, but …” and she shook her head and waved toward the room.

Then she said, “You know, after that day when I gave him the chicken glove, I kind of bonded with him. He called me ‘Miss Tina,’ and he would always ask for me when he came in, and, if I could, even when I wasn’t working in the ED, I would check on him. I mean I knew this day was coming, eventually. His heart wasn’t going to get any better, but …”

She didn’t get any further. One of the nurses rushed up to Tina. “Dr. Howard, they need you up front. Now!”

Tina followed him, stopping only to grab some new gloves from a box on the counter.

I arrived early for my next shift and stopped into the staff lounge to look at the Memorial Board. The board had become “a thing,” as we say these days, and as the person who started it, I kind of felt responsible for it. 

I scanned the pictures, remembered the people and what we’d been through together, the little pieces of their tragic and difficult lives that we shared.

It was the last picture on the board and it was slightly out of line with the others, as if it had been pinned up in haste. It was the picture of Michael, standing between Tina and the nurse, holding his chicken glove.

Brent King spent thirty years as an emergency physician working in busy, inner city emergency departments. Now he writes and rides his bicycles. Though he has had several publications in academic journals and textbooks, this is his first published work of fiction.