How long does it take a clinician to decide what they believe will be the long-term consequences of severe injuries? How much of that projection emerges from assumptions about age and the imperfect assessment of the physical and emotional capacity of someone they have just met? How do these assumptions shape their interactions with a patient and the recommendations they make? Following a MVA, “This is a life-altering injury” was a phrase used by a surgeon almost immediately upon my arrival in the local ER and subsequently by others at a trauma center to which I was transferred. Even with over 20 years in critical care nursing and my training as a medical anthropologist, it took me days to translate what the unspoken subtext of that phrase was: it was a trope for “You’re eventually going to lose one or both of your feet”. With that realization came the feeling that I had just been firmly pushed out of the room with the door slammed in my face separating me from the place where strategies for my future were being decided. And if I disagreed with the inevitability of those assumptions (which I passionately did) how could I reconcile my vision of the possibilities that still existed for me with the limited vision of the people upon whom I was so immediately and thoroughly dependent? My answers (and the hope they engendered) arrived in the person of a doctor whose only assumption appeared to be that there are no assumptions.
“What can you see?” “I see a yellow house on the far edge of the field” “Nothing else?” “I see a yellow house, that’s all, that’s everything”. My universe had suddenly been reduced to the inside of a car, an open meadow and the yellow house in the distance. I had already made that clear to the woman on the phone. Why won’t she stop asking me the same question over and over? The pain in my legs and feet fill every cell in my body with a fire that is consuming me and I can neither make her shut up nor stop her from asking the same stupid question. I could hang up. Yes, that’s it. I’ll hang up and that will silence her, she’ll have to leave me alone even though, to be fair, I was the one who had called her. It had taken me ten minutes (or had it been hours?) to get to my phone when it flew out of my purse to the floor on the passenger’s side. Yes, if I hang up, that annoying, intrusive voice will finally go away but… but that voice and the yellow house, are the only real things that connect me to something that I can neither clearly identify nor let go of. I want to pass out and escape the pain, people always pass out in the movies (…blur the shot then fade to black) why can’t I? The ankle straps on my shoes are barely visible now as the swelling pushes my skin around the edges of both straps. My seat is pressed so far forward I am against the steering wheel so that even though I can lean to my right, I can’t reach around the steering column to release the Velcro straps.
With a pulse of relief, I find myself slowly slipping into darkness when the woman’s voice returns and pulls me back into the light of the early evening. Before she can finish asking, I tell her that all I can see is the yellow house and grass, and trees. “And what can you hear?” I want to say, “only your fucking voice” but my mother taught me better so I reply, “Nothing, I hear nothing”. “Try listening for their siren, they think they are close to where you went off the road”. She pauses but there is no sound beyond the tight, raspy bursts of sound that pass for my breathing. “Try to look behind you, one more time, can you see anything behind you?” I groan with the effort of moving even a couple of inches. “No, only the high bushes and more trees. I know the highway is there but I can’t see it”. “Tell me more about the house”. I start to sob-“it’s a yellow house”. “I know, I really know, how hard this is for you, but they are close, they will be there any minute, and I’m here for you, keep talking to me”. I’m now glad that I didn’t hang up on her. We both pause for a moment and from the other side of the moon, I hear the sound of a siren. I tell her I can hear it. We are proud of ourselves as if together we conjured that sound. “They can see your car, they’re pulling up on the road that leads to the yellow house, can you see them yet?” I can see the ambulance but it is so far away. Why are they stopping way over there when I am waiting for them here? If they are expecting me to get out of the car and walk over, it’s going to be a really long day. I see them unloading things and watch as a couple of them start across the field towards me.
They look like astronauts in their uniforms as they stride towards me in slow motion; I think I’ve seen this movie before or at least the trailer for this movie. They’re just walking but, despite the distance from me, they appear larger than life, heroic. We desperately need a soundtrack with all of this drama. I wonder how it is possible that they can walk in such slow motion without toppling over. I close my eyes for a moment and when I open them, they appear to be back at the ambulance and once again, they are starting towards me. I muse that the grassy meadow has its own gravitational field that is warping the time-space continuum or maybe I am dead and in hell and for all eternity they will come towards me until I blink when they will back-up and start again from the beginning.
The door on my side of the car suddenly opens, two beats later the passenger door yields and I am bookended by serious, concerned faces. I want to explain that the ankle straps on my shoes are compromising the circulation to my feet but all that comes out are gasps, “shoes…please…shoes… straps”. He releases the left strap. There is a flood of relief that lasts for a single heartbeat followed by something beyond pain-blowtorches, stabbing shards of ice, swarms of stinging, angry wasps. I grit my teeth as he reaches for the right strap. They are constantly asking me questions, more questions. I wonder if I say the magic words, “I can see a yellow house”, will that make them stop talking so I can figure out what is going on? But in this place, away from any reality I have ever known, I am afraid it might also make them disappear or at the least back them up to the ambulance to begin crossing the field towards me again. The passenger side guy is wrapping a tourniquet around my right arm as his partner wraps a blood pressure cuff around the left. Rightie tells me I am going to feel better soon. He is right, the drug races through my vein and immediately provides enough relief that I can finally take a slow deep breath. The other members of the crew are waiting with a stretcher. They are only a foot or two from where I am sitting in the car but we all know there is a wide, deep river of pain between me and the sanctuary of that stretcher. They take their positions as if performing a well-rehearsed dance. “On three everyone.” I try to tell them I missed the last rehearsal and if they could just give me a few minutes I could get caught up but by then they have passed three and the only sound out of my mouth is a scream.
I come to as we are almost across the field. I have no memory of the ride to the hospital but as they unload the stretcher and start towards the ER doors, the swaying of the stretcher brought with it a clear memory of the accident. That feeling of leaning into a curve where it takes my head a few seconds to realign with my spine. Again with the slow motion. I see the large spider moving across the top of the dashboard towards me. I reach for the hanger on the seat beside me to sweep it away but the panicked sweep of my right arm pulls my left arm along for the ride causing the car to go off the right side of the highway into a shallow ditch. I try to correct but overdo it and the broad arc of the car, still going around 50 mph, carries me perpendicular to the four lanes of the highway. I can see the horrified faces of the other drivers as they swerve and I helplessly speed towards the opposite side of the road, this time diving head-on into a much deeper ditch before being launched out of it and rolling into a broad meadow. I can’t brake, I can’t move my feet and have no choice but to ride it out until the car comes to a gradual stop. As I begin to process coherent thoughts again, I wonder why no one is coming to see if I am OK. As more time passes I realize I am on my own and need to do something. So I began the infinite reach for the phone and the call to 911.
In the ER I float in and out of a drug-induced bubble, answering more questions. I try to help with positioning as they take x-rays but besides the pain with any movement, there seems to be some kind of disconnect between my brain and my legs. They may or may not be responding to my commands, I can’t really tell. I finally prop myself up to look at my feet but that just confuses me more. I expected to see a bloody mess but there is virtually no blood at all. I am told to lay back again but I resist because I need to figure out what these two strange things attached to the bottom of my legs are, who put them there and most importantly, what have they done with my feet? I am reminded of old pictures I have seen of the deformed foot-stubs of ancient Chinese women who had their feet bound tightly from infancy. My left foot is especially puzzling as it appears to be folded back on itself at a gravity-defying angle. I again resist their efforts to have me lay back and the last thing I remembered before medicine met vein was an image in my head of the Wicked Witch of the West’s feet when Dorothy’s house landed on her. So where are my ruby slippers?
Two of my friends have arrived and are beside the stretcher looking very concerned. I try to tell them how grateful I am to them for coming but can only manage a weak “hi”. I slip away again but awake to hear the doctor explaining to my friends that they haven’t been able reduce the dislocations because, even with large doses of the sedatives, I am fighting them and the bones either won’t reduce or if they do, they slip again almost immediately. The plan is to take me to the operating room to do open reductions. Suddenly tired of hearing myself referred to in the third person, I move and clear my throat. The surgeon solemnly makes the first of what will become in the following days, a familiar, repetitive pronouncement: “This is a life-altering injury”. I wait for him to continue with at least a hint of what that means but he turns and walks out. I mull on this, trying to break the code as I would do again when it was said to me the next day by another physician and then again by at least two more doctors at the university trauma center to which I was eventually transferred. One of them began with a long discussion of how severe the crush injuries were, how the number of bone fragments alone would cause issues with any attempt to do a surgical realignment, what other structures in my foot were almost certainly damaged beyond repair, etc. etc. As the semi-stoned recipient of all of this information, my mind started to wander returning to the words he was saying only when something caught my attention: “Blah blah blah catastrophic blah blah blah not functional blah blah blah intractable pain…” That last one got my full attention but only because it occurred to me that I was overdue for more pain medicine. He finally concluded with The Pronouncement, “This is a life-altering injury”. There it was, doctor-code for what? And then, the ‘AHA Moment’ this doctor, all of these doctors, were trying to prepare me to have my feet amputated.
I wasn’t upset, in fact I was mildly amused. Boy, this guy is just going to be embarrassed when I return in a few months walking on my own two feet to say hello and show him just how wrong he was. But several days of more surgeries, unrelenting pain and/or drugs later and I was losing track of time as well as the sense that I had any part in this process beyond being the purported owner of the body parts everyone was interested in. The memory of the yellow house and the dispatcher’s voice became the last time I could remember feeling as though I had any control or personal connection with what was happening around me. After more than a week of their grim faces, I realized that no one was even considering the possibility of working with me to see if my feet could be saved. Their presumption that at least one amputation and probably two were inevitable filled me with panic. I really understood that they could very well be right; but not yet, not before I had a chance to prove they were wrong. Not before someone agreed it was worth a try because I was worth a try. The thought of an amputation terrified me and I knew that giving up now would haunt me for the rest of my life and forever leave me with an unanswerable, “What if…?” The weight of their somber, negative pronouncements about the damage to my feet dragged on me and I went from feeling determined to move forward and challenge their assumptions to feeling as if I were invisible and trapped in a black hole from which not even the sound of my voice could escape.
The decision was made to transfer me one more time to the hospital affiliated with my HMO and to the service of another specialist. The prospect of hearing another doctor discuss the “life-altering” nature of my injuries felt like it would break me. This guy, whoever he was, could very well be my last chance to convince someone that I would do whatever it takes to give my feet time to heal; that I would try anything he might think of to try to restore at least some function. I could, of course, simply refuse to have an amputation. But without finding a doctor willing (and skilled enough) to take on this challenge and agree that there was at least a possibility (however remote) that my feet could be salvaged, it would be really difficult to move forward (literally and figuratively). I desperately wanted to have alternative possibilities.
I was in the room frantically trying to think of what I could say to convince the new doctor to help me to find those alternative possibilities when he came walking in trailed by a couple of residents. I was immediately distracted by the fact that he had a friendly, easy smile on his face as he introduced himself. Going back to those first encounters in the ER, I suddenly couldn’t remember a single doctor who had looked me in the eye or smiled at me (some of them had never bothered to introduce themselves). He did a quick exam, said he had reviewed my records and scans and then discussed some tests he was scheduling for the next day. He asked if I had any questions. I decided to forestall the inevitable and cut to the chase, “Do you think I am going to lose my feet?” He paused for a moment and then said, “Nah”. With, “see you soon” he turned around and left. With a flash of insight I realized that whatever his first impression had been of my long-term prospects after his review of my medical records and films, he was not prepared to assume anything without his own assessment. That’s all I wanted. I also believe that he understood my desire for even just a pinhole beam of hope to get me through the challenges in the immediate days ahead. That’s all I needed. I lay back in the bed with a smile because I was suddenly certain that, whatever was ahead for me, the yellow house was visible in the distance again and I was pretty sure I had just been given my chance to see if I could eventually walk my way towards it. That’s all I was asking.