Names and biographical details have been changed to protect anonymity.
If you happen to survive jumping from a cliff with a bum parachute in Montana, or make it through a gory wood-chipper mishap in Alaska, the Harborview Medical Center, one of only two Level I trauma centers in the Pacific Northwest, is where you’ll end up. My job there was to bill for anesthesia. I would collect anesthesia records — crumpled yellow sheets covered with doctors’ scribbles — and determine how much patients owed for their temporary inability to feel.
It’s not surprising that trauma is the number-one killer of people under forty, but it had never been so obvious to me before I worked at a hospital. I was thirty at the time, and I hadn’t so much as broken a bone or dislocated a joint. I’m now thirty-eight, and to this day I still haven’t torn a rotator cuff, hamstring, or Achilles tendon. I haven’t sprained an ankle or wrist or had a wound that required stitches. Why? I’m sure it’s because I don’t sky-dive, surf, snorkel, or skateboard. I have never belonged to a sports team or club of any kind. I have never skied on water or snow. I don’t even know how to ride a bike. Seriously. I’ve never been on a bicycle, not once in my life.
A few years ago, my friend Greg lost the lower half of his right leg when a speedboat ran over him while he was canoeing in Minnesota. When I heard the news, I was worried about Greg, of course, but in the back of my mind I knew right away: that would never happen to me.
I just don’t go in for adventure, and I like to think I’m going to live forever as a result.
“But how can you not ride a bicycle?” people often ask. “It’s so easy.”
“The only thing easier than riding a bicycle,” I say, “is not riding one.”
Seattle’s local news is full of reports of people being gravely injured and then rushed to the Harborview Medical Center. The anchors can hardly get though a broadcast without uttering the hospital’s name. When I worked there, watching the six o’clock news was like getting a preview of my workload the following day.
At the office I’d input codes for billable anesthesia events. If someone, say, had a piece of rebar driven through his head and needed 5.75 hours of surgery, I’d input the code for 6.25 hours of class C anesthesia (#44275). Class C is what they use for brain surgery. I believe it’s the most expensive kind of anesthesia. I’d also probably charge for a blood warmer (#30315), which prevents hypothermia when refrigerated donor blood is transfused quickly, and there’d be intubation (#30015). It seemed as if everyone needed to have that plastic tube thrust down their throat. It was practically how patients were greeted at Harborview.
My job didn’t require that I communicate with anyone. I had a half-hour lunch, which I ate in the hospital cafeteria, and two fifteen-minute breaks.
On my morning break I would stand on the smokers’ patio in back of the building. I’d quit smoking a year before, but I still loved the smell of cigarettes.
The smokers and I would watch the red helicopter ambulances come and go to and from the landing pads behind the hospital. I could also see the colossal orange cranes that plucked cargo from the hulking container ships in the harbor and, on a clear day, the Olympic Mountains across the sound.
When my break was done, I’d walk back into the hospital, often with the stuttering thump-thump of an approaching chopper behind me, bearing fresh trauma victims. The office where I worked was deep in the bowels of the building, two floors below ground. In the event of a fire, I could have sprinted to an exit in four or five minutes, maybe, unless I took a wrong turn. Had there been a bad earthquake, I would have been entombed beneath an especially grisly pile of rubble.
The job had a gentle monotony that appealed to me, as if time had stalled. I listened to my iPod all day: Brahms sonatas for cello and audiobooks, which I found soothing. People who work in hospitals need to be soothed.
Everyone has a certain amount of energy allotted to them in life, and since I don’t participate in any sports and don’t watch much television, I have to spend mine on other pursuits. I like going to crowded public places by myself, just to watch people. The first Thursday of every month I join the mobs at Seattle’s art galleries in Pioneer Square for opening day, though I couldn’t care less about the art scene. The day after Thanksgiving I go to Nordstrom, though I have no desire to buy anything. I like looking and listening. Writing is normally a solitary practice, but I prefer to do it in a crowded cafe. Maybe I missed part of my socialization as a child and lack some essential ability to connect with other people. Whatever the reason, if the whole world is a stage, I’m the audience.
By the end of my first few weeks at the hospital I noticed that it took me about six hours a day to do a thorough job, which left two hours to burn. I would have browsed the Internet, but the layout of the office offered no privacy. I sat at my computer in an open room with a handful of other data-entry workers, inputting billing information. So I started reading patients’ files. It was the only moderately interesting activity that might have appeared work-related to a supervisor.
This was in wintertime, which is grim in Seattle. I had just finished a graduate degree in creative writing, which is also grim, but in a different way. I would arrive at the hospital as the sun was rising and leave as darkness was descending. The only time I saw daylight was during my fifteen-minute breaks.
A month or so after I’d started, I discovered the laughter-therapy group. I went up for my morning break and found about a dozen people outside, holding one another’s hands in a circle, bouncing up and down, and howling with laughter. Sometimes one of them would prance into the middle and dance a jig or pantomime playing a trumpet or marching in a parade, and everyone would crack up and applaud and then go back to bouncing up and down and holding hands. Their laughter echoed against the hospital’s art deco facade.
The first time I saw them, I smiled at the sight and took off my headphones to listen. Their laughter was so raucous and sincere, I found myself beaming. Even the inpatients on the smoking patio — a withered, mostly wheelchair-bound lot — smiled between drags.
After that day, I started timing my morning breaks so that I would see the laughter club, which met every day at 10:30 on the grassy esplanade beside the helicopter pads.
Other than my friend who lost his leg to the propeller of a speedboat, I don’t know anyone who has been admitted to a Level I trauma center.
All of my grandparents succumbed slowly to age or one of its many side effects.
In high school my friend Ezra was struck by lightning, but he died instantly and didn’t even go to the emergency room.
A couple of my friends have died of diseases. They were hospitalized but had no need for a trauma center.
Recently a good friend from my writing program was walking his dog with his wife in the evening, an hour before we were all to convene at a bar near my house, when high winds sheared off part of a nearby tree, and it fell directly on them. His wife got out with nothing but a black eye, but the EMTs pronounced him dead at the scene.
When I was twenty-eight, the woman I had dated for the first half of my twenties, Serala, died of a heroin overdose. Her body wasn’t found until the snow had melted in the alley where she lay. She did not get admitted to a hospital.
And when I was ten, my mother got lung cancer (Pall Malls). Six months later she died in the same hospital where I was born.
My office was beside the main hospital kitchen, and the only sound that made it through my headphones was when someone dropped a stack of plates. For the first week or so the crashes startled me. By the end of the second week, though, I didn’t even notice them. Other things that had been alarming at first — the dots of blood, say, on an anesthesia record — also didn’t register after a while.
I got better at my job. When a patient was admitted with a gunshot wound to the face, for example, I checked before automatically charging for the catheter (#30019), since it had probably been inserted on arrival and already billed. This sort of investigation proved to be the most engaging part of the work. In my spare two hours I continued reading about patients. Their plights were often pitiable, and I was tempted to “forget” to charge some of them for portions of their procedures, but I didn’t.
Ralph, who was in charge of billing, said it was important that we avoid overcharging; a lawsuit over what looked like a policy of fleecing patients would be catastrophic.
“What about undercharging?” I asked. “Is that OK?”
“That’s also a bad idea,” he said. I don’t think I ever saw Ralph smile, except for when he fired me. I think he smiled then.
Ralph had fluffy oatmeal-colored hair, a ruddy complexion, and an aquiline face that reminded me of my fourth-grade teacher, whom I had also hated. He was my teacher the year my mother died. In retrospect, it’s not surprising that Ralph was so dour: he had sunk his vital energy into a job that was equal parts monotonous and morbid. For my part, I tried never even to see a patient in person. I almost succeeded.
Once, I had to go up to the pediatric intensive-care unit to get an anesthesia record: they’d sent down an incomplete version. The patient was a kid who’d kite-skated into a telephone pole. His family was there as I strode to the foot of his bed, grabbed the chart, and turned away to find the page I needed. It was raining outside. I could hear the drops shushing against the window. When I looked up, I saw the boy’s reflection in the glass like an apparition: swaddled in white gauze so that he seemed to be glowing under the lights. I could see the catheter bag. I could see the tube (#30015) sticking out of his mouth — a tube I would make sure they paid for. None of them spoke. When I used to visit my mother in the hospital, after they’d removed one of her lungs, we didn’t speak either. There is surprisingly little to say in times like those.
I flipped through the chart, ripped out the anesthesia page, and left.
I didn’t want to waste my break waiting for the laughter club to arrive, so I’d come a few minutes after 10:30, when their session was already underway. But then I wondered how they started. I understood that once they had momentum, the laughter sustained itself. I understood it was contagious. But I was curious to know how they began.
It turns out that the secret to getting the laughter going, the trick used by laughter-therapy groups, is to hold hands and fake it until it becomes real. They stare into each other’s eyes and force it until the laughter takes off.
Certain patients were repeat anesthesia customers. They had been in the hospital for months and needed so much work that they went under the knife at least twice a week. Theirs were the first stories to catch my interest.
Some doctors had a knack for writing. Their prose was clean and strange and supremely blunt: “Walking home from a tavern late at night in Portland on October 28, Edwin G. found himself the pedestrian in a pedestrian v. pickup collision. Admitted with significant, unmediated brain swelling. Little hope of recovery.” Once I began reading, it was hard to stop. The majority of cases were straightforward, even a bit dull, but some stuck with me and would still be on my mind as I walked home. These people I’d never seen populated my life with a consistency that was lacking in my relationships with scattered friends from graduate school and distant family members. I talked to my dad once a month, but the patients were there every day — like the eighty-two-year-old woman who’d fallen down the stairs in her house one night and impaled herself on the stem of her broken wineglass. They’d reopen her abdomen repeatedly to “debride and irrigate necrotizing tissue” in her intestine.
With a patient, I knew intimate medical facts: an irritable bowel, hypertension, allergies, a history of depression, insomnia. I knew their real ages and weights and what pills they took. I noticed trends. Obese people seemed to suffer a disproportionate number of leg injuries, whereas men between the ages of sixteen and twenty-five tended to get shot. Junkies usually had an array of grave ailments. The toughened doctors in the ER might have been smokers, but I doubt you’d catch any of them on a motorcycle after what they’d seen.
After I’d learned to see through the jargon and acronyms to the personal details, my relationships with the patients changed. Pity was slowly replaced by sympathy.
My immediate supervisor, Noreen, had a nervous demeanor, especially considering how little happened in our office. We were just staffing the cash register, just ringing people up, people who weren’t even conscious and wouldn’t understand what they were buying anyway. Frankly I doubt anyone was able to verify a bill. Even the anesthesiologist probably wouldn’t remember the details.
One Friday I was returning to my station after lunch when Noreen, seeming more agitated than usual, told me to follow her. She ushered me into Ralph’s office, down the hall from mine in the catacombs.
We all sat down, and the two of them faced me silently for a moment. Ralph tended to be fatuous and blandly cheerful. Not that day, though. Both he and Noreen were buzzing with sinister energy.
“We’re going to be letting you go,” Ralph said.
“OK,” I said.
“Do you know why?” Now that it was clear I wouldn’t make a scene, Ralph was relaxing into this and looking faintly pleased.
“No,” I replied, blushing and unable to sustain eye contact.
“Let’s not make this any more difficult than it needs to be,” he said, as if repeating something he’d heard in movies.
“OK.” I wished I would stop saying that.
“Why do you need to read everything about the patients?” The ensuing pause was long enough for the phrase to sink in, but not long enough for me to answer. Ralph reminded me that the information was confidential, and that I’d signed a confidentiality agreement when I was hired. He slid a piece of paper across the desk to me. There was my signature, small and childish, beneath a large block of print. He asked me again why I would need to read an entire patient history to bill for a single procedure. Somehow they knew I had looked up information about lots of different patients. Ralph asked what I was trying to find out about those people.
“Nothing. I — I don’t know. I was curious. I didn’t tell anyone anything.”
“You were looking at information that was confidential, and that’s very serious.” They had software that monitored staff searches in the database, he explained, and when activity seemed suspicious, they looked at the history more closely.
I apologized and waited for Ralph or Noreen to say something. They provided no clues as to what else they wanted to hear.
“My job is to look at information that is confidential,” I said.
“Not that information.”
I was about to tell the truth: that I couldn’t help myself; that I couldn’t look at those sheets of paper and not think about the lives they represented. But I knew that would only make matters worse.
There was a lull while Ralph sat with his fingers forming a tidy steeple under his chin. I felt I should speak. The air from the hallway smelled of cafeteria food and bleach. I looked up at the low ceiling. For every five rectangles of white there was one fluorescent light. The one above Ralph’s head flickered quickly, like a strobe.
“Well?” he asked.
“Should I finish the day?”
“No. Give me your badge.”
I knew that later there would be things I’d wish I had said, some defense or comeback, but nothing came to mind. My head felt packed full of gauze, and my face was numb with humiliation. I put my ID on Ralph’s desk. The photo on it had been taken a week after I’d started, and I’d already started to look ghoulish.
The layout of the hospital was outrageously complicated. That day I needed to get away quick, so I took the elevator nearest Ralph’s office, thinking it might be a shortcut. Exiting on the first floor, I found patients lying on gurneys in the hallways. As I searched for an exit, I saw that some of the patients were handcuffed, and that there were cops standing nearby filling out paperwork. I was behind the lines in the ER. Finally I found my way out.
I put my headphones on, turned up the volume, and began to walk back to my empty apartment. By the end of the block I was jogging, wanting to get home as fast as possible. At last I arrived at my door, winded but so elated by the air stinging my lungs that I was practically laughing.
That was eight years ago. I haven’t been back to Harborview since, thank God, but sometimes I see one of those red helicopters passing by, carrying yet another gravely injured person to the trauma center. Each time I do, I shield my eyes and watch until it’s completely out of view.
There is one patient in particular I remember, a twenty-something woman I’ll call Victoria. According to her chart, she was bipolar, sometimes homeless, and addicted to heroin. In the admission report the doctor said she had a son, and that the boy’s dad was not in the picture. Victoria had suffered a psychotic episode, and she resided in the hospital’s psychiatric ward, where she received regular blasts of electroshock therapy, or ECT. For some reason that no one could explain, ECT was billed through anesthesia. I got papers on Victoria much more often than I did on any other ECT patient. As I charged her for the treatments, I tried to imagine her face, but the only face I could picture was my old girlfriend Serala’s. She, too, had used heroin to mitigate the symptoms of bipolar disorder. I was tempted to go to the psych ward and find Victoria, if only to put Serala out of mind, but I decided against it.
Still, one day near the end of my stint at Harborview, when I came up to watch the laughter club, I noticed a young wraith of a woman in a pale-green hospital gown with an orderly standing beside her. She was blond, with long, bony fingers, tattoos on her hands and wrists, and angry eyes. Was she Victoria? She smoked three cigarettes in the short time I was there.
A couple of hours later I came across Victoria’s latest ECT record. It didn’t seem right to me that, if she ever recovered, she’d be greeted with a stack of medical bills. I was tempted to lose that day’s record. A crime of inaction: my specialty. But that would have been illegal. So of course I didn’t do that. Of course not.