of course he has to go now

9

GRAY IS LOST IN THE LIGHT. He squints from the flood of daylight and now is adjusting to the overhead bulb and as his pupils dilate he can make out the figure before him.

No aggravated murder charge.

Not yet. There is some relief in that thought. Ian sees what has become familiar only to him; Gray’s mouth taped shut, his chin covered in bloody clots and hardened mucous, his Izod golf sweater drying in stages from the night’s expulsion of fluids from his broken nose to get air.

Ian sets the box on the folding chair. Gray reads the permanent marker, Virginia – Feeding. He would draw a big sigh if he could, but doing so collapses his nostrils and obstructs in the ingress of air. There is some relief for Gray in the box’s label, at least he is not there to kill him. His eyes go up from the box to Ian’s eyes. Gray isn’t too exhausted to show a modicum of disdain, a look of contempt that would have revealed an asymmetric curl of the upper lip were it not taped immovable. His eyes, though, agree, dilated like a shark, the pupils cut off at the top in the straight dash of the upper eyelids.

“Oh, keep that. You’ll need that. It’s what’s going to keep you alive.” Ian produces a Leatherman multi-tool from his pocket and unfolds a blade and uses it to cut through the clear cellophane tape on the top of the box and he opens the four flaps. From inside he pulls out a 90cc cath-tip syringe with plunger.

“This is going to keep you alive, too.” He reaches back into the box. “And this, too.” A long, thin package that holds a catheter, about three millimeters in diameter. Ian peels the package and draws it from its sterility. He places the top end of the catheter on Gray’s cheek with a few inches of slack leading to the opening of the tube and then measures the rest of the catheter across Gray’s face, down his throat and to the end of his moist, sweater-covered sternum. It’s a pediatric catheter and comes up a bit short.

“As long as it gets past the pyloric,” Ian asserts. “You’ve got to eat.” Gray never looks away from Ian’s eyes. With all the damage he’s sustained he cannot eat, so Ian is going to do a procedure, the insertion of a nasogastric feeding tube through Gray’s nostril down his esophagus and into his stomach, providing it makes all the right turns and doesn’t induce an aspiration episode.

“You haven’t pissed yourself, yet. When the time comes,” Ian reaches back into the box and retrieves a urethral catheter and searches deeper. “Forgot the K-Y though, sorry. We’ll cross that bridge – unless you have to go now. Do you have to go now?”

Gray’s mouth is still taped. He makes no nonverbal response. Of course he has to go now.

“Just let me know, then. We need to get some fluids into you, though, some electrolytes, some calories.” He pulls a can of Ensure from the box. “This liquid diet shit. You’ll need your energy. You ever taste this stuff? It’s awful. But you won’t be tasting this.”

Before Ian moves the box off the chair he finds one more item inside, a roll of hypoallergenic medical tape. He places the roll, the syringe and the can in its place on the chair, and holds the NG catheter up.

“Ever had one of these down your nose? Maybe as an intern, did you ever have to practice on a partner?” No response. “I did. Wasn’t very pleasant. Ginny had one for six months and we had to change it out and I wanted to know what she went through. So, I took one and threaded it up my nose, but I couldn’t get it past my gag reflex.” Ian clears the chair, putting the tape and syringe on Gray’s lap, the can on the floor, and he sits in front of Gray, holding the tube closer. “So, one night in the PICU I talk a nurse into doing it to me. Same thing. It took a housekeeper and an RT to hold me down while she threaded past my gag reflex and into my stomach and it was just a peds cath like this one. It hits the back of your throat and sends you into convulsions. The trick is to keep the force of the insertion consistent so when the reflex relaxes it pushes through down the esophagus.”

Ian stands and walks around the adirondack behind Gray.

“Six months. Because of you.” He tears a piece of medical tape off the roll and attaches it to his sleeve. “This is what we had to do to feed my little girl.” Ian’s purpose in holding this man hostage is crystallizing now.

He reaches around the right side of Gray’s neck and tilts his head up with his right hand and with his left starts to thread the tip of the NG tube up the doctor’s nose. Gray’s scream is muffled by the duct tape. Ian stops.

“Oh, I almost forgot.” He crosses back in front of Gray. “Your nose is broken.” He sits and examines. “What side are you breathing out of?” Ian plugs the left nostril by pushing it closed and air wheezes through the right. He plugs the right nostril and nothing. The congestion of clotted blood and hardened mucous impedes the flow of air.

“Better leave that right one alone. That’s your breather.”

It is here where the irony of this is not lost on Ian. He is about to perform a procedure that if unwarranted would be considered torture, but for Gray, this is the only way Ian can get fluids into him barring an IV, something outside of Ian’s scope of care for his daughter. And this patient is going to need other care in addition to the nasogastric feedings with that rumbling deep in his lungs.

Gray screams again.

Ian goes back behind Gray to his previous position and in one move grasps Gray’s jaw to steady his head and threads the feeding tube up – gag, release, continued pressure – then down the left side. The length of the tube disappears down the nostril until all that is left at the opening is a couple of inches to the top of the catheter. Gray’s face swells and blushes, his eyes bulging in their slits hemorrhage tears, his screaming cut short by the catheter bouncing off his epiglottis ricocheting into his esophagus closing off his vocal fold in the swallow.

Ian attaches the syringe, its plunger fully deployed and slowly draws the plunger back and the base of the syringe starts to fill with fluid. A successful placement. He shows Gray the contents of the syringe as if Gray were paying attention. “A bit acidy. That’ll eat right through your pyloric.”

He plunges the fluid back into Gray’s stomach, removes the syringe, corks the catheter and pulls the tape off his sleeve and secures the catheter in place by taping it on to Gray’s now very rosey cheek, its capillaries beginning to burst. Clear fluid is pouring down his face, blood oozes from his left nostril around the NG tube and begins to bubble out of the right side.

Ian comes back around in front of his patient, lights on the chair and picks the can up off the floor and places it in Gray’s convulsing lap.

“Shit! You can’t breathe!”

He reaches for the duct tape on Gray’s mouth, but the corners have adhered as well as the rest of the swath. Ian digs in with what little nail he has and tries to pull a corner, and another, and on the bottom, but nothing gives. Gray is convulsing fully, his face explosive and wet. Ian stands in front of Gray for better leverage, pressing in hard on his face where the tape sticks to his flesh and finally, a corner. Ian peels enough away to get a good pinch between his index finger and thumb and rips duct tape away off Gray’s mouth. It explodes with vomit, blood and mucous and then Gray sucks air in desperately in a rasping draw that feels as if it is changing the ambient air pressure of the unit. Fluid vibrates in his trachea and upper lobes of his lungs creating tones an octave lower on his expiration.

He assesses his patient, his hostage. Gray is dusky, blue around his lips, around the cuticles of his fingernails. He’s desaturating, RT code for not getting enough oxygen. Respiratory Therapy. Ian knows this because he and Linda were trained as such to take care of Virginia. That is how, after the first three years they kept her out of the hospital except for the sepsis and the collapsed lung.

Ian is back on the folding chair. He’s covered in the fluids Gray expelled and pulls his warm, wet shirttail out away from his body. Gray alternates clearing his airway, hocking over the epiglottis, trying to satiate that persistent need to void the throat that comes with projectile vomiting, with just breathing. The heave forced material into the back of the throat, now with an NG tube to boot. He spits and coughs, clearing his throat, cleaning his vocal cords, saturating with oxygen while he does, blue giving way to rose.

Gray, almost recovered, speaks to him through the liquid dregs of his throat. “You’re a sick man, Mr. McDaniel.”

Ian, for the first time in a week, smiles. “Oh, you’re the sick man here, Doctor Reagan.” He looks down at his shirt. “God, what a mess.” The wet mess is cooling against his skin and it stinks, making his own skin crawl, which is not insignificant, considering the gross injustices he had to perform daily as a care-giving daddy. He removes his shirt, pulling the black tee over his head. The pragmatic of black.

“Time for your feeding.” And with that Ian pulls the plunger from the cath tip syringe, pops the pull-top from the can of Ensure, peels the tape from Gray’s face holding the NG tube, plugs the syringe into the catheter and holds it up just barely past the height of Gray’s nose and fills it with thick vanilla fluid. He waits, standing there, bare chested, depending on gravity’s pull while Gray breathes. What sounds like turbines beginning to whir gets up to a stabilized frequency with an accompanying rush of air are the dryers of the car wash next door. Someone is washing their car this Monday morning after all.

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