Triage

By Tamela Viglione, illustration by Darryl T. Jones

1 September 2000

The red silk blouse slipped from its hanger and pooled like blood at Sonia's bare feet. Her husband picked it up and put it in her hands. "Here you go," he said, and though their bedroom walk-in closet was spacious, he brushed close to her on his way to his shirts, chest against her back, hands spanning her hips with a brief light pressure.

The flowing silk warmed between her fingers. Her throat tightened.

Alan said, "Wish you didn't have triage today."

Sonia looked up. His back was turned to her; he was shrugging into a button-down cotton shirt. "You'll be hot in that," she heard herself say. "It's terrible out there."

He glanced over his shoulder. "The box has air."

Glass-walled corporate stadium boxes cut a cool, immoral contrast to humid triage wards packed with the sick and dying, but Sonia only said, "Oh." Who was she to pass judgment on air conditioning? She'd broken down and bought a hundred AC exemption hours herself, yesterday -- one of which they were enjoying right now. Cooled, moving air teased her hair against her back.

She thrust the blouse back on its hanger. Why had she even considered it? The hospital was no place for silk.

Alan said, "This okay?"

He turned. He smiled as he held his arms away from his sides, but his mouth was tight and his eyes looked bruised. Recent restructuring had turned his company's summer afternoon baseball outings into managerial skirmishes; the casualties were mortgage payments, marriages, and self-esteem. Nobody's job was secure.

Sonia mustered a smile. "Perfect."

"Wish you could come," he said. "This weekend thing is killing you. You need some fun."

A quick laugh escaped her. It surprised her; the sound was bright, for a woman who'd soon be dispensing death sentences. "Thanks but no thanks," she said. "Not that kind of fun."

Alan's mirroring laugh was distracted but warm. "No kidding." He stepped close and squeezed her shoulders. "I'm sorry," he said. "I've got to go. There'll be traffic."

For a moment, she was inside the space of a hug.

She listened as Alan strode through the house. She heard the faint jangle of keys, the soft slam of the front door.

She looked at the red silk blouse.

Forget it, she told herself. It's not right. Not for triage.

The blouse was austere yet dramatic. It would show the ridge of her collarbones, hug the curve of her breasts; it would slide like heat beneath Lyle James's hands.

She turned her back on it. It was the only way she could finish dressing.

Sonia's navy suit was trim, plain, quite appropriate for the head of AmHealth's Tri-County Hospital triage department -- and more like a uniform than anything she'd worn as an intensive care RN back in the double-zees. Good thing she'd gone administrative when she had, though; intensive care units had downsized considerably in the wake of universal health care. Few could afford ICU stays beyond the government's three covered weeks per year.

The appropriate suit was also an uncomfortable suit. It chafed Sonia's skin as she hurried down the concrete halls that connected the employee garage to the hospital. She was late.

A sign taped to the elevator that should've taken her to the twelfth floor offices read Out Of Order -- Again. She spun on her heel. Damn. She'd have to use the central elevators. She doubled back to the hall that led to Tri-County's public lobby.

Steel doors as thick as her briefcase barred the public from the limited access passage she was about to leave. She palmed the ID scanner and braced herself.

The doors parted. The lobby's thick air puffed at her, a sour exhalation.

People crammed the big public space to the walls. Children wailed, adults scowled or sobbed, families clustered in the spaces they'd claimed. Their bundles and blankets littered the tiled floor.

The resealing doors' distinctive thwock announced Sonia's arrival. People turned, stood, shouted questions. They thought she was a doctor.

The two security guards posted at the lobby's central elevators moved a half-step away from the wall.

The voices hushed at once. The lobby crowd was apparently all too familiar with the result of misbehavior: eviction. They'd be thrown out, removed from whomever it was they prayed for in the triage wards -- or else denied any chance at triage themselves.

Those who had no place but the lobby to wait for their government-subsidized care showed the usual obvious problems -- tubercular coughing, tarry melanomas. Beyond that, Sonia saw chemical burns, oddly colored cataracts. More Mexicali refugees.

More human beings to triage for an unchanging number of beds.

Headache bloomed behind Sonia's eyes.

She hurried to the elevators. As she waited for one to arrive, she heard shouts behind her, from beyond the lobby's public entrance.

--no right to decide--

--not God--

--cold-blooded murder--

Triage protesters.

They crushed into the lobby waving posterboard signs and flaunting their glaring inability to understand the reality of limited resources. Security personnel tried to press them back outside; the elevator guards ran to assist security even as the lobby crowd surged toward the fray.

Sonia saw vid equipment, small dark boxes bobbing among the protesters like flotsam in floodwater. Her gut clenched. She squeezed between the arrived elevator's barely opened doors and jabbed the "12" button.

As the doors closed she spotted Lyle James.

She thrust her arm in the narrowing crack. The doors stuttered off her elbow and retracted.

The state's legal proxy was tall. His eyes met hers over the churning crowd. A smile ghosted the straight hard line of his mouth.

Sonia found the hold button.

Lyle skirted the turmoil as if it were a mess on the floor, long legs swinging slow and deliberate from his hips. No one stopped him.

Just as Lyle made the elevator, three harried health techs -- in her mind, Sonia still called them orderlies -- jostled in behind him. Sonia resisted the urge to shove them back out; instead, she released the hold button. The elevator's hum displaced the protesters' shouting.

The techs bitched about protesters and bad lunches. Lyle watched the light panel. Sonia watched Lyle. Last week after triage they'd met in her office to discuss the increased caseload. They'd never gotten to it because when Lyle leaned into her from behind she hadn't pulled away, and when he released her long black hair from its twist she still hadn't pulled away. Then Lyle had unzipped his fly and she'd stripped her underwear from beneath her skirt and he'd thrust himself inside her. After he came he dropped his jaw to the cusp of her neck and shoulder, and his fine dark stubble had rasped that tender skin while Sonia bit back her moans.

They hadn't spoken about it. Not before, not during, not after. Not the two times since, either. It just happened, an intense blunt rush, wordless release.

Sonia recognized it for what it was: sexual morphine. Forget the triage cases, forget the guilt of being a have instead of a have-not. Forget that you couldn't change the world for one single person, not even your own husband; for twelve raw minutes it all went away.

Naming the addiction didn't cure it. Sonia imagined the sound of a zipper pulled down fast, and her stomach twisted with shame and excitement and the inevitable stress of triage.

The bitching techs exited on seven.

She and Lyle rode on in a charged mutual silence, both staring at the light panel. She got the distinct feeling that he knew as well as she did that if they chanced to lock gazes they'd be far later to triage than they already were.

They stepped into the twelfth floor foyer. Sonia rubbed her temples; Lyle smoothed his jacket.

He stood close to her as she palmed the secured foyer's scanner. Almost murmuring, he said, "Traffic as bad for you as it was for me?"

"Unbelievable," she said. She kept her voice crisp, but his question somehow sparked an illicit rush of warmth. That warmth -- and the subsequent twist of guilt -- helped her forget, for a moment, how much she wanted to be somewhere, anywhere but here doing triage. When the foyer's locked doors slid open, she headed for the department's conference room at a breakneck pace.

The five other triage committee members stirred in their chairs when Sonia and Lyle joined them. Sandwich remains littered the broad gray table; pickle and coffee smells made the air thick.

Despite having to decide forty-eight cases before they could go home, the committee members rallied to the obligatory small talk: the broken employee elevator, the hike in the city's AC exemption rates, Mexicali developments.

No one discussed personal lives. In triage, familiarity had the uncomfortable feel of a dangerous act.

Jen, the department's young weekend assistant, patched a live feed of the triage protesters onto their flipscreens.

The small talk died.

Sonia watched blue reflections flicker in the hollows of her colleagues' eyes. She thought of her husband in the cool hostile air of his company's stadium box and looked back down at the protest feed.

Signs and shouts.

The coffee Jen brought her went bitter in her mouth. Too many of the protesters clearly had the means to buy medical treatment beyond what universal health care provided. What if they didn't? What if triage had allotted what there wasn't enough of -- government-paid care -- to their spouse, their child, instead of to a certain-to-die stranger? Would they continue to scream that triage was murder?

No, Sonia thought. No, they would not. People discarded such principles in a single beat of a faltering heart. She'd seen it hundreds of times as an ICU nurse, many times more as head of the triage department.

And lately, she'd seen it in the mirror.

She tapped the screen to close the feed. "Okay, folks," she said. "Let's get through this."

Forty-eight cases. Currently available public ward beds: twenty.

Health care was a constitutional right. Universal health care, government-subsidized medical treatment, was available to all.

Within limits.

Demand outweighed supply. Thus, triage.

Sonia cued the files. Information scrolled on everyone's screens.

Male, Pakistani, estimated age thirty, end-stage TB. Denied. Female, African-American, twenty-three, abdominal bleeding, HIV positive, gravida three bipara. Five-day accept. Female, Caucasian, age thirty-eight, Hepatitis C, jaundice, chemical scarring in pulmonary tissue, ovarian cancer. Denied.

Denied. Denied. Ten-day accept. Denied.

Three minutes or less per life.

Denied. Accept. Denied.

As stipulated by law, a committee of seven specific people -- a hospital administrator, a medical ethicist, a practicing physician, a clergyperson, a community rep, a public health expert, and a state's attorney -- triaged the forty-eight souls who waited, today, for their places to open within the subsidized wards.

Probable outcomes versus available resources determined whether these people would or would not be treated at the government's expense.

A month of six-day weeks together had worn them into their roles. As always, ethicist Dr. Sorbini's quiet weighing of life value points underscored Dr. Radfar's monotone assessments of a case's medical prospects. This month's clergyperson, Reverend Stevens, offered an under-breath prayer for every case and only rarely voted against the majority. Shanine Ferris was the group's stickler, both by her devotion to her duty as community rep and her own forceful personality. But she slowed the process only when she and the public health expert, Dr. Judy McDivott, butted heads over entitlement versus reality.

As Tri-County's triage department director, it fell to Sonia to mediate the Ferris-McDivott matches. Luckily for her, they were behaving today, because Sonia knew she wasn't up to playing referee.

Her fingers keyed the right commands at the right times. She nodded and commented at the appropriate moments. But the only person she truly listened to was Lyle. His precise, occasional remarks seemed like private messages. Her mouth went dry every time he spoke.

Three hours after they'd started, the committee triaged the last of the forty-eight cases.

"Thank you," Sonia said from within her haze. "Thank you all. I'll see you again on Monday. Thank you."

Triage rarely fostered the desire to linger and chat. Today was no exception. Everyone but Sonia, Lyle, and Jen left the conference room as soon as the screens locked back into the table.

Sonia waited as Jen processed case notes and votes. She kept her face smooth as her stomach rolled and flipped.

When the assistant finished, Sonia and Lyle would verify the decisions.

Verification used to be quick. Recently, discussion had been required. The kind that went on behind closed doors.

Lyle stood and stretched, hands laced behind his neck. He smiled a little when he saw her looking.

Sonia hated the shivery anticipation that spilled past her determination to control it. But hating it didn't stop it.

Addiction.

She made herself think of Alan. Imagining his face, the strained smile he'd given her in their closet that morning, pained her profoundly. She shoved the thought away.

Coward, she thought.

"Uh-oh," said Jen from her workstation.

Sonia's wayward stomach tightened into a knot.

"Protesters at the wards," said Jen. The young woman's tone turned ominous. "And news sites. PR wants a touchy-feely."

Oh, no. The last thing Sonia needed. The media ripped triage no matter what PR did. It was a no-win situation. If Sonia showed compassion for the people she and the committee voted out of the wards to give other patients a chance, news sites pegged her as a raging hypocrite, a traitor to the healing profession. On the other hand, if she failed to seem remorseful enough, they branded her as the worst kind of bureaucratic monster.

She bent her head and pinched the bridge of her nose. She could compare lives saved to lives lost till she dropped; news sites wouldn't run anything as unsexy as facts. No. They went for the lowest common denominator, the tear-jerker jolt -- clips of patients transferred to the hospices the media called charnel houses, close-ups of weeping children.

Sonia didn't mean to snap, but her voice cut as she said to Jen, "Where and when?"

Lyle raised an eyebrow.

Casters rolled on a plastic floor mat as Jen pushed backward in her chair. She peeked around the edge of her workstation's wall. "Um. Right now, Sonia. Down in C Ward. Here, take a look." She held out a notepad.

Sonia waved it away. She didn't need to see it. It was part of her job, the job that paid for a hundred AC exemption hours or even a doctor's house call if you wanted one. She'd stand in front of the cameras, she'd be dignified but firm for the protesters, she'd toe the hospital's line.

She stood and slung her briefcase strap over her shoulder. "Sorry, Jen. It's been a long day." Moving for the door, she said to Lyle, "We'll have to put off verification until this is through. Nothing I can do about it. I'll page you when I'm done."

He fell in beside her. "I'll do you one better. I'll go with you."

Now it was her turn to raise an eyebrow. In accordance with the law, she and the ethicist, Dr. Sorbini, were the only two triagers employed by the hospital. Lyle worked for the state; he didn't normally make these kind of appearances. But he had the right to come along, if he wanted.

In front of the twelfth floor elevator, she asked, "Are you sure about this?"

"The state has a vested interest in public opinion."

Sonia looked sideways at him. He thumbed the summons button, gray eyes mild and unwavering.

Saturdays were quiet on the twelfth floor. The elevator arrived empty. Lyle put his hand at the small of her back as they stepped in, and then brushed it along her spine. Sonia's skin tingled, but she wondered at his timing; when other passengers joined them just one floor below, she felt oddly grateful.

Sonia and Lyle arrived at the C Ward scrub room and found Tri-County's PR director in full battle mode. Barbra Evans-Lee's black eyes were sharp as glass fragments as she whispered into her notepad or fired commands at her assistant and passing techs.

Sonia didn't envy Evans-Lee. PR was one of the few administrative positions at Tri-County that sucked more life from a person than triage. Evans-Lee was on 24-hour damage control call, and these days, everything was damage control.

"Hi," said Evans-Lee. She reached for Sonia's briefcase. "Let me have that. Put this on." She snatched a white coat from her assistant and pushed it in Sonia's arms. "We've got three of the local sites out there. Must be a slow day for murders. Here's updates and talking points." She waved her notepad at Sonia's nose.

Sonia pushed her arms into the coat. She realized Lyle would need a coat, too. Before she got out more than "Barb, Lyle's going to--" Evans-Lee snapped her fingers and pointed. Somehow, the lab coat the assistant produced fit Lyle like it was made for him.

Evans-Lee gave them a critical look. Her lips pressed tight. "Too . . . together. Try to look haggard. It'll up the empathy factor." She reached as if to tousle Sonia's hair.

The assistant held translucent gloves for Sonia to thrust her hands into. It gave her a good excuse to evade Evans-Lee. "Relax, Barb," she said, keeping her voice even. "I've done this before." She waggled her fingers and tried not to look as angry as she felt.

After Lyle gloved too, Evans-Lee and her assistant shepherded them past banks of scrub sinks into a corridor stacked with red biohazard containers. She fired instructions with each clipped step. "The protesters are at C Ward's public entrance. We've got vid coverage there. Start with the touchy-feely as soon as you walk out the door. Act natural. Don't look at the vids. Make sure you--"

"Last time I was down here," Lyle said, aside, to Sonia, "we got masks."

"PR doesn't go for masks," Sonia whispered. "Too dehumanizing." At Lyle's grim look, she added, "There aren't any airborne communicables in C Ward. You're up-to-date with your vaxes, right? Just keep your gloves away from your face."

"--you from there," finished Evans-Lee. She turned at C Ward's personnel entrance to face them. "Okay?"

Sonia nodded. "Right." Lyle added a nod of his own even as he stepped aside for a tech with an armload of bedpans.

"Great," said Evans-Lee with martial enthusiasm. "You're on. No, wait!"

She grabbed the stethoscope her assistant held out to her; she stood on tiptoe to put it around Lyle's neck.

Lyle's mouth quirked. "I'm an attorney."

Sonia knew better than to argue with window-dressing. It didn't matter that even when she'd been a student in the nineties, nurses and cardiologists had been the only medical personnel who actually used those things. PR loved stethoscopes because the public still expected them.

Evans-Lee nodded with satisfaction. "You're a triager. It's iconic." She swept her arm toward C Ward. "Go."

Into the ward.

They entered the narrow aisle down the middle of the ward, two more white-coats among the half-dozen or so attending 185 patients crammed into what had originally been a hundred-bed ward. Evans-Lee, Sonia knew, would be doubling around to work the newsies at the ward's public entrance. In a moment or two, the cameras would "stumble" on the head of the triage department personally investigating cases: touchy-feely. Sonia would repeat the facts the newsies never aired, and after they chewed her up and spit her out they'd flow away to some lower point in the universe and leave her to her work.

Sonia's nursing background helped her ignore C Ward's peculiar acidic stench and accompanying groans and retches. Harder to block was the sight of soaked or slipping dressings, oozing sores too long untended, puddles of vomit.

She tried not to judge. The public ward personnel worked hard, but each could work twenty hours a day and the place would still be understaffed. Universal health care mandated treatment for all who needed it -- within triaged limits -- but allocated precious little funding for that treatment.

Lyle said, "Should I do anything special, here?"

He leaned over a cot, hands clasped behind him as he peered at its sleeping occupant, a thin young male. The patient's brown skin was marred with weeping lesions; thrush sores ringed his mouth.

At the other end of the room, Evans-Lee squeezed out from among the protesters clotted at the public entrance. The newsies with her panned their cameras across the ward.

"Um," said Sonia. What could a lawyer do for the boy? Recite his health care rights? "Just . . . nod once in a while."

She unhooked the chartpad from the foot of the boy's cot -- and flashed on the I'm-okay smile Alan had given her in the bedroom closet. He'd had his own problems on his mind, but he'd smiled anyway because he knew how triage wore her down.

Her eyes burned. She blinked and cued the chart.

Mahmod Chaudhary. Male. Age fifteen. No family he'd been willing to name. He had AIDS-III; he hadn't responded to antivirals. He was on the final day of his twelve-day accept.

She gripped the chartpad hard. "We reviewed him today."

Lyle straightened. "Oh?"

Sonia remembered his jaw on her shoulder. She remembered the incredible rush of forgetting the world when he pushed himself inside her, and she wanted to grab his arm and shout I can't do this any more!

"Denied," she said. Tomorrow, or maybe even tonight, depending on when she and Lyle verified today's triage decisions, Mahmod Chaudhary would be transferred to a hospice -- a "charnel house." His death would be painless -- the government supplied synthesized opiates in bulk -- and it would be cheap. It would also be ugly.

Lyle nudged his chin at the roving newsies, Evans-Lee beside them pointing out hospital-friendly vid ops. "How about another one, then."

Sonia's heart pounded. "Fix his blanket, at least." The thin blue hospital coverlet was bunched around the boy's knees. "He's got to be cold."

She thought he'd hesitate. He didn't. He pulled the blanket up under the boy's chin.

Exclamations.

The newsies bunched toward a bed. Evans-Lee blocked their way with arms spread wide. Behind her, two white-coats bent over a blanketed form. At C Ward's public entrance, the protesters buzzed and stirred.

"Doesn't look good," Lyle said. His mouth was quirked in a dry half-smile.

It not only didn't look good, it wasn't good. Sonia recognized the white-coats' postures and motions. Somebody had died and the vids were still rolling. Now there'd be hell to pay. Even Evans-Lee wouldn't be able to--

The ward lights flickered. Dimmed.

A chorus of fucks and shits rippled through the ward. The protesters at the public entrance roiled like angry bees; patients cried out.

Lyle eyed the ceiling as he rubbed his stethoscope's disc with his thumb. Softly, he said, "Stay close, Sonia."

Flicker. Dim. Flicker.

Brownout, thought Sonia. My God. Did I turn off the air when I left the house? She couldn't remember. A kind of panic gripped her. Why in the world had she bought those AC exemptions? She'd sworn she wouldn't let the heat get to her. But it had, and thanks to her and thousands like her the power grid was overloading.

The lights went out.

A long pure second of utter stillness -- shattered by a metallic crash.

The ward erupted. Shrieks and more crashes. Emergency lighting hitched to life and threw eerie light over unnecessary but very real panic. Bodies surged toward exits.

"Sonia!" Lyle grabbed her arm. She dropped the chartpad she'd been holding. Around them, mobile patients staggered and flailed, dragging bedclothes, dangling catheters, knocking into one another.

The boy Mahmod thrashed in his cot as he cried out in terror. To Sonia's horror, the boy flopped off his narrow bed; he thumped to the floor and moaned.

Lyle shouted in her face, "This way!" He hauled her down the aisle, kicking aside an overturned cot and shouldering past clutching patients.

"Let go of me," Sonia cried, but he didn't seem to hear her; he threw an arm across her and pressed her to a wall, blocking her from chaos.

From beyond the ward, she heard the piercing wail of sirens.

Sonia's watch told her that the brownout had lasted less than three minutes. Cleanup took over an hour.

Techs moved through C Ward reattaching IVs, righting stands, heaping soiled and twisted linens. Security swept out the remaining protesters, and the newsies, too, though they didn't retreat any further than the public entrance. They filmed the panic's aftermath as Evans-Lee paced and growled into her notepad.

Some of the C Ward patients, those who'd been separated from crucial medlines or traumatized in some other fashion, hadn't survived the panic. Doctors and nurses tended to the rest.

Sonia hadn't been a practicing RN for years, but she put her hands to work wherever they were needed. She wasn't surprised that this calmed her; it always had. It reminded her of what mattered most to her.

She caught herself thinking, I miss this.

She patted the wrinkled arm of the elderly woman she'd just re-cathed. She got a weak but sincere smile.

According to her chart, this woman's pancreatic cancer was responding well to marker therapy; altered phages were shutting down the diseased cells at an incredible rate. If she hadn't been admitted to the ward -- if a bed hadn't opened to give her this chance -- she would've been gone in matter of weeks. Pancreatic cancer was fast.

Sonia wanted to stay with the old woman. It felt good, there, being in a place where triage had worked for the better. But then she thought of Mahmod Chaudhary. She worked her way back to him.

The boy had been returned to his cot. He slept again already, his body withdrawing from its losing viral battle. His narrow chest heaved in a shallow uneven rhythm.

She touched the boy's hand, checking the tape that held an IV line in place.

Behind her, Lyle said, "There's nothing else you can do for him here."

She turned. The state proxy's iconic stethoscope hung askew; blood speckled his coat. He'd put his hands to work, too.

He said, "We've got verifications waiting for us." He looked hard at Sonia, then gave Mahmod a deliberate glance. "We should recheck the votes. Don't you think?"

Sonia clamped her teeth to keep her jaw from dropping. Did Lyle mean what she thought he did? Reverse Mahmod Chaudhary's denial? Slip his case, switch his triage decision with someone else's?

Her hands shook. Yes. They could do it. Mahmod could keep his bed. It would be so easy.

As easy as discarding principles. Sure. Nothing so hard as, say, smiling when you wanted to cry.

Sonia felt an overwhelming need to get to a phone. She needed Alan. She needed to tell him she'd remembered what mattered most to her.

She looked up to meet Lyle's eyes. It was as painful as the knowledge that triage paid for one person's chance by taking away another's. She said, "Do you have anyone waiting for you at home, Lyle?"

A muscle twitched in his cheek. After a long moment, he said, "No."

Sonia didn't look away. "I do."

Something like a wince flickered in Lyle James's expression. He buried it, gray eyes cooling to a tense detachment. Then he looked away.

"We should talk," she said. Tears rose in her eyes. She didn't try to fight them. "After we finish verifications."

Lyle moved around her to stand beside Mahmod's cot. "Should we?" He stared down at the boy.

"Lyle . . . ." Sonia swallowed. "About . . . this case." Her vision blurred. She lifted her face toward the ceiling to drain her tears without touching her skin. "We can't slip it. It's not right."

"No," said Lyle evenly. "It's not. Does that mean it's wrong?"

Sonia blinked rapidly. "I'm sorry," she whispered at the sleeping form on the cot. "I'm so sorry."

"So am I," said Lyle. His voice was a whisper too.