The outrageously loud ringing of his cellphone does its job, dragging Joonmyun from the deep, dark pit of exhausted slumber. He stares blearily at the time before he picks up the call. Just after two in the morning. Not so bad. He’s managed to get nearly a whole hour of sleep.

“Car crash victim,” he’s told. “Arriving in three minutes.”

Three minutes is not long enough for him to get from his bunk bed in the on-call room on the top floor all the way down to the emergency department on the ground floor, but that’s okay – the triage and trauma staff will handle the first few minutes anyway. Joonmyun stops quickly into a bathroom on his way down, then splashes water on his face to wake himself up.

He enters the trauma bay just as a blood-covered young man is being lifted from the ambulance stretcher onto the trauma bay gurney. He’s strapped to a spineboard, stabilizing head blocks are taped to each side of his head, and a paramedic is announcing his report to everyone in earshot. “Kang Muyeol, male, age 21, driver of a car traveling at high rate of speed, the car collided head-on with another vehicle which had crossed the centre line. Blood pressure 100 over 60, pulse 125. Open laceration in the right frontal parietal area was packed to stop bleeding….”

Road accidents with two vehicles will have more than one victim, and worried that more trouble may arrive soon, Joonmyun asks the second paramedic if there are any other patients on their way.

“The two people in the other car were taken to another hospital.” She lowers her voice and whispers, “The passenger of this vehicle was dead at the scene. We sent her in a coroner’s ambulance.”

“You mean you pronounced her?” Joonmyun raises an eyebrow. Officially, only a qualified physician can pronounce death.

The paramedic grins. “It doesn’t take an M.D. to know when a headless woman is dead,” she says, and Joonmyun gives her a wry smile. Fair enough.

The on-call neurosurgeon has been called as well. Tonight this is the first-year resident Huang Zitao. Joonmyun has met the tall, permanently exhausted-looking 25-year-old multiple times this year, and every time it’s been in the trauma bay. Their on-call schedules seem to regularly coincide. Whoever does the rostering is probably balancing the first-year resident with Joonmyun, who as a cardiothoracic fellow, has nearly a decade’s worth of experience over the junior doctor.

Nurses are cutting the victim’s clothes off, and Dr Huang is inspecting the long, gaping gash on his head. Joonmyun glances at it as he moves to start examining the chest. Glistening white bone is clearly visible, and a line of pink brain tissue the consistency of toothpaste runs parallel to the laceration. It doesn’t take a brain surgeon to know that that’s not a good sign. It’s clearly an open skull fracture, and the bruised and swelling brain is getting squeezed out through the fracture line like rice getting forced out of the valve of an over-full pressure cooker.

Zitao beckons a hovering intern over and instructs her to stitch up the gash. “I’m going to open it again in the OR,” he explains, “so it doesn’t have to be a work of art. Just stop the bleeding.”

The intern grimaces, and Joonmyun understands why. There’s a growing mound of macerated brain tissue oozing from the wound, but Zitao simply grabs a gauze pad and wipes it away. “Don’t worry about the gunk,” he tells her. “Just close the skin up.” He moves around the head of the bed to give her space to work and leans down to speak directly into the patient’s ear.

“Kang Muyeol, can you hear me?” he asks, and when Muyeol slowly opens his eyes and replies in the affirmative, Zitao introduces himself and begins explaining the examinations and investigations they’re going to do now.

Joonmyun leaves him to it and begins to examine the chest and abdomen. It’s actually not unusual that the patient is conscious despite the fact that his brain is leaking out of his skull, but he knows it won’t last. As the brain continues to swell and more pressure gets put on vital areas, Muyeol will quickly fade out. There a name for this phenomenon. They call them “talk-and-die” patients.

“Type and cross for six units of blood,” he instructs a trauma nurse, “and get them to send down some O negative in case he crashes. Pressure?”

“90 over 60.”

“Get another liter of fluids into him and get an X-ray tech in here.”

Zitao is now on the phone to the CT radiologist, asking for a brain scan. The X-ray technician arrives with his portable X-ray machine, and Joonmyun steps back to let him set up. He watches one of the monitors as Muyeol’s blood pressure begins to rise and stabilize, thanks to the fluids Joonmyun has ordered to replace his blood loss.

Zitao comes over and they step back far enough that the patient won’t overhear them. The junior doctor looks stressed out. “He needs a craniotomy,” he tells Joonmyun, “and the NS chief has all four of our ORs booked from 7.30 this morning. If one of his VIP patients gets bumped by this case he’ll give me a craniotomy.”

Joonmyun glances at the clock on the wall. It’s nearly 3 am already, and he sees Zitao’s dilemma. There’s no way they’re getting this patient scanned and through a craniotomy fast enough to avoid delaying Zitao’s boss in one of his rooms.

“Ask them to give you a general surgery room,” he suggests.

Zitao gives a hollow laugh. “I’ll ask for a Porsche while I’m at it. I’ll have more chance of getting that.”

The chest X-ray goes up, and they both go over to inspect it.

“The mediastinum is wide,” Joonmyun murmurs. This tells him that the aorta, the biggest artery in the heart, has torn and is leaking blood into the space around the heart. A leaking aorta, like a leaking dam, can burst at any time. Joonmyun needs to replace the artery with a Teflon tube before this happens, because a burst aorta is a death sentence. He turns to Zitao. “I’ll need to get an aortogram.”

With the chest injury on top of the brain injury, Muyeol is now officially a multiple trauma case. His brain and his heart both need urgent surgical repair. It’s physically possible to operate on the brain and heart at the same time, but Joonmyun will have to thin Muyeol’s blood with an anticoagulant while he’s clamping the aorta, or the non-flowing blood will clot up the artery. But he can’t anticoagulate if Zitao’s going to do brain surgery. The brain is one of the bloodiest organs in the body, and any attempt to fix it without the body’s clotting mechanisms working would be disastrous. No, the surgeries have to be done separately, and Joonmyun’s going to have to fight with the young neurosurgeon about who gets to operate first. It’s not the first time they’ve had this battle, and it won’t be the last, and in the end it’s a battle neither of them will really win. Which is better, a brand-new aorta in a brain-dead patient, or a working brain in a body dead from aortic dissection? 

Zitao continues to assess the patient. “Muyeol, are you still with me?”

“Yeah,” the patient replies, but Joonmyun can tell he’s sleepier, more distant, and he sees Zitao’s frown. The neurosurgeon tests Muyeol’s hand grasp, and his frown gets deeper.

“Head’s going bad faster than I’d like. Let’s get him to CT.”

“I need my angiogram before we do anything else,” Joonmyun tells him. “If the aorta blows, brain surgery will be pointless. I need to fix his aorta before you do your craniotomy.”

Zitao scowls. “I’m calling my attending,” he threatens, rather in the same way a kid might say “I’m telling my mom”. Joonmyun hides a smile. He remembers the days when he was a resident and used to call the attending cardiothoracic surgeon at times like these, hoping his chief of department might bully more senior surgeons from other specialties into doing what he wanted. Most of the time, the attending would just growl at him for waking him up and tell him to deal with it himself, and by the pout that comes onto Zitao’s face as he listens on his cellphone, he’s pretty sure the resident is getting something along the same lines.

The rest of Muyeol’s X-rays show no spinal fractures or dislocations, so Zitao peels off the tape strapping the big blocks to each side of the patient’s head and Joonmyun helps the trauma team slide him off the spineboard, which is returned to the hovering paramedics who have finished their paperwork and are impatient to get back on the road. Zitao’s on his phone, trying to follow Joonmyun’s advice and get the people in charge to give him a general surgery OR so that he won’t have to mess up his chief’s neurosurgery schedule.

“There’s a liver transplant going on?” Zitao gestures wildly at the ceiling in frustration. “I don’t care if there’s a liver transplant going on! I need an OR right now!” There’s a pause, then he sighs. “Okay, okay, fine. Set up one of our NS rooms. We’ll just have to deal with the scheduling later.”

“What about my aortogram?” Joonmyun protests when the resident hangs up.

“No way,” Zitao shakes his head. “No time. He’s fading fast. Brains first, big bloody hosepipes second.”

“We have to make time! There’s no point in a craniotomy if he dissects.”

The ED chief appears between them, raising his hands as they start to face off. “Calm down, gentlemen,” Kim Minseok tells them with all the long-suffering patience of a parent. “Here’s what we’re doing. Dr. Kim, we’ll take him straight from CT to the angio suite for your aortogram, and then to the OR so you can do your craniotomy, Dr. Huang. As soon as it’s done, Dr. Kim, you can crack his chest and do whatever you want.”

“Fine,” Joonmyun sighs. It’s a compromise that favours the neurosurgeon, but something has to give. There’s really no way they can manage both injuries at once.

“God,” Zitao says hopelessly. “The chief is going to kill me. That OR has back-to-back electives scheduled today.”

Joonmyun knows what he means. Repairing an aortic dissection is going to take him at least eight hours, which means the neurosurgery OR schedule is going to hell, and the lineup of elective VIP neurosurgery patients will have their surgeries cancelled. Zitao’s boss is not going to be happy. But there’s nothing anyone can do about it.

He suddenly feels very tired. He’s had less than two hours’ sleep in the past two days, it’s the eighth hour of his 12-hour call shift, and now he’s going to be in theatre for most of the next day.

The trauma room’s intercom buzzes. “The patient’s parents are in the waiting room,” the receptionist informs them.

Zitao and Joonmyun share a look of mutual dread, their brain-versus-heart battle forgotten in the knowledge that their problems are nothing compared to what these parents are going through. They fall in step as they head out to talk with them. Joonmyun finds this the hardest part of his job. The most complex surgical procedure can’t compare to the difficulty of telling parents that their child is in critical condition. With just a few words, he can inflict more pain than he ever can with a scalpel.

The middle-aged couple are sitting on one of the benches in the corridor outside the emergency department and holding hands. The mother is visibly holding back tears throughout their presentation, but both of them remain admirably calm as Joonmyun tells them about the probable damage to the main artery in Muyeol’s body and that it will need surgical repair. He listens as Zitao explains the head injury and gets consent for brain surgery. The parents ask the usual questions about how bad Muyeol’s brain damage will be, whether his face has been badly injured, and if they can see him before they go for surgery. Zitao dodges the brain damage issue and tells them there’s no obvious cosmetic damage to his face, and Joonmyun adds that he’s not in severe pain. Doctors have to be like politicians sometimes, stressing the good things and avoiding the bad. Unfortunately, there’s no time for the parents to see Muyeol before he goes to CT.

They return to the trauma room, where Muyeol is being prepared for transport to the radiology department. Radiology is the floor above the emergency department, and the elevator ride and short roll down the corridor takes less than a minute, but it’s always unnerving transporting a critical patient who should be hooked up to a sea of specialized instruments and resuscitation equipment. Field trips to radiology are like spacewalks, the patient tethered to life only by battery powered monitors and scuba tanks of oxygen.

“What’s his pressure?” Joonmyun asks.

“90 over 50,” a nurse replies.

“I don’t want to transport him until we get some blood into him.”

“It’s on its way,” the nurse says, while Zitao starts to do his neuro exam on Muyeol yet again. This time Muyeol can only move his fingers and toes on his right side. The left side remains motionless. The brain is rapidly failing.

“Dr Kim, I need to scan him right now.” Zitao is edgy, wanting to transport Muyeol to radiology immediately, but Joonmyun is worried he’ll crash on the way.

“I need to hang the blood first,” he says. “His haematocrit’s only 28 and he’s had seven liters of fluids but look at that.” He points at the monitor. “His pressure is falling again –“

“I’m dying!” The patient suddenly cries out. He tries to pull the oxygen mask away from his face and a nurse grabs his arm and tells him to stay calm.

“But I can’t breathe!” He begins to struggle with the nurse, jerking her arm and rolling his head from side to side.

Joonmyun looks at the monitor. His heart rate, steady at 120 for the past half hour, has suddenly jumped to 190, and his oxygen saturation is falling as he watches.

“Pressure?”

“70 over palp.”

“Get anaesthesia here stat,” he orders. “And get me a chest tray - and call the cardiothoracic resident down here.”

Zitao stops making noises about getting his CT scan. He can see what’s happening, just like Joonmyun can. The crashing blood pressure can only be due to blood flooding out of a dissecting aorta. The dam has burst. Muyeol’s inability to breathe is a sign that his chest is filling with blood, crowding his lungs. His heart is pumping faster and faster to try and make up for the decreased blood volume. He’s shocking out, and opening his chest and clamping his aorta right here, right now, is his only chance of survival. Anaesthesia are on their way to insert an endotracheal tube and put Muyeol to sleep, but if they don’t arrive in the next thirty seconds, Joonmyun will have to do it with him awake.

Nurses and techs dart in and out from other ED rooms, bringing the equipment he needs. Joonmyun inserts another IV line and Zitao starts unwrapping the chest tray they bring him and preparing the chest hoses Joonmyun needs to drain blood and air from the chest. Neurosurgery has taken a back seat now, and every hand is needed. At the head of the bed, the respiratory technician is squeezing an ambu bag, forcing air into Muyeol’s lungs. Between squeezes, Muyeol gasps out a repeated phrase. “I’m dying,” he tells them. “I’m dying.”

He's right, Joonmyun thinks. He is absolutely dying, and if anaesthesia don’t get here right now, Joonmyun is going to have to start open heart surgery on a conscious patient. He pulls on sterile gloves just as the anaesthesiologist runs in and begins sedating the patient. The intern dumps a bottle of antiseptic solution over his chest.

“50 over palp,” someone calls. The EKG monitor shows runs of ventricular tachycardia. Muyeol’s heart is running dry. The respiratory tech is sweating with the effort of squeezing the ambu bag. Muyeol’s lungs are collapsing and he can’t force the air in. 

And Joonmyun knows all this frenzied activity is useless. Like a plane with its hydraulics destroyed, Muyeol’s body is still flying right now, but it has no hope of ever landing safely. But he can’t give up. Not yet.

His cardiothoracic resident hasn’t arrived from the ward yet. “I need an assist!” he yells, and Kim Minseok is immediately opposite him, gloved and ready. The ED chief is a trauma specialist, not cardiothoracic, but it hardly matters now.

Joonmyun grabs a scalpel from the tray and plunges the blade to the hilt in Muyeol’s chest wall, cleaving a 12-inch window. A huge glob of clotted blood slithers out and plops to the floor at his feet, splattering them both liberally with blood. Minseok jams a metal rib spreader into the wound and they haul it open. Ribs crack and pop as the chest splays apart. Minseok holds back the foamy pink lung and Joonmyun starts to probe, looking for the rupture. Thin purple blood flows unchecked out of the open chest and onto their clothes and shoes. 

Muyeol’s blood pressure collapses. His tracing on the monitor writhes chaotically as the heart’s rhythm degenerates into useless quivering. An alarm sounds from the monitor. Joonmyun reaches deep into the chest and grabs the heart in his hand, squeezing the floppy ventricles.

Empty.

“Empty," he says aloud. He doesn’t need to elaborate. The frenzied activity in the room goes still. Joonmyun takes his hand out of Muyeol’s chest. Blood drips from his fingers onto the floor, and he stares grimly into the splayed-open chest while Minseok calls the time of death.

There is a short, heavy silence. When Joonmyun finally looks up, Minseok meets his eyes. Neither of them say anything. They’re both experienced enough to know that they’ve done everything they could, and also experienced enough to know that words aren’t going to help.

“Dr Kim, will you talk to the family?” Zitao has been watching, his back pressed against the wall to stay out of the way. The thought comes to Joonmyun's mind that least now Zitao doesn’t have to worry about his chief’s neurosurgery schedule. He nods. This is a trauma surgery death, not a neurosurgery one, so the young resident is off the hook.

He takes off his gloves and instructs the intern to close the dead man’s chest. “It doesn’t have to be pretty,” he tells the shell-shocked kid. “Just close it up.”

A nurse brings him a fresh set of scrubs, and he changes and washes his arms and face, then gets her to check his hair for any residual splatters. Appearing before the family soaked in their loved one’s blood is not a good look. He leaves the trauma bay behind him, the intern stitching up the open chest and the cleaning staff already arriving to mop up the blood and sterilize the equipment and bay for use by the next patient. 

He walks slowly down the corridor. He’s done this so many times over the years that he’s developed a coping mechanism. It’s like an emotional dimmer-switch inside him. He doesn’t turn the lights all the way off, because he fears that if he goes into that emotional black hole, he’ll never find his way out again. Instead he turns himself down. He doesn’t allow the impact of what he’s just done to sink into him. He keeps the details clear in his mind, but the emotions attached to them are not allowed to surface. Not now. They will have to surface at some point, maybe after today’s shift, or maybe at the end of the week when he gets some days off in a row, and then he’ll have to deal with them, but he can’t do that now.

He sits down opposite the waiting couple. They’re pressed close together. Their faces beg him to tell them there was a miracle, to tell them he saved their son, to tell them there is still hope. His right hand, always so steady in surgery, begins to tremble. He covers it with his left to hide it. He takes a deep breath, focuses, speaks.

“Four hours ago, your son’s car was in a head-on collision with another vehicle.” They’ve heard it already, but people in states of acute worry forget and distort things easily, and he’s found repeating the situation helps, in some small way, to set the scene and prepare them for what’s to come. “He was brought here with a severe head injury and devastating internal injuries. We did everything we could. But he has died.”

He watches their entire universe fly apart. In front of him, their lives disintegrate and scatter like dust in the wind, into a thousand fragments, a thousand directions. Joonmyun’s words have destroyed everything about who they were, who they are, and who they will be. They are no longer parents. The twenty-one years of love they have poured into their son have been snatched away, leaving them as empty as the floppy, bloodless heart Joonmyun held in his hand.

He sits, squeezing his right hand as hard as he can so that it will stop trembling. He forces his emotional dimmer switch to its lowest setting. He presses his feelings into a small box in his head, to be opened and looked at later, when he doesn’t need to be the calm one, the responsible one, the one in charge. When he can be alone.

Pastoral ser