Saturday, August 7, 1988#
Everybody talks about how peds is cute, Frank thought as he put his light back in his coat pocket and closed Valeria’s right eyelid. He re-opened the blinds, and the morning sunlight streamed into the private room on the 8th floor. The hospital room was surprisingly quiet for a Saturday morning. Rounds didn’t start for a few minutes, and Frank appreciated the ephemeral peaceful moment. He took a deep breath and let it out slowly while making an effort to relax his tight muscles all over, one at a time. Cute little kids, bouncing back surprisingly well from pneumonia. That one pediatric oncologist who wears a clown costume some days just to see his patients smile. A birthday cake for a kid with sickle cell. Grateful parents who leave chocolates out for the nurses and docs. He reached out, gently brushed a stray wisp of black hair that had fallen across Valeria’s other eye, and shook his head slowly. Nobody likes to talk about the Valerias.
Dr. Larsen’s voice in the hall brought his attention back to the morning routine. Frank flipped through the pages for his three patients on his clipboard, nodded once, took one more deep breath, and strode into the hallway to meet the rest of the team for morning rounds.
The team paused outside room 8423 and Dr. Larsen pulled the chart out of the rolling cart. “OK, Frank, this one’s yours, right? OK, give me the 30-second version.”
“Valeria Fabbri is our 17-year-old girl with a severe traumatic brain injury 2 weeks ago today.”
“Oh, right, the joy ride that wasn’t,” said Dr. Larsen.
Frank nodded. “Her CT yesterday showed partial resolution of her small bleed. It’s now been 24 hours since her last inhaled anesthetic, but she does not respond to painful stimuli and she has no pupillary response. Ice water irrigation of either ear canal showed no saccades. EEG shows no cortical activity. Other organ systems are stable. Her father is planning to meet with the team today at 3 p.m. regarding intensity of continued care.”
“Any comments from the rest of the team?” Dr. Larsen looked at each of them in turn.
The neuro ICU fellow added that she showed no cough reflex when her trach was suctioned. “Alright,” said Dr. Larsen, let’s make sure we’ve done everything by the book.” He walked over to the nurses’ desk and asked if Valeria’s nurse could join them. “No spontaneous movement? No turning the eyes to follow noise or people?” No reactions to blood draws or to any other touch? The nurse just shook his head each time. Dr. Larsen went on with a few similar questions.
The team went into the patient’s room, and Dr. Larsen proceeded to conduct a thorough neurological examination. Finally he put away his penlight and reflex hammer and sighed before turning to the team. “So, what do the data show about her chance of ever resuming awareness?”
Frank was about to speak up when the resident said, “less than 3%.” No one argued with that summary, though Frank thought 3% was on the high side.
The attending asked if the family had met with the chaplain, and Frank nodded. “Alright,” asked Dr. Larsen, anyone object to the current plan?” He looked at each member of the team. “Okay, if the family agrees, we will turn off the ventilator after they have a chance to say goodbye following the family meeting. I’ll want you to supervise, Ben,” he said looking at the resident.
They all moved on to the next patient, and the work of the hospital continued.
By 2:40, Frank had done what he needed to for his other patients, and went to Valeria’s room for the family meeting. As always, her father was there. He had basically kept vigil in her room since she was admitted. “Hello, Mr. Fabbri,” Frank said.
“Hey, Frank,” he responded. “Valeria’s older brother had to go back to New York, and Mrs. F. felt like this would be too much for her, so it looks like it’s just me for the family meeting. And since nothing positive has come up since our discussion Tuesday, I’m still at that same place of miserable acceptance. I still can’t believe this is where we are, but, well, I’m a practical man, and the facts are the facts.”
Frank nodded. Tuesday night he’d been there to take Mr. Fabbri’s rage, then his questions, then his apology for yelling at the closest human. Frank had said no apology was needed: “I can’t imagine what you’re going through. No one expects to lose a child.” Mr. Fabbri had asked for a minute alone. Tough guys don’t cry and all that.
But since then, Mr. Fabbri had seemed to admit Frank into his confidence. Over the next few days he mostly reminisced about what Valeria was like. “I’m just a businessman. Family business. But every parent wants something better for his children. Valeria was everyone’s friend, with one of those thousand-watt smiles. You wouldn’t know it–she was tuned in to the social life around her, and wasn’t the type to brag–but she was also the smartest one in the room. At her graduation a few months ago, I think half her class was shocked that she won academic awards. I was the obnoxious parent in the audience yelling ‘Go, Valeria!’ every chance I got. I was so excited for her. She was going to be successful on her own. Independent. Continuing to make us proud.” He shook his head once, hard, and pulled a handkerchief from his suit pocket. He was the only parent Frank had met in the ICU who was always dressed up.
Frank recalled all that with an appreciation for how much of a crash it had been for Valeria’s father, from on top of the world to disbelieving grief. Coming back to the present, he said, “Thanks, I hear you. But Dr. Halley–he’s the resident who rotated on a few days ago–will be here in” (he glanced at the clock) “about 10 minutes, and he’s the one who needs to record your consent and then change all the device settings and medications.”
Mr. Fabbri nodded. After a pause, and a quick look at Frank, he continued. “You know, I gently leaned on the police last week to find out how it happened.” Frank sat down and listened raptly. Everyone at the hospital had been eager to find out how the safety features had failed on the old, shuttered, mini-roller-coaster carnival ride. Mr. Fabbri looked at Frank quite seriously. “They told me this had to stay confidential. I’m trusting you, OK?”
Frank nodded. “Of course!”
“First you have to know that I’m a guy that people don’t cross. I don’t mean concrete boots and all that drama. But if you rip me off in a deal, I’ll make sure you regret it. … Have you heard of the company Independent Construction? They were the biggest contractors in the state. Their owner reneged on a contract with me.”
“No,” said Frank, “I haven’t heard of them, but then again I’m not tuned into the construction world.”
“And you’re not going to hear about them. They went bankrupt a year later. And their owner had personally guaranteed some of their earliest loans, so he filed for bankruptcy the same day.”
“Oh.” Frank said, finally understanding.
“Look, the point is, I protect my family, too. Nobody hurts my kid. You have to keep that in mind.”
“OK,” said Frank, believing him wholeheartedly, and for a minute starting to review in his mind all of her care at the hospital, to make sure he or the team hadn’t done anything to bring down this man’s wrath.
At this moment, the resident, Ben Halley, walked in. “Sorry I’m late,” he muttered, so rotely as if to be how he habitually introduced himself. And, Frank thought to himself, that wasn’t so wrong. But it was only 2 minutes after 3:00, and Mr. Fabbri just gestured with his hand as if to flick a crumb from a table. Dr. Halley took a deep breath and started in describing their efforts to care for Valeria, the evidence for her bleak prognosis, and their proposed plan to let her breathe on her own, and to give medications as needed to keep her comfortable. “I need to ask you to sign this consent document for decreasing the level of care. Take all the time you need.” Frank had gone over all this with her father on Tuesday night, and Mr. Fabbri just reached for the form, scanned it quickly, and signed it. “Would you like any time alone with her before we move ahead?”
Her father shook his head. “I’ve been here nearly every minute. I’ve said my I love yous and goodbyes.”
Ben acknowledged his response and turned to change her ventilator settings and to give some i.v. medication doses. After a few minutes, he said, “As we discussed, it may take a little while to see if she will keep breathing on her own. Frank, are you able to stay, and document her status over time? I’ll be on the floor with one of the other patients if any concerns arise.” Frank was glad to stay.
After Ben left the room, Mr. Fabbri continued. “So this miniature roller coaster had been decommissioned two years ago. This old couple had run it for like 30 years. See, the ride had a branch point and there were two possible ends to the ride: the bunny ride, they called it, with a long gentle decline, and what they called the teenager ride, with a sharp, long dip before curving back to the start. The old guy says she couldn’t have caused the problem because of the safety measures, and because that scary loop had been broken for three years before they shut it all down. Turns out that timing was important, because the woman was developing Alzheimer’s, and starting to forget important things. As I said, the ride hadn’t worked automatically for like 15 years. When a car would come to a certain spot on the track, she would press some button that would divert the car onto the teenage loop and lower a safety barrier near the start of that loop. The five years ago that the teenager ride stopped working wasn’t a coincidence. That was when she went into the nursing home. For the previous ten years she had been the only one who could consistently make the teenager ride work correctly.
“When they decommissioned the ride, they bolted on a safety barrier at a convenient spot 10 or 12 yards down the bunny track. But the barrier and gate to the scarier ride they didn’t bother with–they couldn’t lower the barrier and they figured it was rusted shut. And they locked the place down, put barbed wire around it, the whole nine yards. So anyway, after my daughter and her boyfriend had this terrible accident, of course they looked up the old guy, and they find out his wife had wandered away from the nursing home the same day as the accident. She had wandered over to the ride, and since the kids had cut the wire fence wide enough to basically leave the front gate open, she had wandered in and had apparently been there at about the time the kids … crashed.
“Well, so the police detective being skeptical, he brings the old woman back. She doesn’t even recognize her huusband at first. He asks her politely to show them where she works, she climbs in her usual little control booth at the junction for the teenager track, and they talk about what she does. She explains how the daggum thing always had a glitch: ‘Ya hafta kick it just so, and hold the button down,’ or something, and it all has to be done in just the right order and when the cart is at just a certain point on the way towards the junction. To top it off, she can’t see very well. She says all she can see is a blur and listen for the clickety-clack. Or something like that.”
Mr. Fabbri stopped talking for a minute, just shaking his head gently. Frank was struck by the irony that this woman who didn’t know where she lived and probably couldn’t turn on the TV was apparently the only person on the planet who could follow these complicated instructions.
“So they day they took her back to the ride,” continued Valeria’s father, “the detective and the old man had set things up with a backup car, and while sitting with the old woman they set it running. They’d done this with the old man running it and he showed them how he couldn’t see how the crash could have been possible, with all the safety equipment. But now with her in the booth, she turns away from the conversation with them when she hears the cart first start down the track towards her, listens for the magical clickety-clack, watches for the blur, and does the complicated button press and kick to send the car onto the teenager track. It goes onto it, and that side track hadn’t been maintained for five years, so the cart flies off the track from 50 feet up in the air and crashes into the ground, right next to the spot where the kids had landed. Bells at the end of the teenager track started ringing. So the detective and the old man just stared and listened with horror as the old lady smiled and said, ‘it makes a lot of racket, now, but the kids love the noise. I wish I could see the kids, but my vision. Oh well, I hope the kids had fun.’ And then she says, ‘Excuse me, they’ll have to wait the next ride, I have to find the bathroom.’ And they drove her back to the nursing home.
“Apparently the old man was just heartbroken. He thought he had done everything possible to keep the place safe. They say he told the detective, between sobs, ‘It’s been a place of fun and happiness for 30 years. We were always careful. I can’t believe it’s ended like this.’”
The room was very quiet. Frank glanced surreptitiously at Valeria, whose breathing had slowed further.
Mr. Fabbri continued. “So the old man had followed the procedures according to the best advice he had. He’d tried to prevent injury. They’d even decommissioned the thing and essentially wrapped it in barbed wire. He’s really not to blame. His wife obviously doesn’t know what’s up and isn’t really even all there. She obviously isn’t to blame. My sweet daughter and her now dead boyfriend did a dumb thing, but other kids had apparently been doing it all summer, and they obviously weren’t trying to get hurt, and they were teenagers. I mean, I can’t really blame them. I’ve on and off been blaming myself for not teaching her better, but they were basically adults. The boy was generally a good kid. And, frankly, I was stupider myself as a teenager. I can’t really blame them. And they’re both dead anyway, or nearly so.”
They both look over at Valeria, and she has stopped breathing. Frank notes the time, listens with his stethoscope for a minute by the clock, and then pages Dr. Halley, who he knows will do the same thing before officially pronouncing her dead.
Mr. Fabbri doesn’t need it in writing. He stands to leave and looks at Frank. “So you know how I told you nobody hurts my kid without paying for it, right? Well, the problem is, my little girl is dead, and there’s nobody to blame. Nobody to settle a score with. Nobody even to hate.” He shook his head, turned, and walked out the door.