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I am called to the emergency room for Mr. X.

"Gangrene," says the ER doctor.

I am in my first year of doctoring. Mr. X is a veteran and has no local doctor. I am the "star doc", meaning I am the doctor of the day to admit sick people to the hospital if they don't have a doctor.

"Gangrene," I repeat. I have never actually seen gangrene. Eewww, says part of my brain, while another part ticks off medical information. Gas forming bacteria. Treatable now, though it didn't used to be.

"Is it bad?" I ask.

"Yes, both legs," says the ER doctor impatiently. "Got a code." He hangs up.

I go to the emergency room. To the room with Mr. X. Gangrene smells awful. He has a dangerous ill stench, made worse by lingering alcohol fumes and unwashed clothes and body. He isn't very with it.

His legs are black from the feet to just below the knees. Not dark, not bruised, not old blood. Black like charcoal. Obviously dead. Very dead. And attached to a more or less living man.

Mr. X now crashes. The heart monitor starts bleeping. Tachycardia, he is in atrial fibrillation and his blood pressure crumps. We quickly sedate and shock him and he's back in a regular rhythm. We put him on a ventilator to keep him stable. A second intravenous line is going, bacterial cultures pending and antibiotics are on board.

Now what? The emergency doctor came in to help when he was crumping. We are running lots of fluid in both intravenous sites to keep his blood pressure up. "His kidneys are shot," says the emergency room doctor dispassionately. "Unless they start working, he's a goner."

"Um," I say. I'm reading the labs. He was at the VA Hospital 250 miles away 2 weeks before. Now, why didn't they notice the gangrene? He had to already have it. Oh, it was the opthomology clinic. He was sitting in a wheelchair. They must not have noticed that he hadn't been in a wheelchair before and must have chalked up the smell to....well, who knows? Darn, he would have been better off if they had noticed then.

"Amputations, right?" I say to the ER docs.

"Yeah," he says, grimly. "Both legs. They'll have to go above the knees. He's not going to be very happy when he wakes up."

"Unhappy or dead." I call the internal medicine doctor on call. He doesn't want to come in. I want help supporting the patient's blood pressure. We are now needing "drips", currently dopamine. I'm not feeling very sanguine about drips. He finally agrees.

I then argue with the surgeon. "Lifeflight him," says our surgeon.

"But...."

"No. He's sick as snot, he's a veteran and he'll need a ton of rehab. Send him to the VA."

"It's 250 miles."

"Send him."

Ok, right. I call the VA. They are calm about it and the lifeflight is ordered. Fixed wing plane, will get to us in four hours at the earliest.

We can't find any next of kin. Well, he won't live without the amputations, so consent is assumed. He came to the emergency room (finally) so we'll treat him. Wish he'd come earlier.

The internal medicine doctor arrives. He's a bit cranky. I don't take it personally. Much. We get the latest round of lab work.

"Hey! His kidneys are working!" Our patient has a catheter and has started putting out urine. The two lines of intravenous fluid have been running steadily. His creatinine, a measure of kidney function, has improved significantly. "Well, he might survive," says the ER doctor.

Our internist looks things over, has little to change, dictates a quick note and is off. I work on my note, slower in my first year of practice. Mr. X is still sort of stable when I go home. The plane arrives and he is taken 250 miles to the VA hospital.

When people say a wound is terrible, I think of his legs, black to both knees. I wonder, again, if he survived amputation and what happened next. I will never know. This is one of the dark cases, dark places, dark images that my mind remembers when people speak of horror. One among many. And sometimes I just want to smash something, so the image will go away.