I shook my head. I didn’t know any details, but working where I did, I guessed it had to be related to drugs or a gang fight.
“Louis was on his way home from night college. He is the first one in our family to finish high school and the first one ever to go to college. He is only nineteen. He works during the day in the bodega on 149th and Third Avenue and twice a week at night he goes to City College. We are very proud of him. His mother is still in Santo Domingo with his two sisters. Only he and his fourteen-year-old brother came with me to New York. Tonight on the way home, he saw his little brother across the street fighting with some other kids. When Louis crossed the street and pulled the kids apart, one of them drew a gun and shot him. Doctor, he did nothing wrong.” His voice began to crack. “Please help him.”
His pleading eyes stared at me and I had to look to the floor to escape them.
“I know we don’t have insurance,” he said, “but here … maybe this will help to pay for a special test or to call in a specialist.” With those words he opened a wrinkled envelope he had taken from his pocket and offered me ten one-hundred-dollar bills. “This is all the money I have saved. I have nothing else.”
I gently pushed the money back to him and placed my hands on his shoulders. “I am so sorry, but there is nothing that anyone can do.”
The grief welled up in him from that deep and shadowy reservoir that runs back through our ancestors. As it overtook him, it pulled his face into the contortion of crying he had probably last known when his own father died. Beneath my hands he began to physically deflate like an air mattress with the plug pulled.
Overhead, I heard an announcement about an ambulance coming in with trauma. I knew we would need the trauma room. I started to guide him back toward the waiting room. He stopped and went back to Louis. He held the young man’s face in his hands. Tears now freely ran down his cheeks.
“Adiós, hijo mío. Que Dios te acompañe.”
He touched his forehead to Louis’s forehead.
I wished without hope that I would never have to feel this man’s pain.
The overhead speaker: “Squad Eighty-four for Trauma One. ETA eight minutes.”
I gently took Mr. Ramirez by the arm and led him away. He was now compliant. I left him in the waiting room. His younger boy was there now. A volunteer would help them through the business of death.
I went back and sat down at the nurses’ station. One of the nurses told me that the ambulance was here with the victim of a gunshot wound to the abdomen. I heard myself say, “Move Ramirez to the backup trauma room and get ready for the ambulance.”
My plug had been pulled too. I felt drained. So much injury to the spirit. When will it ever end?
JERRY BALLENTINE, D.O.
New York, New York
ON THIN ICE
We were in the midst of an unusually busy shift in the ER when I examined a girl of sixteen or seventeen who was seated in a wheelchair. Her anxious parents had brought her in with a sprained ankle. I ordered an X ray of the ankle and said to my most aggressive and efficient nurse, Eileen, “Put some ice on the patient in room six, she’s on her way to X ray.” Eileen grabbed a disposable rubber glove, filled it with ice, and entered the treatment room, seemingly in one fluid motion.
Once in the room, Nurse Eileen took immediate note of the bulbous and oversize nose on my adolescent patient and slapped that ice pack right on it. “We’ll get you to X ray right away,” she said as she quickly moved on to her next patient.
Somewhat confused, the parents moved the ice pack from the abnormally shaped but uninjured nose and placed it on their daughter’s swollen, tender ankle. Eileen, seeing this, ran back into the room, snatched the ice off the ankle, and replaced it on the now tearful patient’s nose.
“Leave it there,” said Eileen menacingly as she jogged off to the next patient. The family, now wondering if they had taken their pride and joy to the right hospital, quietly removed the ice pack from the cold nose and replaced it on the injured ankle.
Enter Eileen one last time. Seeing the family interfering with her attempts to ease the patient’s suffering was the final straw. Eileen looked the parents right in the eyes and told them, “If you don’t leave the ice where it belongs, the swelling will never go down and your daughter could end up with a funny-looking nose for the rest of her life.”
MICHAEL I. GREENBERG, M.D.
Wayne, Pennsylvania
EAVESDROPPING
A new intern was nervously taking a detailed history from a prim elderly woman concerning her abdominal pain. She was nearly deaf, and the questions from the intern were being relayed by this lady’s grandson, who would lean over and shout in her ear. As the intern went through a long list of standardized questions, the entire ER listened in—not only to the shouted questions but also to the answers given in this nice old lady’s piping voice.
Finally, in an effort to determine if the abdominal pain was from an obstructed bowel, the intern asked, “Are you passing any gas?”
The grandson dutifully leaned over and yelled in her ear, “Grandma, have you been farting?”
The old lady drew herself up and replied in a voice that penetrated every corner of the department, “Not me, must have been the doctor!”
BRADFORD L. WALTERS, M.D.
Royal Oak, Michigan
BOOM
The rescue squad arrived with a twenty-eight-year-old male. He was badly bruised about the face, neck, and upper torso, with a fair amount of generalized swelling and abrasions. He was clearly despondent, and the paramedics confirmed that he was extremely depressed. Apparently he had taken an overdose of pills several hours prior to his arrival in the Emergency Department.
When asked about the type of medication he had taken, the patient admitted to using a fifth of vodka to wash down several nitroglycerin tablets in an attempt to kill himself. In response to questions about the bruises on his head and chest, he became even more despondent and described how he had repeatedly and quite forcefully rammed himself into a wall in an attempt to make the nitroglycerin explode.
ROBERT G. POWELL, M.D.
Ashland, Virginia
THE CHILDREN OF
ST. BARNARD’S
CHILD ONE
I never knew the baby’s name. This was not due to an oversight on my part: No one ever gave him a name. A pity, for the baby was a fighter and deserved better.
It happened during the mid-eighties at St. Barnard’s emergency room on the South Side of Chicago. It was a rough neighborhood—and a correspondingly rough ER. If it was nasty and it happened in our neighborhood, it came to us. I remember treating paramedics bleeding from facial lacerations caused by bricks thrown through the windshields of their ambulances.
I was a moonlighting resident. I needed the money. I needed the experience even more. The Barnyard, as it was known to all other hungry residents, provided both. This particular night I felt especially blessed: We were double covered. Charlie was out of his residency, boarded, smart, and willing to teach. I remember feeling that with him behind me, the shift couldn’t go wrong.
Then, they all came in at once: an unresponsive, hypothermic drunk; a screaming, bleeding man who ended up on the receiving end of a disagreement conducted with kitchen knives; a scared, hypotensive seventeen-year-old who had just delivered herself of a pregnancy she had up to now kept secret; and the seventeen-year-old’s just-born baby.
Charlie and I looked at each other. Welcome to the Barnyard. “I’ll take the stab wounds, you take the baby,” he said. “Then you take the drunk and I’ll take the mother.”
The baby. My God, he was a little peanut of a thing, laying on the stretcher and gasping. I had never put a ventilation tube into the lungs of a newborn, much less a preemie. The baby laryngoscope blade barely made it in his mouth.
I said a there-are-no-atheists-in-foxholes kind of prayer, and the tube fit between the vocal cords. We had him ventilated, and we had a pulse. But the pulse was too slow for a neonate: six
ty. So, we did chest compressions, and I put in an umbilical line and started pushing the drugs. I tried to guess a weight. How can you guess the weight of a smidgen-sized soul?
Still, the baby held its own. He was stabilized. Time to call the neonatologist and arrange for a transfer. They got her on the phone for me. Her first question: “How much does the baby weigh?” I didn’t know. “Well, get a weight. If he’s less than five hundred grams, there is no point in continuing the resuscitation. They can’t survive at less than five hundred grams.”
So we all stood around and stared at our baby, the baby we had got back from death, while the nurses rounded up a nursery scale. It felt like the whole ER staff stood there as I lowered him onto the scale. The neonatologist stayed on the line, and even Charlie strayed in, having single-handedly saved everyone else in the department in the meantime.
Less than five hundred grams. Not even close enough that I could fake it. A roomful of faces fell simultaneously. “Just pull the tube and forget about it,” said my neonatologist. Easy for her to say. She wasn’t looking at the kid. I hung up and walked over to the baby, turned off the line, pulled the tube from the lungs. In my naïveté, I thought that would be the hard part. We all stood there, mute, watching him.
He kept breathing.
“He’ll stop soon,” I said. “Let’s get back to the others.” Disconsolate, we all shuffled out. My drunk was on a warming blanket. His temp was up. We told the mother about her baby. She didn’t care. I wrote up a couple of charts, and then looked over to the room.
He was still breathing.
And he kept on breathing. Dear Lord, was the scale wrong? If I, like a fool, rushed back in and reintubated the kid, wouldn’t I just be resuscitating someone with severe brain injury? I gritted my teeth, and wrote up another chart. I looked over again.
Still breathing.
Word began to spread. First, it was a few ward clerks who came and stood in a circle around the stretcher. The next time I glanced over, it was some nuns. One chart later, and a collection of paramedics stood there. Then, some beat cops. No one gawked. No one spoke. All had seen life wasted, wasted daily, wasted badly. They had numbed themselves to that pain. This was somehow worse. This little baby did not want to waste his only chance. He struggled, and struggled, heart continuing to beat at the too-slow rate of sixty, chest muscles continuing to try to draw air into fluid-filled lungs.
I noticed that the policemen had their hats off.
I couldn’t stand to keep looking over there. I vanished to suture a long laceration. When I returned, my eyes were drawn inexorably to the room. His room. To my relief, it was empty. It was over. Now they could take his little body to the morgue, or the funeral home, or wherever they put small dead people who gave life their best shot.
I looked down at my chart. A large plastic bag was in front of me with the now dead baby sealed inside.
It was labeled TISSUE SPECIMEN FOR PATHOLOGY.
I never knew the baby’s name. They never gave him one. A pity. He deserved better.
CHILD TWO
He had a handsome face. I could see that, even though half of it looked like mush.
He was fifteen years old. He came in with his mother, a quiet woman, who sat patiently by his side. He had tripped while playing basketball and fallen onto the jagged edge of the Cyclone fence, ripping open the left side of his face.
The wound was awful: stellate, deep, and with enough twists and turns, flaps and layers to challenge a plastic surgeon. This was out of my league. This required someone with more expertise than I had. I was going to have to get the plastic surgeon on call. Foolishly, I told the mother that. Then I called the plastic surgeon.
“Medicaid patient? I’m not coming in for that,” he said.
“But it’s his face,” I pleaded. “He has to wear that face for the rest of his life!”
“Transfer him to Cook County. An intern will stitch him up there.”
“That’s just it. That’s all he’d get: an intern. I can do a better job than an intern and I don’t think I can do a good enough job.”
“I’m not coming in for a Medicaid.”
“But you’re the plastic surgeon on call. You’ve got to come in and take these cases on your call days. Besides,” I added, foolishly trying to reach a heart that wasn’t there, “it’s his face!”
“I’m sick of Medicaid, sick of endless paperwork, hostile bureaucrats, mindless lawsuits, and no pay. Medicaid is a joke. I’m not coming in.”
“I’ll call the hospital administrator. You are obliged to come.”
The plastic surgeon, who must have taken the Hippocratic oath at some point in his life, blew up. “I’m retiring at the end of the month. I’ll call the hospital administrator and submit my resignation right now. I’m not coming!” He hung up.
I was stuck. No other plastic surgeon would come in. They were not on call. I went back in to face the mother. She took the news calmly. I told her that I was not the best person for the job. I told her that I would do the best I could. I told her that it was her choice: I could transfer him to Cook. She might find someone better there.
She looked at her son’s beautiful face. No, she said. She would take a chance on me.
I did my best, but that’s all I can say. I still think of him, now. I wonder what he is doing, down on the South Side of Chicago with a mother who loves him and half a beautiful face.
CHILD THREE
He did not have a beautiful face. It was all doughy and acne scarred. It didn’t help matters that his eyes were two red puffs and his mouth was held in the rigid contortion of trying not to cry. At eleven, he was almost as big as the cop who brought him in.
“We just need to confirm the abuse,” said the cop, looking equal parts embarrassed and bored. “Well take the pictures down at the station.”
The boy had called the police himself. He called not to report his own abuse, which was of long duration. That was evident. The scars on his back and chest and legs were classic electric-cord whip injuries: the narrow hairpin loop marks that look a bit like a brand. He had hundreds of scars of different ages. I could see the shiny, flat, well-healed ones that he probably got at six. The scars that were still red were acquired at age ten. The fresh ones looked less than a week old.
He had not called to report this. He had called because, on this day, his mother had started to beat his younger brother.
He sat there silently crying. He cried because he felt rotten. He sobbed because he had turned in his mother. He cried for his little brother. He cried for himself.
I wrote up the chart. I went to the vending room and got some microwave popcorn. I brought him the bag. We sat together eating the popcorn, he and I, and I felt as I watched him munch in silence that I was wrong. He had one of the most beautiful faces I had ever seen.
TRACEY GOESSEL, M.D.
Hunt Valley, Maryland
Like ripe fall fruit from a wild apple tree, babies tumble from the wombs of careless and innocent unnoticing young mothers. In contrast is the agony and yearning of the barren and infertile woman. And when the mind is weakened by mental illness, the power of this deep and primitive reproductive urge becomes seen as it forces its way up into the light of daily behavior.
THE WISH
In an upper-income community hospital Emergency Department, a fifty-year-old matron complained of mild abdominal pain and fever. The patient was on an antidepressant, but she had no other significant medical history. Her physical exam was unremarkable. Lab tests did little to further the diagnosis. I decided to proceed with a pelvic exam. A female nurse set the patient up in the GYN room.
As I approached the room, the nurse shook her head in disbelief suggesting we were getting close to a diagnosis. The pelvic exam revealed that the patient’s labia were pinned together with three large, rusty safety pins.
The patient apparently had a long psychiatric history, including obsessive behavior focused on her inability to bear children. Two weeks earlier, the
patient had purchased a small chicken at the market and had inserted it, piece by piece, into her vagina. She had pinned her labia to keep the chicken in place and was waiting for it to develop into a baby.
The patient was subsequently admitted to the psych unit, but not before she was washed out with two liters of Betadine douche and the entire chicken carcass was accounted for.
GREGORY DAVID POST, M.D.
New York, New York
EVIDENCE COLLECTION IN
THE EMERGENCY ROOM
She is a 13-year-old waif,
with a 16-year-old body,
and a lifetime of cares.
And as I pluck ten hairs from her head
(with the roots),
and scrape whatever I can find from under her fingernails,
and comb her pubic hairs into the envelope,
and take the pictures,
and write down the story,
with details about her mental state,
and how she cried,
and trembled,
and seemed believable,
I wonder.
How a father could do this to a daughter,
his drunkenness notwithstanding.
And I wonder
how a mother could be in such denial,
her marriage notwithstanding.
And I wonder how a 13-year-old child
can ever survive such a violation
to her childness,
and her humanness.
And where will she be in ten years?
Or twenty?
And what kind of life will she have?
And her children?
And her children’s children?
And I wonder if I’ll ever get used to this.
And if I do,
will I still like myself?
KEITH N. BYLER, D.O.
Edwardsville, Illinois
Emergency! Page 2
