Emergency!

by Mark Brown, MD

  What Howie was trying to say was “Puja!” (“Push!”) Instead, to this young woman who was delivering her first baby in the backseat of a car, he was yelling, “Whore! Whore! Whore!”

  THOMAS MOTYCKA, M.D.

  Columbia, South Carolina

  NOT EVER

  I was finishing up an unusually busy Thursday shift. Seven patients had been brought in all at once from a car accident. Fortunately, the injuries were minor, but the paperwork had kept me busy until two hours beyond my 3 P.M. changeover time. Finally, I finished. Just before I headed out the door, one of the nurses called me to the phone. “An emergency,” she said.

  “Emergency.” In no other setting could that word be so overused. The nurse’s grim expression puzzled me as I reached for the phone with my left hand, my right holding my white coat slung over my shoulder.

  “Philip?” my wife’s voice sobbed. “I think our daughter has been killed.”

  “What?” My knees buckled as my shout reverberated around the large chamber.

  During my wife’s dance lesson, our four-year-old, Lauren, had wandered away from the child care area. She had been found in the otherwise unoccupied weight room, asphyxiated by a two-hundred-pound bench press she had dislodged across her chest.

  Two good friends from the nursing staff drove me to the medical center where the ambulance had taken my sweet baby. I refused to fantasize. Lauren’s condition was critical, but I knew so little that I concentrated on good thoughts and hopes. Tears rolled down my cheek.

  On my arrival, I was led to the “quiet room,” which is reserved for grieving families, to join my weeping wife. I do not like quiet rooms. I needed to be with my daughter. My daughter needed me with her. My wife needed me to be with my daughter, too, for she could not.

  “The doctor told me that if she recovers, she’s going to be brain damaged,” she said. “Did I do the wrong thing to bring her back?” My wife had just finished recertifying in CPR training the week before and had administered CPR until the ambulance arrived.

  “No,” I insisted. “No one can tell what will result.”

  A nurse led me into the trauma room where the pediatric surgeon was having difficulty starting the arterial line. Lauren had been completely limp when she arrived in the Emergency Department. Now I noted that she was responding to the painful stimulus with primitive reflexive posturing. I pulled up a stool, stationing myself by her side, and held her hand. For the next two hours I sat there, calling to her gently, telling her stories, singing her songs. Lauren’s favorite song had always been “You Are My Sunshine.” Every time I came to the last line I became too choked to produce it. Rhythmically, the ventilator went up and down.

  Over the next few hours Lauren showed small signs of improvement, and by 11 P.M. we had all moved to her room in the neurological intensive care unit.

  Our friends rallied to our needs. Through the evening and throughout the night, visitors brought comforting words, gifts, and good wishes. The magic and power of all our hopes permeated the room. Lauren continued to show good signs. At two in the morning she reached up and scratched her scalp. I rejoiced. At the very least she would have self-care.

  Then, at 4 A.M., our miracle bloomed. Lauren opened her eyes and, around the endotracheal tube, mouthed “What happened?” Tears, laughter, the rejoicing of redemption filled our room.

  Later that morning, an astonished neurosurgeon gave permission for removal of the ET tube. Within an hour, Lauren had wiggled her arms free enough to disconnect all her other tubes. Late that night Lauren was transferred to the pediatric ward, and the next day she and her dozen new dollies piled into the wheelchair and rolled out the door.

  Every day I see patients who recover, and all too often I deal with the families of those who die. Yesterday, a fifteen-year-old boy was brought in with a head injury sustained in a car accident. His mother stood in tears at his side, holding his hand and calling softly to his unresponsive limpness. I would like to have said, “I know how you feel.” But no one ever can. Not even now.

  PHILIP L. LEVIN, M.D.

  Browns Summit, North Carolina

  MAKING SENSE

  It is rare that I suffer for my patients anymore, and I almost never do while I am actually in the ER working. Sometimes when I’m home, hours later, I remember the weeping parents of a child who drowned, and let myself feel, if just for a moment, the smallest visceral pain. Not for the child, whom I never really see as a living person. But for all of us: the parents, the baby-sitter, myself, my own children …

  I tend to take solace, though, in the thought that with greater vigilance things like this might not happen. Not that I’m judgmental: I do care about my patients even when they’re alcoholics or junkies; I understand the pain of the mother whose son was shot holding up a store, the terror of the chronic lunger gasping for breath after years of smoking, the helpless rage of the hemophiliac with a now worthless knee after he played in a game of soccer, when he knew he shouldn’t. And it isn’t that I haven’t done all these same things in my own way, for I have.

  But still, there is some comfort when you can find a reason for tragedy, a defect of character that changes, even a little bit, an innocent victim into someone who had it coming. Maybe it makes the daily onslaught of misery seem just the tiniest bit less cruel. Or maybe it merely lets me feel safer myself.

  One night at about 1 A.M. the paramedics brought in a twenty-five-year-old man from an auto accident. His BMW was destroyed, and he was comatose, with vital signs that were preterminal. I knew without even thinking about it that he was going to die. Such knowledge always makes resuscitations run smoothly; there’s no frantic behavior when you know nothing you do can harm a patient.

  What I noticed most about this patient, while members of the trauma team stripped him of his trendy outfit and started IVs and hooked up monitors, was how serene he looked in the midst of all this activity. And what a striking specimen he was. He had the physique of an athlete, or a model. Even his tan was just right. I also noticed the odor of alcohol when he breathed. Not overwhelming, but undeniable. To me, it was like a breath of fresh air.

  Running a trauma code involves doing many things at once, but I managed in the next few minutes to develop a clear picture in my own mind of this man who was going to die so young and who, for all the tragedy of it, I knew with a great bone weariness, had done this to himself. Like many another Southern Californian, I was sure, he had been blessed with too much: youth, looks, money, the time to work out, preen, and strut. And now, driving drunk after a late night out, he had killed himself. I only hoped that the driver in the other car wasn’t hurt too bad. (Though I felt in my gut he would be, I comforted myself with the thought that, at least according to the statistics, there was an awfully good chance he’d been drunk too.)

  By the time the patient’s heart stopped, after our multiple interventions had failed, several of his friends had made their way to the waiting room. Here’s what they, and the half dozen or so others who slowly streamed in throughout the night, had to tell me.

  The patient had moved to L.A. one month before, after graduating at the top of his class at a prestigious law school. He had been hired by a top law firm in town, and was driving home from the celebratory dinner they threw for him when the accident occurred. He’d had a beer with dinner, apparently, and another not too long before leaving, but they were certain he hadn’t drunk anything stronger. (In fact, the blood level ultimately came back close to zero.) We also later found out from the police that an eyewitness had said the other vehicle, a van, had suddenly swerved into the young man’s car, hitting him head on. I never did find out if that driver was in fact drunk, or how bad he was injured.

  The patient’s older brother, tall like the patient but skinny, with scraggly hair and wearing old jeans, told me he himself was the black sheep of the family, a struggling artist, while his brother was the golden boy. Although he’d always wished his parents would be just as proud of him, he’d never really resen
ted his brother—how could you resent someone so generous and loving? An ex-girlfriend said she’d never respected a man so much, and still considered him her best friend, even though the romance hadn’t worked out. A couple of new colleagues from work said this guy was amazing—so bright and yet so easygoing and noncompetitive. The current girlfriend was merely inconsolable.

  Usually I try to avoid giving terrible news over the phone, but his parents lived in St. Louis. When I woke the father it was about 4:30 A.M. their time. After I said I was calling from California with some very bad news, there was silence. And there was more silence as I described the accident, and then more as I went over all we had tried to do. I went slowly, hoping to be gentle but direct, trying to allow him to ask any questions before he heard “dead” and excluded any other input, trying to say the things people like to hear about “not feeling pain” and “happening quickly,” wanting not to keep him in suspense but also to cushion the blow, wishing I would be able use my words to do for him what an arm around the shoulder sometimes does, and, finally, dreading the terror and pain and rage he would feel, and which he might direct back at me, the messenger. When I was done, after what seemed like a very long speech, uninterrupted by sounds from the other end of the phone two thousand miles away, there was a bit more silence, and then the father said: “So what are you telling me?” And then I heard him say to his wife, “This is someone from California. There’s been an accident. Ask him what he’s saying.”

  I was on the phone with them, on and off, for much of the rest of the night, and though they clearly knew that their son was dead, they never really seemed to understand, each in turn asking from time to time “So what happened?” or “What exactly are you saying?” or “You’re a doctor from California?” I never talked to them again, after that night, and I don’t know if they could ever make sense of what had happened. I certainly couldn’t.

  JEROME R. HOFFMAN, M.D.

  Los Angeles, California

  CONTINUITY OF CARE

  Residency interviews are a nightmare. I sit there in my interview suit complete with tie. Do I look too conservative? Not conservative enough? A rivulet of sweat inches down to my boxers while the man behind the desk rifles through my file, searching for something: a flaw or an interesting tidbit. Eventually he sits forward and with a level gaze poses the question: “Why do you want to practice emergency medicine?”

  An honest answer would be, “I’m not entirely sure why, sir. Perhaps you, as a practicing emergency physician, could tell me.” But instead I launch into my well-rehearsed oration on the benefits of emergency medicine as a career. I am careful to include all the catch-phrases: opportunity to treat a variety of medical complaints, to bring primary care to the undeserved, to have a flexible, pager-free lifestyle …

  If my answer has not left the interviewer comatose, he may counter with, “Well, don’t you think you’ll miss the continuity of care that primary practice offers?” To this I assert that emergency medicine has its own continuity, and that emergency physicians can follow a patient’s course both in and out of the hospital. Sometimes, if I feel relaxed, I tell this story:

  It was an unusual day in Seattle. The sun was shining over the city. I was enjoying my first day off in three weeks of a surgical rotation, walking along the street carrying a Nordstrom’s bag containing a salmon and some vegetables from the Public Market. A distressed teenage girl was stopped on the sidewalk. Next to the business-lunch crowd who were studiously avoiding her, I’m sure I looked like the country cousin shopping in the big city.

  The girl came to me and plaintively asked, “Sir, can you help me?” She wore a black-and-white houndstooth overcoat and her clothes had a lived-in look. Her face was a harsh mosaic of bruises and abrasions masked with eyeliner, blusher, and lipstick applied with questionable skill.

  I was about to ignore her plea when something caught my eye. I stopped. “Sure, what can I do for you?”

  “Thank God,” she exclaimed, turning her head to the sunlight in an obviously practiced gesture. “Finally, somebody who will listen to me.” Listen was all I could do for the next few minutes as she told me her story with the rapidity of a telemarketer. Her name was Cathy. She was a high school senior from Chehalis. Her parents were visiting relatives in Iowa, leaving her alone at home under the lax supervision of the neighbors. She had come to Seattle yesterday to go shopping. Somehow she had become separated from her friends, and had walked across town, hoping to meet them at the bus station. A gang of kids had beaten her and taken the purse with her money and return bus ticket. She had spent last night curled up behind a dumpster, afraid that she was going to be murdered or raped. She hadn’t had anything to eat since yesterday, and she didn’t think she would last another night on the street. No, she hadn’t contacted the police, because she was afraid her parents would find out that she had left town against their strict admonitions. She feared they would ground her forever. Yes, she had tried to call friends in Chehalis, but no one was home. She was really just a good kid that had made a bad decision, and if she ever made it back to Chehalis alive, she would never leave again without her parents’ permission.

  “All I need is twenty-seven dollars for a bus ticket back home. You can even walk me to the station and watch me buy the ticket.” Her eyes darted back and forth between my face and the Nordstrom’s bag.

  She thought that I had stopped in deference to her vulnerability. In fact, it was a five-centimeter red crescent above her left eye that had caught my attention. In the crescent were eighteen size 6-0 Prolene sutures. I knew that below the Prolene were four more of Vicryl. I had stopped to admire my suturing handiwork. Not bad for a third-year student, I thought.

  “As soon as I get back to Chehalis, I’ll mail you your money,” she continued. “I can even wire it to you if you want. I’ll pay you back. Honest. I promise.”

  Sometime during a blur of bad coffee and late nights, the surgery intern and I had been called down to the ER to help sew up drunks with head lacerations. When I showed up, the trauma doc had grunted and pointed down the hall at a gurney holding a restrained figure with a pillowcase for a head. She had been spitting blood at the staff. The chart had listed her name as Krystal, and she had been delivered by a police unit returning from a domestic violence call. Her medical history read: “None of your fucking business, you donkey-faced homo.” As I cleaned the blood from her hair and face, she spewed forth with a continuous diatribe about my supposed sexual orientation toward animal species and humans of both sexes. Giving her a local anesthetic was a tough battle despite my advantages of height and weight.

  Suturing of the wound would have been dangerous to us both were it not for a passing nurse who procured a mirror and appealed to Krystal’s vanity. “If you don’t hold still and let the boy do a good job of stitching that up, you’re going to look like you chase parked cars in your spare time.”

  Krystal lay still and silent for the forty-five minutes it took me to close her wound. As I finished, the intern returned to chide me for using too many sutures and to take me back upstairs. I had not been responsible for her discharge instructions, but looking at the ten-day-old wound, I knew that she had not kept her follow-up appointment for suture removal.

  “Even if you could just give me a ten or a twenty, I’d be that much closer to home,” she implored sweetly.

  “OK,” I distractedly mumbled, “let’s go to the bus station.” Again she thanked God. The walk to the Greyhound terminal was short. I preferred her previous obscenities to her current saccharine effluence. As we neared the window, she held out a hand for money to buy the ticket. When I pulled out a credit card, she became suddenly tense.

  “They don’t take credit cards here.”

  “The little sign says they do.”

  “Well, maybe they do, but they don’t like it,” she warned.

  “They’ll get over it.”

  “There’s a bank machine around the corner; you could just get the cash and wouldn’t have
to use your card.”

  The apathetic woman in the window ignored our dialogue and asked, “Where are you folks going today?”

  I turned to the girl, “Well, where do you want to go, since you know you can’t cash the ticket the moment I walk out?”

  “Bastard!” She pivoted and stormed out.

  “Sorry.” I shrugged to the cashier, and left.

  She was walking slowly back up the sidewalk. I matched her gait. “Get the fuck away from me or I’ll scream.”

  “When was the last time you ate?”

  “What do you care?”

  “I care. Why don’t you let me buy you lunch and take the stitches out of your face?” Her hand came up and her ring finger worried one of the tiny blue filaments at her brow. She stared at me. “Can you do that?”

  “Why not? I put them in.” She looked surprised.

  We sat at the counter and she wolfed three hamburgers. Between bites she told me a different story. Her name was Christine, and she was from Moses Lake. Her father taught shop and coached football at the high school where she had been a junior. Her mother sold cosmetics, and spent the rest of her time “trying to ruin my life.” She couldn’t stand the farm-boy jocks her parents wanted her to date. She found school tedious and frustrating, and her sharp tongue landed her on probation all too frequently. She’d run away from home with her boyfriend, an older, notorious, small-town coke dealer with a black Trans Am. They were going to make the big time: live in a nice house, own a ski boat, and throw wild parties for all their friends. They’d laugh at the hicks living back in Moses Lake. The competition in the city cocaine trade had proved too much for her friend, however, and soon he was sampling more than he was selling. One morning, after the money ran out, her boyfriend slapped her around and pushed her from their room. She was to come back with a hundred dollars or not come back at all.