by Robin Cook
Almost without pressure, the supersharp scalpel cut smoothly through the skin in the groin region. I began to dissect with the scissors, but I couldn't control them very well. I changed and used a hemostat clamp, not to clamp a vessel, but to bluntly separate the tissues by opening the clamp after I pushed it into the fat. That method caused less bleeding, and I began to make some headway, going deeper into the thick layers of fat. Down there, deep in the groin, I saw nothing I recognized, nothing; it was like feeling around in the dark — until I stumbled on to a vein. I had no idea which vein it was, but, by slowly cleaning around it, I was able to follow along it to a larger one, which I hoped was the femoral vein. If I was right about that, then the first vein I had encountered was the coveted saphenous vein, but I wasn't sure. I was all thumbs, dropping the instruments once or twice, altogether nervous about my role. After all, what would the surgeon say if I told him I hadn't operated before except to put in cutdowns for IV's and remove warts? I thought about asking him if I had the right vein, but such a confession of ignorance would only have gotten me removed from further participation.
At any rate, I plunged on, hoping I'd found the saphenous vein and not a nerve. The job grew progressively more difficult. In fact, it was a mess. I pushed and pulled on the vein, trying to strip it out, bluntly spreading the hemostat, dabbing blood with a gauze sponge to keep the field clear. Several times the vein broke and blood spread, but I somehow managed to stop it with a hemostat after a few wild stabs in the dark. There was some consolation in this bleeding, because it proved that the structure I had isolated was indeed a blood vessel.
Perhaps the hardest part was trying to get a tie around the hemostats that I had placed deep in the wound to stop the bleeding. Putting the silk around the tip of the hemostat was easy enough, but trying to maintain tension on the first throw seemed all but impossible. Then, when I released the hemostat, the tie I had just made would pop off and the bleeding would start again. All in all, from a technical standpoint I might as well have been butchering a hog. I glanced self-consciously over at the surgeon from time to time, but he seemed oblivious to my trials and intent on his side, where all was under control.
What a way to learn, I had thought. But it seemed the only way. If he had known I was a novice at vein stripping, he wouldn't have let me do it. It was as simple as that. So I pushed on, finally freeing up all the tributaries to the saphenous vein. Even with the tributaries isolated, I was nervous about cutting the vein in two, an irrevocable act. So I went to the ankle and made a cut, locating the saphenous vein easily there because it was the same one I had used doing IV cutdowns. I threaded a stripper up inside the vein and pushed it out through the inguinal incision. After tying the vein to the stripper at the ankle, and using a bit of force, I pulled the whole thing up through the leg, ripping out the vein. A spurt of blood, a sharp crunchy sound, and the vein came out, all shriveled up at the end of the stripper. The surgeon had long since finished the other side and disappeared for coffee, leaving me to sew up the whole job. I never heard anything dire about the day's results, so I assume that the lady was none the worse for my debut.
Despite my having sewed hundreds of incisions in the OR, the first few emergency-room lacerations had been major affairs for me. For one thing, in the ER almost every patient is awake and sharply observant. On my first ER day, when the nurse asked me what kind of suture I wanted, she might as well have asked me for the population of Madagascar. In the OR, the surgeon stipulates what kind of suture material he wants for the skin before the case starts; you merely take what the nurse gives you, even if the surgeon has already departed, the room. But in the ER I was faced with a variety of choices — nylon, silk, Mersilene, catgut — which came in all sorts of thicknesses. The nurse wasn't trying to put me down; she just wanted to be told. "What sutures will you be using, Doctor?" I had no idea. "I'll take the usual, Nurse." "The usual, Doctor?" Obviously, there was no usual. "Uh, nylon," I tried.
"What size?"
"Four-O," I told her, wondering what I was ordering.
Needless to say, I quickly learned about sutures, and also about suturing, but always by trial and error. On the first case, I put in too many stitches, and on the second case, I came to the end of the laceration with too much skin on the top. Slowly but surely I learned the little tricks, like excising beveled edges, and even fancy stuff, like small Z-plasties to change the axis of a laceration in order to reduce scarring. I came to enjoy suturing quite a bit, because it was a clear problem with a neat, clean solution that I quickly enough learned to provide. It made me feel useful, a rare and cherished sensation.
All that learning was behind me now. The surfer was waiting, a sheet over his head. Through the little window at the site of the laceration, I began to clean and anesthetize the area with xylocaine. After trimming the edges slightly, I poised the needle with the attached nylon suture about midway from either end of the laceration and back a few millimeters from one edge. Guided by a rolling motion of my wrist, the needle pierced the skin, traversed the laceration, and emerged on the opposite side. I withdrew it with the needle holder. Then, barely catching the edges of the wound with the needle, I brought the suture back to the original side and tied it, not tight, but just a little loose so that the swelling of the wound would bring the edges together. Four more sutures finished the job.
The other patient was a somewhat mysterious twenty-year-old girl who appeared chronically ill. She admitted to having been diagnosed and treated for systemic lupus erythematosus. The name alone sounds forbidding, and, indeed, lupus is a serious disease. It was one of the diseases we had discussed ad nauseam in medical school because, being so rare and ill-understood, it was good for a lot of academic speculation. So I didn't feel entirely unprepared— except that she was complaining of abdominal pain, which wasn't a common symptom for someone with lupus. Trying to connect the two in my mind, I palpated her abdomen and asked questions about her condition, which either she or her mother answered. Then, needing to think, I went back to the desk-counter in the center of the ER and racked my brains for some association between her pain and her basic disease. While I was trying to come up with a suitably exotic lab test, mother and daughter walked by, said that the pain was gone, thanked me, and went out the door. So much for my challenging diagnostic mystery, and one of the few ER cases that four years in medical school had prepared me for.
At that point, Almost came rushing in and practically collapsed in front of me, putting his forehead on the counter, panting and wheezing. His real name was Fogarty, but we called him Almost because he invariably held off until the very last moment before coming into the ER to be treated for his asthma. It was like waiting until you ran out of gas so that you could coast into the filling station. The nurses led him, blue and heaving, into one of the rooms while I prepared some aminophylline. I had seen Almost several times, beginning with my second day on ER duty. From medical school I knew quite a lot about asthma in terms of pulmonic pressure gradients, pH changes, smooth muscle function, and allergic phenomena, and I even knew about the drugs that were useful — epinephrine, aminophylline, bicarbonate, THAM, and steroids. But I hadn't known a thing about dosages. So, the first time, while Almost was in another room puffing on the positive-pressure breathing machine, I ran into the staff room and looked it up in a paperback. Anything to avoid asking the nurses. Actually, from ward cases I had an idea of what and how much to give a reclining patient. But this guy was walking around, not lying in bed, and that makes a big difference. You cannot use the same amounts. To ask the nurses something else would have demoralized me. Anyway, old Almost and I had gotten used to each other, and an amino-phylline IV did the trick, as usual.
While the ER sometimes got so crowded that patients sat on the floor or stood against the walls, it was more usual to have a steady stream over the twenty-four-hour period, amounting, perhaps, to 120 or so on weekdays and twice that on Saturdays. It was now about 10:30 a.m. The stream had started to run, and I was on
my feet, moving quickly from one room to the next, calling the private M.D.'s, not really thinking too much, almost unaware of the omnipresent fear of the next big case.
One chart read "Chief complaint, depressed." Thirty-seven-year-old lady. As I walked into the room she lit a cigarette, cupping her hands around the match as if in a great wind. Throwing her head back with the cigarette precariously perched in the corner of her mouth, she looked at me blankly.
"I'm sorry, ma'am, you can't smoke in here. Those green metal bottles are filled with oxygen."
"All right, all right." Obviously irritated, she ground the cigarette relentlessly in a small stainless-steel dish accidentally left on the examining table. She was silent now. When the cigarette was totally destroyed, she looked up and stared aggressively into my eyes, about ready to explode, I thought.
"Your name is Carol Narkin, is that correct?"
"That’s right. Are you the only doctor here?" She wanted to get at me.
"Yes, the only one here now. But we'll call your doctor, too. His name is Laine, it says here on the chart."
"That’s right, and a damn good doctor, too," she said defensively.
"Have you seen him recently?" I was trying to calm her down with routine questions, working around to why she had come to the ER.
"Don't get smart with me."
"I'm sorry, Miss Narkin, I must ask a few questions."
"Well, I'm not answering any more. Just call my doctor." Angrily she looked away.
"Miss Narkin, what am I to say to your doctor?" She didn't budge. "Miss Narkin?"
Clearly, I couldn't help her, and so I walked out, thinking I'd go back after the next patient. Why had she come here? There was no point in calling her doctor without being able to give him some sort of report. When I returned to see her after a few minutes, she was gone. That was typical of ER work— brief, inconclusive encounters and a lot of wasted time.
Next the nurse pressed five charts into my hand and pointed a bit sheepishly into the next room, where I was confronted by an entire family — mother, father, and three kids — standing there waiting to be treated.
The mother spoke. "Doctor, we came because Johnny here has a temperature and a cough."
I looked at the chart. "Temperature 99."
"And as long as we were here, I thought you wouldn't mind looking at these spots on Nancy's tongue. Show the doctor your tongue, Nancy. Arid Billy fell at school last week. See his knee, see that scrape? Well, it's been keeping him at home, and he needs a note. And George, he's my husband, he has to have a doctor sign his welfare statement because of his back condition, since he doesn't work and since we just came from California. And I've been having trouble with my bowels for the last three or four weeks."
I stared at the faces. The husband didn't meet my eyes, and the kids were busy climbing on the examining table, but the mother was loving it, looking at me excitedly. My first impulse was to throw them out. They should have been at the clinic, anyway, not the ER. We weren't set up for routine outpatient care. But if I indulged my temper, I was sure the mother would complain to the hospital administrator that I had failed to see them in their hour of need. The administrator would report to the attendings in charge of the teaching service, and I would end up getting shit on. That was how much you could count on support.
Besides, it was still morning; bright sun flashed through the windows, and I felt pretty good. Why spoil it? So, instead of getting angry, I looked perfunctorily at the spots and the scrape, and gave them a few pills. But I drew the line at the welfare paper. I couldn't tell anything about a bad back with the resources of the ER; and lots of times I'd treat these guys and see them running around on motor scooters the following day.
The next patient, a drunk called Morris, was also a frequent visitor to the ER. His chart read "Intoxicated, multiple bruises"; the description fit. Apparently the man had fallen down a flight of stairs, as was his habit. When I entered the room, he propped himself up on his elbows with great difficulty, his eyelids half covering his pupils, and bellowed, "I don't want an intern, I want a doctor!" Incredible how such remarks could sink into the tenderest recesses of my brain and cause such havoc. That stupid drunk really hurt my feelings. He made me aware again that I often had to run to the review book for a dosage, that I was scared most of the time, that I had spent four years memorizing a million facts and didn't seem to know anything. With him, I couldn't hold myself back. "Shut up, you drunk old fart!" I shouted.
"I'm not drunk!"
"Any more comments like that and I'll throw you out of here on your head."
"I'm not drunk. I haven't had a drink in years."
"You're so drunk you can't even keep your eyes open."
"I am not." He practically rolled off the examining table trying to point his finger at me.
"You are so." Our level of communication was not high. We continued the childish exchange while I examined him roughly, actually bending my reflex hammer as I pressed it against his Achilles tendons but proving he had tactile sense in his lower extremities. I ended up sending him to X-ray, more to get rid of him for a while than to get films of the bones under his bruises.
About that time of the late morning, the number of patients coming in began to exceed the number going out. A bunch of screaming babies arrived together, as if by conspiracy, and were distributed to various rooms. I really didn't enjoy treating babies. It was rather like my conception of veterinary medicine— zero communication with the patient. Half the time I was forced to ignore the child and try to make some sense out of the mother. Moreover, I found it nearly impossible to hear anything through a stethoscope on the chest of a screaming two-year-old. The usual problems were colds, diarrhea, and vomiting— nothing serious. These kids seemed to anticipate my arrival, saving up so that they could either urinate or defecate while I was examining them.
That Saturday morning was no exception. Children were all over everything, up to their usual tricks. The first baby had had a discharge coming out of its right ear for several days, which the mother thought was Pablum, but she became suspicious when the discharge continued even after she changed the baby's diet. From the general hygiene of the two of them, I thought possibly it was Pablum, but it turned out to be pus. The baby had a roaring infection in both middle ears, behind the eardrums. The right drum had ruptured, causing the discharge; the left drum was still intact, bulging outward from the pressure behind it. It would have been proper to make a little hole in the left drum to release the pus, but I didn't know how to do that, and when I talked to the private doctor, he only wanted me to treat with drugs— penicillin, as usual, and gantrisin, a sulfa drug. When I emphasized the seriousness of the unruptured left eardrum, he cut me off, saying he would see the child Monday morning. Dutifully, I wrote the prescription for the penicillin and the gantrisin.
The next baby had not been eating well for a week. Some emergency. The next one had diarrhea, but only once. It seemed incredible to me that a mother would rush her child to the hospital after a loose bowel movement, but one soon learns that nothing is incredible in the ER. A few other children had colds and stuffy noses and mild temperature elevations.
In order to be thorough, I had to look in every ear, down every throat. This work was often more like wrestling than medicine. Children, even young ones, are surprisingly strong, and although I always entreated the mother to hold the child's arms against its head during the examination, she'd invariably let go and the child would grab for the otoscope, pulling it away and bringing with it a little drop of blood from the ear canal. That made everyone joyous and confident, naturally, but I'd try again, peering into the little hole in the contorting, screaming infant. If any of them had really high temperatures, 104 or over, I'd ask the mothers to give them tepid sponge baths. That morning we had two such cases going. All in all, the ER was sometimes like a pediatric clinic. Of course, there were occasional emergencies, but not as often as the public thinks. Mostly the problems were trivial, stuff that sho
uld have been treated in the clinic.
When the odd and horrible thing did happen, the whole staff would become somber and withdrawn for several hours. One morning, a small, dark lady had come in quietly, carrying a small baby in a pink blanket. At the time I hadn't paid any attention to her, being busy with someone else. A nurse took a clean chart and disappeared with the mother. A few seconds later, she reappeared on the run, saying that I should see the child immediately. When I entered the room, the child was still swathed in the pink blanket. Opening it and pulling it back, I saw a blue-black baby, its abdomen swollen to twice normal size and hard as a stone. I couldn't be sure how long it had been dead, but I guessed for about a day. The mother sat in the corner, not moving. We didn't talk; there was nothing to say. I had just looked at the baby, marked the chart, and walked out.
About once a week a pair of hysterical parents charged into the ER with a convulsing child. The child was usually pretty young, and the first time I saw one of those I almost passed out from anxiety. This little girl was about two years old. She lay doubled up, with her arms pressed against her chest; saliva and blood drooled from her mouth, and her whole body shook with rhythmic, synchronous, convulsive jerks. As usual in such cases, the child was out of control of both her urine and her feces. Still terrified, but relieved because the doctor was there, the parents put the girl down on the table. Since they were too hysterical to be of any help, I asked them to wait outside. I also wanted to avoid their judgment of my action — or inaction — for, in truth, I didn't know what to do. Then one of those great nurses bailed me out by handing me a syringe and offering to hold the child while I tried to find a vein. Suddenly I remembered: amobarbital IV. The next problem was getting the needle into the vein. Even on a quiet, resting child, finding a vein can be difficult. On one who's convulsing, it can approach the impossible. How much drug to inject was another dilemma, but I thought I'd just give a little and test the reaction. Finally getting into a vein, after several abortive probes, I gave a squirt, and the child's convulsions suddenly slowed down and then stopped; her breathing stayed strong, thank goodness. My terror of convulsing children decreased somewhat after that experience, especially after I learned to use Valium, or paraldehyde and phenobarbital intramuscularly. But the first time it could have gone either way.
