by Robin Cook
"Doctor, 84," a nurse called to me from the main counter. I picked up the phone outside Room B and poked the 84 button.
"Peters, this is Sterling." Sterling was the orthopedic resident. "I finally got hold of Dr. Andrews, who's covering staff orthopedics this month, and he thinks that a hanging cast would do for Morris."
There was a pause. I began drawing interconnected circles on the scratch-pad by the phone. This bastard Sterling didn't intend to come down and put on a hanging cast, whatever the hell that was.
"Why don't you have a go, Peters? And if you have any trouble let me know, okay?"
"I've got about eight patients here I haven't even seen yet."
"Well, if he has to wait too long, call me back."
"For Christ's sake, Sterling, he's been here since ten o'clock this morning. Don't you call that long? I mean nine hours?"
"Aw, that's all right. Give him a chance to sober up."
Arguing with Sterling involved more effort and thought than I wanted to put into it, and, furthermore, it went against my new determination to keep my distance, not to get pissed off. "Okay, okay, I'll get to it as soon as I can." I hung up the phone, mentally mapping out the next half hour.
"Nurse, have the attendant draw up some warm water and get a supply of plaster ready down in the ortho room."
"What size plaster, Doctor?"
"Two- and three-inch, four rolls of each."
Putting on my most nonchalant air, I wandered into the doctors' room and quickly scanned the shelves for a book on orthopedics. Mercifully, I found one and turned rapidly to the index. There it was— cast, hanging, see page 138, which turned out to be a discussion of breaks and fractures of the proximal humerus, just what I was looking for. Despite my apprehension at being shoved into still another strange task, I was impressed by the ingenuity of the hanging cast, which did, in fact, work by a kind of traction. Rather than encasing the patient's whole arm and shoulder, the cast was placed only around the area just above and below the elbow, where its weight would pull downward on the fractured bone and ease it back into alignment. The whole arm was then pulled into the body by swathing the cast to the chest; this held the arm immobile but allowed movement in the shoulder. Amazing.
A nurse stuck her head in. "Doctor, there are nine patients waiting."
I knew that I would hear from the nurses if a real emergency arose; now was the time to get rid of Morris once and for all. After replacing the book, I headed toward the ortho room, somewhat better prepared to make a hanging cast than I had been five minutes before. As I entered the room, it became obvious why Morris had been easy to forget for the past hour or so. He lay on the examining table fast asleep, snoring lightly, cinched in place by a broad leather strap. Nor did he awake when I cranked him into a sitting position, holding his head to keep it from flopping over. Damn that Sterling; this was his job. I had heard the television blaring in the background while he was talking on the phone with me. After cutting Morris's left shirt sleeve off at the shoulder, I fashioned a piece of stockinet for the underside of the cast and slipped it on his arm, trying not to disturb the fracture.
"Doctor, there's a call on 83."
I didn't even answer the nurse, hoping that whatever it was would solve itself.
"Ohhhhh." Morris came to when I positioned his arm for the cast. "What are you doing to me?"
"Mr. Morris, you broke your arm falling down the stairs, and I'm putting a cast on it."
"But I don't—"
"Yes, you do! Now don't say another word." I hoped Sterling would ask me for a favor some day. After soaking the plaster rolls in water long enough for the bubbles to stop, I wrapped them around and around Morris's arm, building the cast up layer on layer. I made it big, almost an inch thick. Since it functioned by its weight, mine was going to work very well.
"Now just stay where you are, Mr. Morris. Don't move. Let it dry."
Reaching the main portion of the ER, I picked up 83, but no one was there. Good strategy. It was only seven-thirty; I was already eleven patients behind, and I knew it would get worse. Grabbing a handful of charts, I started off, glancing at the top one: "Skin rash."
Skin problems drew a blank in my mind no matter how many times I read and reread the descriptions of papulosquamous erythematous pruritic vesicular eruptions. The words lost all sense, twisting and turning in my memory so that if I saw a patient with anything other than acne or poison ivy I was lost. And there in front of me stood a man with a violent pruritic eczematous erythematous rash. I knew what it was, because a dermatologist had used those words to describe my sunburn after an Easter week in Miami during medical school. It meant itchy, wet, and red, but dermatologists preferred complicated scientific jargon. In fact, dermatology is the only branch of medicine still using Latin to any great extent — appropriate, in a way, since I couldn't see that the science had advanced very far since the days of alchemy. Although the terminology and the diagnosis of skin disorders were difficult, the treatment was simplicity itself. If the lesion was wet, you used a drying agent; if the lesion was dry, you kept it wet. If the patient got better, you continued what you were doing; otherwise you tried something else, ad infinitum.
The patient standing before me was a skinny, sallow-faced fellow with dark hair, bushy and unkempt. Looking at his hands and his arms, I couldn't think of a thing except how little I knew about dermatology. He didn't have a private doctor, which meant I would have to call one, and I wondered what I could say without sounding like an idiot.
I noticed that the rash was on the palms of his hands, too, and some distant bells began ringing in my mind. Only a few dermatological disorders occur on the palms of the hands. Syphilis is one. Hmmm. I was so involved with my own thoughts, I hardly heard the patient when he said that he had neurodermatitis and needed more tranquilizers. I was still trying to remember the exact list of those diseases that occur on the palms when his words suddenly scored in my consciousness. Neurodermatitis. With practice, I had developed an ability not to show surprise or gratitude when such sudden gifts of diagnosis were presented, and I continued to look at his arms knowingly until sufficient time had elapsed. It made me feel that my knowledge of dermatology at least equaled his when I guessed correctly, that he was on Librium. He was thankful to get some more.
As evening spread into night, my steps became labored and slow, and my fear mounted, giving rise in my imagination to a series of hopeless cases waiting to descend upon me. There was no pause in a continual stream of patients that kept me always five or six people behind. My suturing became more rapid, out of a combination of necessity and diminishing interest. Whenever I sutured, the people waiting stacked up, so I had to be fast, dispensing with trimming the edges and other fancy stuff. I was not haphazard, just less careful, and perhaps more easily satisfied. As, for instance, with the man who had a flap laceration on his arm. During the daytime I probably would have excised the flap and closed it as a linear cut. Now I just sewed it up, flap and all, hoping for the best.
In the eye-and-ear room a four-year-old boy sat forlornly on the examining table. His grandfather stood nearby. As I entered, the boy started to whimper, putting his arms to his grandfather, who held him while I read the chart. It said, "Foreign body, right ear." After talking quietly with the little guy for a few minutes, I convinced him to let me look in his ear. Far up in the canal I could see something black; it looked like a raisin or a small pebble.
Since the grandfather didn't know an ear, nose, and throat man, I picked one out of the M.D. roster, a Dr. Cushing, and gave him a call.
"Dr. Cushing, this is Dr. Peters at the ER. I have a four-year-old boy here with a foreign body in his ear.
"What's the family name, Peters?"
"Williams. The father's name is Harold Williams."
"Do they have health insurance?"
"What?"
"Do they have health insurance?"
"I haven't the slightest idea."
"Well, find out, my boy."
>
What a scene, I thought, retracing my steps into the eye-and-ear room. With a dozen people waiting, I've got to find out about the health insurance. No, the grandfather said, they were not insured.
"No, no insurance, Dr. Cushing."
'Then see if any of the adults are employed."
Once again I returned to the eye-and-ear room to quiz the concerned grandfather. Actually, I knew that this information gathering was easier than calling a dozen or so physicians until I found one who wasn't so concerned about getting paid; but it seemed gross and inhumane, just the same.
"Both the parents are employed, Dr. Cushing."
'Tine. Now, what is the problem?"
"Little David Williams has a foreign body in the ear, something black."
"Can you take it out, Peters?"
"I suppose so. I can try."
"Good. Send them to my office on Monday, and call me back if you have any trouble."
"Oh, Dr. Cushing."
"Yes?"
"I had a little girl in here this morning with infections in both middle ears." The Pablum child suddenly came back into my consciousness. "One drum was ruptured, and the other was bulging out. Should I have drained it?"
"Yes, probably."
"How do you do that?"
"Use a special instrument called a myringotomy knife. You merely make a tiny incision in the lower, posterior part of the eardrum. It's very simple, and the patient gets immediate relief."
"Thanks, Dr. Gushing."
"Not at all, Peters."
Thanks for nothing, Dr. Gushing. After all that nonsense, I had to go fumble for the foreign body myself. As for incising the eardrum, I decided that I should consider myself instructed on the procedure.
Back in the eye-and-ear room, I immobilized the boy and reached into his ear, trying to grab the black object. It came apart as I pulled the forceps back, and when I looked at what came out I didn't want to believe my eyes. It was the back leg of a cockroach. The little fellow was sobbing now as I dug out the cockroach piece by piece, feeling sorry for the boy and wanting to have it over and done with, nearly vomiting with revulsion. The last few pieces came out with a great gush of irrigation. The boy's crying gradually subsided, and I swabbed out the ear with disinfectant. He seemed all right, but I felt pretty faint.
Throughout the last of this procedure, a nurse had been fidgeting behind me. She now informed me, somewhat icily, that Morris was still waiting down in the ortho room. Sometimes these nurses bugged me nearly to death, especially at night. I did feel a bit guilty about Morris, though, because he had been with us for almost twelve hours now, and I suppose my guilt added to my animosity toward the nurse. Being deep in sleep, Morris couldn't have cared less. His cast was quite dry. Unfortunately, I had to wake him up in order to bind the cast to his body with an Ace bandage, and in so doing I came in for a little more verbal abuse, which seemed to me not quite up to Morris's usual standard. What bothered me a bit was whether Morris would be able to move his shoulder, with his left arm bound so closely to his chest. But I was doing it by the book, and the clinic would ball me out on Monday if anything was amiss. Returning to the main part of the ER, I told the fidgety nurse that Morris could go home, if she could find time between coffee breaks to give him a tetanus shot.
By ten o'clock the place was really hopping, jammed full of all manner of bodily ills. With the rise in clientele, I had fallen slightly further behind, perhaps by a dozen charts. Standing quietly in the middle of the main waiting room was a woman who wanted me to examine a small puncture wound on the bridge of her nose inflicted some eight hours earlier by a pair of pruning shears. Her name was Josephs. I didn't know why Mrs. Josephs had waited so long, but, in any case, her doctor had sent her to the ER for a tetanus injection. That was sound enough. However, the tetanus toxoid only helps the body to build immunity; furthermore, it is a slow worker. It seemed wise to supplement the tetanus shot with some premade antibodies for temporary protection, especially on a wound over eight hours old. We had just received a new shipment of a very good human-antibody serum called Hypertet, but I couldn't give it to Mrs. Josephs without first calling her physician, a Dr. Sung, who was well known for his sharp tongue and antiquated medicine. I dialed his number with trepidation.
"Dr. Sung, this is Dr. Peters at the ER. Mrs. Josephs is here, and I am about to give her the tetanus shot, but I feel she should have something to hold her until the shot takes effect."
"Yes, you're right, Peters. Make it a dose of horse antitoxin, and do it quickly, please. I don't want her to wait."
"We have a very good human tetanus-immune globulin called Hypertet, Dr. Sung. Wouldn't that be better than the horse serum? It's much faster, and besides—"
"Don't argue with me, Peters. You don't know everything. If I wanted Hypertet, I'd order it."
"But, Dr. Sung, if I use horse serum, there's a chance of allergy, and I'll have to skin-test her. All that takes time."
"Well, what the hell are you getting paid for? Now, get on it."
The sharp crack of the disconnection shot into my ear. Well, screw it. Old Dr. Sung was practicing very bad medicine, and someday it would catch up with him. Why should I get steamed up? Too bad about the Hypertet, though, all nicely packed and ready for injection. Ten to one the old bastard hadn't ever heard of it. So this is what we get paid for, I thought, grimly working through a long set of directions for sensitivity testing on the side of the horse-serum bottle while fifteen people waited outside.
But I didn't get very far with the horse serum. A siren, off in the distance, brought back the old fear. To my horror and disbelief, three ambulances pulled up simultaneously, and the crews jumped out and started unloading pieces of people, all victims of the same automobile wreck, putting them in rooms where others were already waiting. One smashed body would have been terrifying; five were simply overwhelming. While the nurses called upstairs for help from the house staff, I tried to do something, anything, before the situation immobilized me. One of the patients was a young boy with the side of his head crushed in. His breathing was extremely stertorous; at times it stopped altogether, only to resume seconds later. I started an IV, which the kid probably didn't need right off. But he would need one eventually, and I kept busy putting it in and getting some blood for type and cross match. Inserting an endotracheal tube came next, an automatic choice. Normally a very difficult procedure for me, this one was easy because the boy's lower jaw was so broken up that I could pull it away from his face. After sucking out his mouth and throat, bringing up bits of bone and a lot of blood, I put in the tube for him to breathe through. Surprisingly, his blood pressure was all right. I wanted to stay by the boy, even though there was nothing more for me to do for him just then, but the other patients were lying everywhere, crying for help — and, anyway, a neurosurgeon was on his way down. Later I heard that the boy had died a few minutes after leaving surgery. It bothered me for a while, until I rationalized that he had been virtually dead when I got to him.
Now, after all these months, it was easier for me not to get emotionally caught up in any one case. Other problems were waiting, demanding attention. The lady in the next room, for instance — she was critical, too. A huge area of skin and hair, running from her left ear to the top of her head, could be flapped back, revealing a network of multiple skull fractures, like a cracked hard-boiled egg ready to be peeled. The pupil on the left side was widely dilated. Where to begin? While I was looking at the skull, she suddenly vomited a pint or so of blood, which splattered off the table onto my pants and shoes. Thank goodness for the IV, providing some direction for my chaotic thoughts. I hurriedly got that going, at the same time sending up a blood sample for type and cross match to get some blood available for transfusion. Since she had vomited blood, I thought we might need eight units rather than the usual four, although her blood pressure was surprisingly strong. This matter of acceptable, even normal, blood pressure in the face of clear body failure had begun to bother me. All the boo
ks cited blood pressure as a prime and reliable indicator of general systemic function, but most of my experience seemed to be going against that rule. At any rate, I poked around at the woman's abdomen, trying to think where that blood might have come from.
Just then a nurse urgently called me into another room, where a man was barely breathing and, she thought, convulsing. Apparently hit in the stomach, he had been one of the drivers, I guessed. The nurse handed me some amobarbital to stop the convulsing, but before I could give it I realized that instead of convulsions, he had what some call the dry heaves, a kind of retching. He vomited a little, too, not blood but a stale-smelling alcohol that also managed to splash on my shoes. When Dr. Sung called back in the midst of all this wanting to know if I had given the horse serum yet, I was tempted to unload on him, but I just said no, we were busy.
A motorcycle had been involved in the same accident. The rider was virtually skinned alive. He had abrasions all over him except on his head. He was one of the few who actually wore a helmet. Every weekend had its quota of wiped-out easy riders. For sheer gore they were unmatched — so bad, in fact, that a standard hospital joke went around about the motorcycle patient who arrived at the hospital in several ambulances. Total body bruise, fracture, and abrasion was a better description for this one. If they could talk at all, those fellows would staunchly insist that a motorcycle wasn't so dangerous, because you got thrown free when you had an accident. But being thrown free at sixty miles an hour, onto concrete, on your head, and then getting run over didn't leave us much to work with. This one was not only totally abraded; his left lower leg was crushed as well. The two bones were hanging out at a forty-five-degree angle, with the foot attached only by some thread of sinew. Pants, socks, bits of sneaker, and asphalt were squashed into the wound.
