by Robin Cook
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 books 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.
Surprisingly, he was conscious, although dazed.
"Do you have any pain?"
"No, no pain. But I have something in my right eye."
God, with all that injury he was worried about a cinder in his eye. I took it out. His blood pressure was all right, the pulse a little high at 120. I started an IV and sent up a sample for type and cross match, arbitrarily picking five units of blood to be available. He apparently didn't need blood right away, but he obviously was facing some bone surgery. With a hemostat I
tried to stop a little of the blood oozing out of the leg muscles, which were in plain view. It amazed me how little he bled.
I went back to the lady who had vomited up the blood and was relieved to find her blood pressure holding up well. Perhaps she had just swallowed the blood, I reasoned; after all, she was bleeding from both nostrils. Twenty minutes had passed since the ambulances pulled in, and some others from the house staff were there now, helping to stabilize the patients. I got X-ray to come down and shoot a group of heads and chests and other bones. No description could capture the uproar of that time. It was total chaos, as colds and diarrhea and babies and asthmatics mingled with broken bones and crushed heads. Nor did matters improve much when the attendings arrived and began ordering everyone about. The OR, alerted earlier, finally began to absorb the automobile-accident patients.
Dr. Sung called again, threatening to file a complaint with the hospital if I didn't get right on that horse serum. At that point I didn't give a damn about his horse serum, so I hung up on him. This brought him storming in about twenty minutes later, ready to give me hell, just as we were moving the last of the critically injured up to surgery. I stood there, covered with a mixture of blood and vomitus, vaguely hearing him rant. This lunatic could get me into real trouble, so I didn't say anything except to mention the Hypertet again, and how much quicker it would have been. That made him even madder, and he stomped out taking his patient with him. Sure enough, a written reprimand showed up in my box a few days later. So much for priorities.
By eleven the cyclone had passed, leaving the usual jumble of patients with lesser complaints, a much larger number than usual because of what had gone before. They were everywhere—inside, outside, sitting on the ambulance platform, on the floor, in chairs. I began to go from one room to another, half listening, performing like a tired machine. One man had fallen by his pool during a party, breaking his nose on the diving board as he went down and cutting his thumb on a gin-and-tonic glass. The nose was straight, so I left it alone. The laceration I sutured rapidly, after telling his private M. D. the sad story. Even he sounded drunk.
It was, in fact, a big night for drunks; most of them were suffering from minor cuts and bruises or premature hangovers, with nausea and vomiting. And the kids were still coming in, long after bedtime, with their diarrhea and runny noses and fevers. Occasionally I had one with a temperature of around 104, yet I wouldn't be able to find anything wrong. This made me very uncomfortable. As a human being you have an almost irresistible desire to treat; you are expected to treat. The parents almost invariably clamored for penicillin, but I had enough sense not to give in most of the time. To treat a symptom like fever without a firm diagnosis is bad medicine; and yet I often got only a fleeting and rather limited look at the eardrums or the throats of those miniature screamers. Sometimes I treated, sometimes not; always I went on half-educated guesses.
It went on being a typical Saturday night in the ER. The crowd thinned out about 1:00 a.m. From now on we would see less of the various things that drove people away from their TV sets during the evening to seek the sanctity of the ER—things like colds, diarrhea, and minor puncture wounds. In about an hour, the problems that were keeping them from falling asleep would begin to appear. The same ailments they had ignored all day and through the early evening would, of course, keep them awake, forcing them to the ER in the middle of the night to see the astute and understanding intern. Like itchy thighs. On another tour of duty, I had fallen asleep around 5:00 a.m. only to be awakened because some patient had itchy thighs.
Slightly after one an ambulance pulled up without its siren, and the crew unloaded a peaceful-looking girl in her early twenties who was in a deep sleep approaching coma. Ingestion. The usual, as I found out: twelve aspirins, two Seconals, three Libriums, and a handful of vitamin tablets. All of these drugs, except maybe the vitamins, could be dangerous—especially Seconal, a sleeping pill—but you had to take quite a few of them if you were really serious. Otherwise it was only a gesture, a childish cry for attention within the social fabric of the individual's life; the usual ingestion case is a young woman lost in the unreal world of True Romance magazine. I could be interested and sympathetic, but not in my state; I was so tired that any sense of empathy had long since dissolved into irritation. How could this stupid girl pull such a stunt so late on a Saturday night? Why couldn't she throw her little show on Tuesday morning?
As they always did, several members of the family and some friends arrived shortly after the ambulance. They stayed in the waiting room, nervously talking and smoking. I looked down at the girl sleeping on the table. Then, putting my hand on her chin, I forcibly shook her head and called her by her first name, Carol. The eyes opened slowly, so that only half the pupils were showing, and she whimpered, "Tommy."
"Tommy, shit." Irritation became anger as my exhaustion and hostility sought expression and won. I ordered some ipecac from the nurse and decided to pump her out. The pumping-out procedure was no bargain for either of us, but I wanted to make her remember the ER. Besides, I knew that when I called her private doctor he would ask what I had gotten out of her stomach.
An ingestion stomach tube is half an inch in diameter. After cranking her into a sitting position, I crammed one down her throat, through her left nostril. Her eyes suddenly shot open all the way as she retched and struggled to get free of the attendants holding her. She vomited a little around the tube as I pushed it farther down into her stomach, and then everything in her stomach came up, including an undissolved Seconal and a portion of one of the Librium capsules. When I pulled the tube out, what remained came with it. A few minutes later the ipecac took effect, causing her to vomit again and again, even though her stomach was empty. By now Tommy had joined the others in the waiting room. Perhaps he also wanted some ipecac, so as to play a full role in this melodramatic event.
After sending up a blood sample to see if the aspirin had changed the acidity of the blood, and finding out that it hadn't, I called Carol's doctor. I told him what she had taken and that, aside from being sleepy, she was all right now, nicely tranquilized.
"What did you get when you pumped her out?"
"One Seconal, bits of Librium, not much else."
"Fine, Peters, good work. Send her home, and tell her father to call me on Monday."
Soon after that Carol was taken home, in all her glory, covered with vomitus. I never questioned my harsh attitude toward her, not after eighteen hours in the ER, and, while I'm not proud of it now, that’s the way it was.
Back around midnight a new shift of nurses had come on. It was now two, and I was really sagging, but the new nurses were a clean and spirited bunch, displaying remarkable agility and garrulousness for that time of night. The contrast made me feel even lousier, like a silhouette. And the next patient didn't help. Her chart read, "Depressed, difficulty breathing."
As I walked into the room, my dismay was instantly confirmed by the sight of a lady in her late forties who was wearing a light blue negligee. She lay on the table, one hand pressed dramatically against her ample upper chest. Two other ladies stood nearby hysterically telling me and the nurse that their friend was unable to breathe. I could see from a distance that the lady was breathing very easily.
"Oh, Doctor," the lady whined, drawing out the word in a deep southern accent. "I cain't hardly breathe. You have to help me."
She smelled like week-old martinis. One of the hysterical ladies produced a prescription bottle. I looked at it. Seconal.
"Oh, those little red pills. I did take two. Was that all right?" The southern lady looked at me with fluttery eyelids; she was having a hell of a good time at two o'clock in the morning. I had a strong impulse to throw her neurotic ass out of the ER. That was a sure administrative bomb, however—perhaps even career suicide. Despite my disenchantment with the system, I hadn't come to that.
"Do you hear anything strange, Doctor?" I was forcing myself to listen to her chest, which was totally clear. "Oh, you're going
to take my temperature and blood pressure," she said gleefully. "I do feel rather faint. I just cain't understand what's happening to me." On her arm went the blood-pressure cuff and into her mouth the thermometer, silencing her at last. I was glad of the opportunity to get away from her for a few minutes by calling the doctor who covered the hotel where she was staying. He said to give her Librium.
Back in her presence, I coaxed myself to be civil. "Madam, the hotel physician has suggested Librium for you."
"Librium, Doctor? Are those the little green and black pills? Well, I'm afraid I'm allergic to those. They make me so gassy, and sometimes," she said, sitting up now, moving into high gear, "sometimes if s so bad my hemorrhoids pop out." With this, we were fully launched into her extensive pill history and the dreadful details of her lower gastrointestinal tract. In the middle of her recital, a performance worthy of Blanche DuBois, I interrupted to say that perhaps orange Thorazine would do just as well.