I knew also that, for me, a relationship could be only with a man with whom I recognized a soul connection. None of me feels that this type of link can be jury-rigged by any virtual algorithm, no matter how inventive Silicon Valley considers its calculations.
Still, eventually, I had relented, but I made sure to deploy the excuse of my tricky emergency medicine schedule to keep my involvement in the process (what amounted to a couple of months) only tangential. There was Rick, who had clearly posted a photo from twenty years prior and had a penchant for discussing beer and golf exclusively. (I disliked both only a little less than I disliked him.) There was Doug, who repeatedly reminded me that he was an attorney, no matter the topic of conversation; yet, when I finally bit and asked where he practiced law, he gave a verbose answer about the many ways one can be an attorney and not actually practice law, weaving in a discussion of his entrepreneurial interests. I felt my eyes glaze over as I listened to the man lie about his identity. And I can’t leave out Frank, who had obviously posted someone else’s photo entirely. He rambled on about his divorce from seven years before; how he had no hobbies, few friends, and spent all his free time co-parenting a teenager who appeared not to want to spend any time with him. It was for all these reasons that he figured he’d meet a companion through online dating. I politely finished my drink, stating, “Ugh, so sorry. I’d better rush home. I have to get to the ER tomorrow. I know it’s only six-fifteen p.m. now, but my morning shift starts super early . . . No, please. You stay and enjoy. I’m safe to walk home, and I walk pretty fast, so I don’t want to be rude.” I pushed my chair back to wriggle myself free from the booth. “Have a beautiful night,” I added, already halfway to the door.
Frank was the last. It was my experience with Frank that made it clear he should be the last. There were no regrets. And thankfully, all of them got away.
I planned to use the 4 a.m. lull to avoid responding to the latest two date requests and instead get the code meeting preparation out of the way. Of course, in an ER, downtime is never guaranteed at any hour. Just two weeks earlier, I had worked nonstop straight through the night. I hurried to send home the drunk who had come in ten hours earlier and finally gotten a purchase on sobriety. The CT report on my patient in Room 9 had confirmed appendicitis, so Surgery was called to claim its final patient of the shift. And I had to sew up a facial laceration on an elderly man before admitting a middle-aged woman with multiple rib fractures who had taken a spill down a flight of stairs during a seizure. The stable but hypotensive patient would certainly have to be seen by the next doctor, who was already fourteen minutes late for her shift—but who’s counting?
But on this night, a chilly Wednesday in November, the magic hour was holding: At 3:30 a.m., my last patient in the department, a fifty-year-old man complaining of “itchy feet for three months,” was well on his way to being cured. There was no rash or infection, just a man who needed lotion. The pharmacist on duty was willing to oblige by sending over a tube of generic moisturizer for the patient to take home to commence the healing, and I could finally sit down at the computer to scroll through my queue on the electronic medical record tracking board to ensure that all my medical notes and orders had been signed. But first I would grab some coffee—I was so tired that my bones ached. Four a.m. tired is nothing like being sore from yoga class or a hard run; it’s a deeper throb, a psychic ache.
Here is the blessing and the curse of the 4 a.m. downtime. When everything goes quiet—the techs running back and forth; the patients requesting Percocet, ice, and turkey sandwiches; the nurses asking you to enter all your verbal orders from last night into the computer; a physician on call for a specialty service asking if the consult you placed from the ER is really an emergency or could wait until tomorrow or, better yet, until whatever month a clinic appointment could be made for the patient in question—the inner voice swells until it becomes an existential nudge. Why am I here? What am I really doing? What’s my purpose?
But who has the energy to navigate this conversation at 4 a.m.?
Yup, it was a good time to get coffee.
Just as I had pushed my chair away from the desk, my screen flashed blue, the color code that told me a new patient had arrived. The magic hour evaporated, and what came up in the complaint tab completely dispelled any charms 4 a.m. usually held: “Hemorrhoid.”
The nurses had triaged the patient, Mr. Erik Samuels, with an “emergency severity index” of 4—given that the scale of patient urgency goes, in descending order of severity, from 1 through 5, only a 5 was less critical. So, I wouldn’t need to rush. I scrolled through the chart to make sure I didn’t miss anything. (Five years later, my memories of rounds with Dr. Jaiswal were still with me.) The patient didn’t have a fever, and his other vitals were insignificant: blood pressure 145/86, heart rate 76, respiratory rate 16, saturating 100 percent on room air. I skimmed his electronic medical record. He had a history of hemorrhoids, which each time appeared to have been treated appropriately with a brief course of steroid cream. He also had a history of an inguinal (groin) hernia. Five years before, he had been seen in the hospital’s outpatient surgery clinic but had declined any surgical intervention, and then had never returned to that clinic again. It didn’t appear to be anything serious.
But then I saw it: A yellow flag appeared on one of the patient’s earlier notes, from three years before: “Violent Behavior Alert.”
We deal with all kinds of threatening behavior in the ER. By federal law, we are required to evaluate anyone, at any time, with any ailment. For many people, the ER is the only place they can go, particularly those without medical insurance. But it’s not the uninsured who use the emergency department the most; it’s the insured.
A 2011 survey by the Centers for Disease Control and Prevention explored the reasons the insured find themselves in the ER. Often it is because they feel their health needs aren’t being met by their primary care provider; perhaps their doctor doesn’t respond quickly enough to their phone call, email, or text. Even when a patient is able to reach their physician to schedule an appointment, they may feel they are simply too sick to wait for the appointment. So, when patients arrive at the ER, they may be delirious from infection or psychotic from a chemical imbalance; they may simply be belligerent drunks, or so entitled from unchecked privilege that even polite questioning causes them to blow a fuse. Whatever the case, it pays to be extremely cautious in the ER.
Actual statistics on violent incidents in emergency departments are sparse; only a small number of dedicated studies have been done. The more pressing issue is that these incidents go largely underreported. The reasons for this are manifold. Many health care providers feel that nothing is done when reports are made, which effectively diminishes the impetus to disclose assaults. Others, fearing they could face scrutiny or blame for not having prevented the violence, become habituated to it: It simply becomes part of the job.
According to the 2003–2007 Workplace Safety Survey by the U.S. Bureau of Labor Statistics, workers in health care and social services are five times more likely to be victims of a nonfatal assault than average workers in all other industries combined. A 2009 Emergency Nurses Association study showed that 20 percent of respondents had been physically assaulted at work more than twenty times in the past three years.
Many television programs don’t depict hospital departments accurately. No, the ER staffs are not Hollywood beautiful—you won’t find us in the pages of Vogue or GQ, and we’re not all sleeping with one another (I’ve worked in only one hospital like that)—and given the size of your average American, it turns out it would be extremely difficult to create an emergency airway using a steak knife, a straw, and a bit of twine. But TV does get one part of ER life right: Medical personnel in hospitals are often attacked by the patients they’re trying to help. In the most horrifying instances, people walk into hospitals and clinics with guns to murder providers who save lives. Anything can and does
happen.
Once I saw the yellow flag on Mr. Samuels’s file, I took a deep breath and clicked on the alert note:
Patient grabbed the left breast of female physician while she was performing an incision and drainage on his neck abscess. When it happened, the female physician put down her instrument and left the patient room. The procedure was completed by a male physician.
The rest of the chart read like any other for an abscess treatment, recommending that the patient return in two days for a wound check.
Hot bile constricted the back of my throat, and my face flushed. I didn’t know what bothered me most: the patient having committed sexual assault, the offhand manner in which the attack was described, or the fact that the patient was instructed to return to the ER for routine care after he had perpetrated a crime against one of our providers.
Yes, this patient would wait. He would wait while I pushed my chair back, stood up, walked to the break room, poured myself a cup of coffee, went to the restroom, and finished some notes. He would wait until I was done with everything. In the comment section next to the patient’s name, I typed in “History of assault on staff,” and then called the triage nurse to request that he assign Mr. Samuels to one of the male nurses.
“Sure thing. He just has some swelling on his bottom,” the nurse responded.
I stood up, secretly hoping that the coffee pot would be empty and I’d have to beg someone to teach me how to brew a new pot. Then I’d wait, drip by drip, until it was ready.
As I turned the corner to head to the staff kitchen, I heard someone shuffling back to Room 7, where Mr. Samuels had been assigned. I heard the dragging of feet and a groan of pain. With my stainless-steel mug in hand, I continued past the sounds to the kitchen.
There are plenty of occupations in which employees have no choice but to deal with anyone who shows up: restaurant server, flight attendant, shoe salesperson, hair stylist. Emergency medicine is the same. But before I became a doctor, I had always assumed there would be less violence and more civility in medicine. We train for a minimum of seven years and spend countless sleepless nights restarting hearts and resetting bones, and yet, now that I was practicing, I knew that we in the ER were no different from those working in service industries. We aren’t spared from rude or belligerent patients. We are punched, kicked, called “cunt,” and even shot at—none of which should ever happen to anyone in any line of work, but it does. And as doctors, we are exposed to this violence by the very people the law mandates us to treat.
As a resident, I had trained and lived in the South Bronx. Mercy Hospital, one of the busiest hospitals in the country, had good reason to have an in-house police precinct complete with a jail cell. Given the prevalence of violent crime in that part of New York City, and the fact that Mercy was one of the highest-volume trauma centers in the country, people assumed we were under constant threat, but that was not my experience. It’s true that we were in the trenches as community members, standing side by side with the South Bronx residents. We knew the police officers, firefighters, and EMTs by their first names. They’d often send the ER staff donuts after we’d helped them unload the fourth gunshot wound, second cardiac arrest, or first pediatric stabbing of the day. We at Mercy might not have had the newest equipment and our scrubs might not have been handsomely monogrammed, but we showed up every day (many of us fueled by the strong and delicious Cuban coffee from the bodega across the street) to take care of as many patients as humanly possible. The faster we worked, the more patients arrived; the more patients, the sicker they seemed to be. If we began a 7 a.m. shift by attending to the twenty-five patients still in the waiting room from 10 p.m. the night before, that simply meant it was a regular Tuesday.
I once treated a patient for a minor GSW to his leg. He was a drug dealer in the neighborhood and, gauging from the substantial roll of money in his pocket, successful in his chosen field. At the end of my shift, he beckoned me over.
“Don’t worry about anything around here, Doc. I got you,” he told me—and he meant it. In that way, we were a team. So, I was never physically harmed in the South Bronx.
It wasn’t until afterward, when I was working one day at Andrew Johnson’s smaller community hospital location, in South Philadelphia, that I encountered my first violent patient, a young man whose mother had brought him in heavily intoxicated. (Although, at twenty-nine, he was technically an adult, in this neighborhood it was a cultural norm for grown men to come to the ER accompanied by their mothers.)
That evening had been peaceful until he was rolled into the department vomiting. The two night nurses who were planning Girl Scout events for their daughters and the evening clerk who was surfing the Web stopped what they were doing to register and triage the new arrival. The patient was deposited in the room kitty-corner to the doctors’ station. After safely dumping her son off for the ER staff to deal with, the young man’s mother left, and the triage nurse kept his room dark to encourage him to sleep off his intoxication. His was a simple case: I would examine him, prescribe medicine for nausea as well as intravenous hydration, and discharge him back to his parents in the morning. He likely needed none of these treatments; routine intoxication is typically best “treated” by simply kneeling in front of a toilet bowl. But because the young man had been brought to the hospital, we were obligated to provide the medical show the family expected.
“Sir, may I examine you?” I asked.
“Suuuurrrree,” he slurred as he moaned and clutched his stomach. He seemed well enough and cooperative.
I told him I would examine him quickly and then the nurse would give him medication for his vomiting. He leaned forward; his lungs were clear. He slumped back; the heart sounds were normal.
“Okay, now open your eyes.”
I was inspecting his pupils with the otoscope—the ophthalmoscope head was missing, but really, any light source would have done the trick—when, out of nowhere, a fist came careening toward my face. There was no context to his violence in that moment. There was no good reason and no appropriate justification for it. Being drunk never changes a person, but it does grant their shadow selves free rein to step forward.
I heard my glasses fall to the floor and then slide across the linoleum. In the half-lit room, I saw nothing but a smear of the patient’s blond hair and pink skin. As my head jerked, I sensed movement, but I didn’t know if it was him or if I was simply readying myself for the next blow. In that same second, I reflexively flung my right arm forward with every ounce of force I could muster, the otoscope still in hand. When it made contact, I heard a crack and a thud as the patient’s body reeled back onto the stretcher.
Without my glasses, I was essentially blind—I don’t mean blind in the way of needing reading glasses for the morning paper, but blind like I couldn’t get to the sidewalk without a walking stick or a guide dog. I knelt carefully to pat down the floor, and luckily my hand reached my glasses, which were right against a cabinet, still intact. I pushed them on and stood. The patient was still lying on the stretcher, his eyes closed. He was breathing, and I didn’t see any blood. But I did see a small, red circular impression in the middle of his forehead where the otoscope head had made contact.
At that point, the nurses and the other attending physician had rushed into the room to see if I was all right.
The other attending on shift was Dr. Crist, a six-foot-four retired military man with a voice as big as his stature. He surveyed the scene.
“Well, we’d better add a head CT to his orders,” he said.
He continued that he would assume care of the patient, and in his clear, understated way, he declared, “There’s no fucking way we should come to work for this shit. These idiots coming in here thinking they can do whatever the hell they want to! Who gives a shit if he’s drunk? He’s just a lowlife. Why the fuck do these people bring in their shit family so we can take care of them?!”
I just stood t
here, my face throbbing. I couldn’t answer Dr. Crist’s questions. They’d been rhetorical, anyway. I appreciated his expressions of rage; my own anger was too choked up in my chest and bound with shame. I didn’t know then the exact source of the shame, but I knew what I felt: I was ashamed that a man had struck me in the face; that the blow had left purple welts on my nose and cheek that hurt when I put my glasses back on; I was ashamed that I couldn’t scream at the patient or pummel him the way I believe a man who harms a woman deserves to be pummeled. Maybe most of all, I was ashamed that I had been made to feel so weak in my position of supposed power. I was a grown-up now, a doctor, not a child witnessing my father’s violence at home.
Big Hector, a nurse whose nickname describes him perfectly, asked if I was okay. The other techs and nurses did, too. They called Security as well. My interaction with the Philadelphia police was brief. An officer took my statement, and we completed the necessary paperwork for the department so that the patient would be banned from care in our hospital system. I declined to press charges, given that it would require a lot of my time to do so and because while I was sure the man’s violence had had nothing to do with his inebriation—violence never does—I had doubts about whether the charges would stick in a man with a documented history of intoxication.
The Beauty in Breaking Page 7