Just Here Trying to Save a Few Lives

by Pamela Grim

  After the last of the others on the panel trotted out his or her answer, they passed the microphone to me. I held on to it for a moment, trying to compose my thoughts, what thoughts there were. As I did so, I stared across at the sea of faces in front of us, all so young, so splendidly well educated, so wealthy, privileged and impossibly naive.

  “Well,” I said, trying to smile, “my mother was an alcoholic.”

  All sound evaporated. The room became perfectly still, not another cough.

  “And my grandfather, my dad's dad, was an alcoholic.”

  No one moved.

  “I know this doesn't answer your question in any way that applies directly to you—everyone has to find his own way. But in some ways, for me ER is all about family baggage, the stuff I dragged into adulthood with me.” I could feel myself groping for a moment. “Like my granddad.” I made a gesture meant to evoke a distant prairie. “It's funny, because I never met him. He was my dad's father. Dad was raised on a farm on the plains in eastern Montana which is the poorest, most godforsaken piece of tundra you ever want to see. In the thirties it was the northernmost reach of the Dust Bowl of the Great Depression. You can't—none of you sitting here can really quite imagine it. That land was bitter cold in the winter, and it was winter up there pretty much all the time. Martin—my grandfather—tried to farm it all the way through the Depression years, but he was a man who never had a bit of luck. There was no water—no rain—nobody to sell anything to, no nothing, for over ten years.

  “You know those courageous settlers who came here from the old country with just a dream and ended up in a new world rich beyond their imagination? Well, Granddad wasn't one of them. At the tail end of the Depression he gave the farm up. In 1940, or thereabouts, his youngest daughter died and my grandmother left him. A year later his three boys went off to fight in World War Two. Granddad was left alone up there in the badlands with nothing but drink to keep him company.

  “The last time my dad saw him was after the war. It was the middle of another bitter-cold winter. Granddad was working on a dam project down south of Bozeman. He was in his fifties by then, living out of a little wooden shell he had built himself on the back of his pickup truck. He was pouring cement all day and drinking two pints of whiskey a night. By then he was coughing so bad he could scarcely smoke a cigarette. So Dad took him up to Missoula to a tuberculosis sanatorium. And Granddad died there of advanced TB: a drunkard's death. Nobody knows where he's buried.”

  I paused.

  “That was my granddad.” I shrugged. “And my mother…”

  I stopped again. The room remained ghostly quiet. I could hear myself breathing. I was afraid of what I was going to say next.

  “Every day,” I said, “every day I go to work and I see my granddad. I see the drunks and the addicts, the people who have fallen right off the edge of the earth. I see people who have made every bad move anyone could make, made every major mistake there was to be made, and by the time I see them, they are paying for it, sometimes with their lives. That's why they came to the ER.

  “When you work in emergency medicine, you are seeing patients who are the least common denominator as far as human beings go; people who are heartbreakingly stupid and ditty and drunk and high and obnoxious—unbelievably obnoxious. These people have all flowed out of the darkest side of life. And when you are finished with them, that's mostly where they'll return. So each of you who is thinking you want to go into emergency medicine will have to ask yourself, ‘Do I really want to do this?’” I tapped my chest. “I know the answer for myself—every day I work I'm taking care of someone who is just like my grandfather, someone just like my mother. But everyone in this room needs to ask himself or herself, ‘Do I want to spend the rest of my life with addicts and idiots and drunks and psychotics? Is this what will make me happy?’ “

  I peered at all of them over the top of the microphone. “Very few sane people answer yes.”

  I passed the microphone on. I had said my piece and made a complete fool of myself to boot. I scanned the faces in front of me. Everyone was staring toward me, but not actually at me, each face with mouth slightly ajar. I had a feeling deep in my bones, a not unpleasant and faintly snobbish feeling, that of all the young students sitting in that room that day, not one would go into emergency medicine.

  B. now sits down next to me, steeples his bloodless hands and picks up his paperback. Next to him on the desk is a thermos-style coffee cup with a drug company logo on its side. There's the reality issue again. I lean forward. “You should put that in your book,” I tell him, pointing. He looks at the cup and then back at me. “You mean…the coffee cup?” I look at him and realize that he isn't my problem. I am my problem. Just as I think this, the trauma bell goes off.

  “I'll take it,” I say, patting him on the back as I stand. Better to keep busy. B. nods, absentmindedly tapping the Dictaphone in his breast pocket. A man without demons.

  I head out toward triage looking for Donna. From the hallway, I can see her sitting at the triage desk, musing over the electronic blood pressure monitor. Digital readout is 123/99.

  “What's coming in?” I ask her as I reach the door.

  “Trauma-wise?” She shrugs. “No idea.”

  “Who took the call?”

  She shrugs again. I lean a little further into the triage room and can now see the patient whose blood pressure she is taking. He is a middle-aged man in a business suit, the suit coat folded carefully on his lap, and he's wearing aluminum foil. He has an aluminum foil hat perched on his immaculately bald head, aluminum foil tents on each shoulder and rings fashioned from aluminum foil on each finger of his right hand.

  “Well, the thing is,” Donna is telling him, “when they talk about safe sex, what they really mean is condoms…”

  I walk on. I don't want to know any more. Another inexplicable patient. Inexplicable. This was the second one tonight. Donna had triaged one just hours before. She told us the story. A man brought in a very pregnant woman, clearly far into active labor. He ran up to the triage window and screamed—panic stricken—“She's gonna have a baby right now.”

  Donna barely looked up.

  “You the father?” she asked him.

  “Of course I'm the father.”

  She pulled out a triage form. “What's the patient's name?”

  He turned to lean over the mother of his child and asked, “Honey, what's your name?”

  Donna gave me the look she gave him: deadpan incredulity. “He didn't know her name,” she said, shaking her head. “Didn't know her name…”

  There was another inexplicable case yesterday, a trauma that did not go well. It was the worst kind of case, tragic and, well, weird. A man of thirty-five came in via EMS—gunshot wound to the abdomen. He had an innocent-appearing injury, a single, small jagged hole in the right lower abdomen from which a small tongue-like piece of fat extruded. The patient was alert and awake, but his blood pressure wasn't so great. As I checked him over, I started my usual trauma history routine.

  “What's your name?”

  …Jamie Something…

  “How old are you, Jamie?”

  “Fifty-two.”

  “You have any medical problems?”

  “No.”

  “Take any medicines?”

  He looked at me. “Yeah.”

  “Yeah, what?”

  “I took a lot of pills.”

  “You took?”

  “Yeah, I took.”

  “Today?”

  “Yeah, today.”

  “What did you take?”

  “Aspirin, man, I took a bottle full of aspirin. Then I drank bleach, you know, bleach for clothes.”

  “Were you trying to hurt yourself?”

  He looked at me, scowling. “I was trying to kill myself.”

  “And then you got shot?”

  “Yeah.”

  I gazed at him, confused. “Did you shoot yourself?”

  He gave me another look. “Are yo
u crazy?” he said. “Why would I shoot myself?”

  I opened my mouth, closed it and opened it again. I was trying to figure out what to ask him when Donna said, “Oh boy, guys. We're losing his pressure here.”

  There it was: 62/40. While we were chitchatting, the patient was drifting away.

  “I got a bad feeling,” Donna said as she prepared a second line.

  The patient's words echoed in my head. “…aspirin, man, I took a bottle full of aspirin.” I had that same bad feeling. This guy was going to die

  I put a central line in, put down an NG tube to wash out the aspirin, started blood, clotting factors, everything. The surgical team arrived, took one look at the patient and whisked him immediately (stat!) to surgery. There they found that the bullet had transected the right iliac artery, one of the twinned vessels that reaches down to supply the legs. Also there were by now several liters of blood in his gut. All this was fixable; what he needed was blood transfusions and a vascular repair. But even with transfusions at maximum volume, he remained severely hypotensive—and even after an uneventful vascular reanastomosis and a quick closure, he was just barely hanging in there. And then he, quite undramatically, faded away—died—the next day, at noon, twenty-three hours after he arrived. Everyone knew what he died of: diseases with lots of initials (ARDS, DIC, ASA OD) but no one I talked to had any idea how a man who wanted to kill himself with an overdose of aspirin somehow came to be shot by somebody else.

  And so it always goes, the life of a doctor—stories, stories, stories. Some that end in a great denouement and a life saved. Others that fade to nothing or fade to death. And each story takes place in a setting of complex banality—the ER with the triage desk littered with coffee cups and streaks of dried blood, the dingy linoleum floors, the posters: YOU HAVE THE RIGHT TO A SCREENING EXAM and SEATBELTS SAVE LIVES. The zombie paramedics, surly nurses smoking out in the well light of the ambulance bay, breath smoky from the cold alone.

  While I was thinking this, I had walked out through the wheezing automatic doors, and now I stood in the well of the ambulance bay, looking out into the night. In the distance a siren began to wail. Was this the trauma victim coming to us this soon? I should be inside, I tell myself, starting to get the intubation equipment set up. But still I linger here, staring up at the night sky, listening to the siren. I hear it now as I heard it when I was young, before I became a doctor, back when that sound always stood for the lonely city, empty streets at three A.M., rain, lost luck and the end of the line. Plus an echo of something more haunting; an echo of the long-ago sound of a freight train, a sound that spoke of other places, lives better spent and long, inexorable travels into darkness and night.

  The siren passes. It's not for us.

  One of the security guards now comes ambling down the driveway. He sees me, holds his arms up and out, leaning back to address the sky. “What are we doing inside on a beautiful night like this?” he shouts.

  “Oh, you know,” I shout up at him in return. “The usual. Saving lives. All that.”

  The doors wheeze open and Tony, the other security guard on tonight, leans out. “Trauma coming in,” he tells us.

  “Yeah, okay,” I say. “I'm aware.”

  “Well, they're waiting for you in trauma. Nudge, nudge, wink, wink.”

  I sigh and trudge back through the electronic doors, away from the night and into the blue fluorescent light.

  Donna and Mary Ellen are already in the trauma room. Donna is opening up the medication cart. Mary Ellen is laying out the form for record keeping. Bill, the tech, is doing pushups.

  “Fifty-six,” he says, “fifty-seven, fifty-eight.”

  “Anybody hear anything more?” I ask.

  “EMS called again—they're transporting now,” Donna tells me. “A car hit a pedestrian and then ran into a bridge. They already pronounced the two in the car DOA. They're bringing in the pedestrian.”

  “EMS pronounced people dead in the field?” I ask, puzzled. Usually our EMS transported anything that looked to be alive in the last thirty days.

  “I don't know,” Donna says, leaning casually up against one of the cabinets. “I think they were very clearly dead.”

  We both stand there thinking the same thing, I'm sure: decapitation.

  “Beauty,” Bill says, rising up from the floor and dusting off his hands.

  “So what about the pedestrian?” I ask. I start stripping off my dirty white coat and strapping on a blue plastic gown.

  “Chest trauma is all they said.”

  I hit the intercom with my elbow. “Call upstairs,” I tell Mary at the desk. “See if you can track down Surgery.” Her response is an electronic squawk.

  I move to the head of the bed and run through the intubation equipment. I know these things as if they were a lover's face. The arched endotracheal tube with its deflated balloon cuff. The laryngoscope handle and, as I fit it into place, the laryngoscope blade. I open the blade up to ignite the light at the tip, the intubation “beacon of hope” or “sentinel of disaster.” As I do, I try to ignore the image that always sits in my heart, a well-worn image: that of a box, a plain cardboard box. While I organize the equipment I also mentally do what I am powerless not to do. I open the box and look inside. There they all are, all my failed intubations, every one of those times that, for whatever reason, I couldn't get the big tube down that little hole. Included are the times I couldn't get the tongue out of the way, or the vocal cords were so far anterior I couldn't get to them, or the patient vomited and I couldn't see, or any one of a thousand catastrophes.

  There's a special section of the box devoted to blunt trauma, like what is coming in tonight. Blunt trauma victims are usually the worst kind of patients to intubate. The face can be mangled beyond recognition. Sometimes you're not sure at all where the airway is; you have to follow the bubbles down to their place of origin. What's more, you have to intubate without moving the neck at all, because if the patient has a fracture of the cervical spine and you move the neck, you'll pith him like a frog in some biology experiment. And there it is: lifelong paralysis—that knowledge sits in the box as well.

  There's more stuff in the box. Can't get an airway through the mouth? That's when you need to do a “crike,” a crichothy-roidotomy. To do this, you take a knife and plunge it directly through the soft tissues of the neck and then into the trachea. Follow it with a small plastic tube you use to breathe for the patient. Connect the Ambu bag and there you go. It sounds easy.

  It is not easy.

  I pull on a pair of latex gloves and then slide another pair over them. HIV and AIDS have raised the ante for physicians who do invasive procedures. As everyone knows, any patients we care for could be infected. Years ago in Baltimore, researchers demonstrated that 15 percent of all trauma patients were positive for HIV. It's probably higher now. Ergo: any errant needle stick or mishap with a scalpel could change my life.

  I thought about being with Doctors without Borders in Nigeria, smiling to myself. Perhaps no one put an actual gun to anyone's head, but each person had risked his or her own life in their own way—all that cigarette smoke and not a glove to be had. But then, they saved lives…so many lives.

  Well, I think, as I set up the suction, I could leave all this—the failed intubations and the crikes, the nights, the drunks, the two A.M. train wrecks, the heroin ODs, the long-time shooters who will risk my life as much as they have risked their own. There I could be, harvesting hair sproutlets, Kenny G in the background, assisted by a nurse who would not say, as Donna is saying right now, apropos of something I did not catch, “…and I'm tellin' ya, fuck all of 'em. What the fuck do they know about this?”

  I close my eyes for a moment, and as I do so, I see a hair transplant patient lying in a darkened room—something like a tomb—and me with my blue plastic gown on sitting over him, acting somehow like a Nazi doctor experimenting on bald heads. And the darkness of that room hurts my eyes like bright light.

  I open my eyes again su
ddenly. Now I remember a woman patient I had last week. She was in a bad auto accident—luckily her only injury was a broken ankle—but that ankle had been smashed to smithereens. She would have to go to the OR to have it repaired. She was also an old shooter; she shot heroin IV. I found telltale needle marks, including fresh ones, all up and down her arms and legs. The skin rarely lies.

  And she was pregnant.

  As part of her workup I was going to order an HIV test. The hospital requires that the patient sign a form giving permission for the test. I gave her our form along with a pen advertising some antidepressant to sign it with.

  “I don't want no HIV test,” she said, handing the pen back to me.

  I was taken aback. “Why not?”

  “I don't want to know what it shows.”

  “Honey, we need to know. You're going to surgery.”

  “I don't want to know.”

  “But if you have HIV, there are drugs you need to take. Drugs that can make you live a lot longer.”

  “I told you, I don't want to know.”

  “And there are drugs you can take so your baby won't catch the virus from you.”

  She fixed me with a baleful gaze. “I don't want to know.”

  There it was again, the inexplicable. Just think, I tell myself, I could walk away from her and, in time, even get rid of her memory. That was the most important thing, the memory…

  Other things, too, other memories. An eight-month-old boy had fallen out of bed and suffered a skull fracture. The mother was crying, Dad was stoical, but I couldn't look at either one, couldn't even stand near them. I had to walk away, shaking my head in disgust. That's because when we first got the baby, as we were cutting her little yellow jumpsuit away, we found the child also had a broken arm and large bruises on the legs. No kid gets that from rolling out of bed. It was child abuse and nothing but child abuse.

  We lost the baby's pulse almost immediately on arrival, and after that it was all downhill. She died—officially—about forty minutes later; there was nothing we could do. It was the only time I ever saw Donna cry. I found her sitting out in the ambulance bay, smoking a cigarette, sobbing. “I just can't take this stuff,” she told me as I patted at her shoulder in an inadequate way. “I just never could take stuff like this.”