Copyright © 1996 by Mark Brown
All rights reserved under International and Pan-American Copyright Conventions. Published in the United States by Villard Books, a division of Random House, Inc., New York, and simultaneously in Canada by Random House of Canada Limited, Toronto.
VILLARD BOOKS is a registered trademark of Random House, Inc.
eISBN: 978-0-307-82959-7
v3.1
CONTENTS
Cover
Title Page
Copyright
INTRODUCTION: THE DOORS
Mark Brown, M.D.
PROLOGUE: ON BECOMING A DOCTOR
Jerome R. Hoffman, M.D.
PART I
TRAUMA CENTER
Jerry Balentine, D.O.
ON THIN ICE
Michael I. Greenberg, M.D.
EAVESDROPPING
Bradford L. Walters, M.D.
BOOM
Robert G. Powell, M.D.
THE CHILDREN OF ST. BARNARD’S
Tracey Goessel, M.D.
THE WISH
Gregory David Post, M.D.
EVIDENCE COLLECTION IN THE EMERGENCY ROOM
Keith N. Byler, D.O.
THE UNEXPECTED MIRACLE
Diane Birnbaumer, M.D.
PART II
MAN’S BEST FRIEND
Blaine Houmes, M.D.
GOT MILK?
Susi Vassallo, M.D.
TREASURE HUNT
William Maloney, M.D.
ODE TO A JOHN DOE
Al Lopez, M.D.
EL HOWIE
Thomas Motycka, M.D.
NOT EVER
Philip L. Levin, M.D.
MAKING SENSE
Jerome R. Hoffman, M.D.
CONTINUITY OF CARE
Robert G. Ripley, M.D.
PART III
DO YOUR BEST
Mark Brown, M.D.
LASTING IMPRESSIONS
Susan K. Sucha, M.D.
HARD TO SWALLOW
Randal P. DeFelice, M.D.
PICTURE PERFECT
Name withheld
GOOD FELLOW
Bill Davis, R.N.
PLEASE TAKE A NUMBER
Stephen J. Playe, M.D.
THE DOLL HOUSE
M. C. Culbertson III, M.D.
THE LAST RITES
Jerome R. Hoffman, M.D.
A BLOODY MESS
Lawrence M. Linett, M.D.
IN SEARCH OF THE GOLDEN FALLS COBRA
Paul L. Snodderly, M.D.
THE FIRES OF HELL
Nicholas M. Timm, M.D.
PART IV
JEEPERS, CREEPERS
Peter M. Midgley, M.D.
DAMSEL IN DISTRESS
Brenda Hill, R.N.
LAUNDER YOUR MONEY
Denise Abadie, R.N.
UNSAFE SEX
Denise Abadie, R.N.
THE HUMAN VINEYARD
John Riordan, M.D.
HARD COPY
Name withheld
SHORT TAKES I
Sylvia Sydow, M.D.
CONSTIPATION
David Vilabrera, M.D.
DOCTOR KNOWS BEST
Scott Oslund, M.D.
THE GRAPES OF WRATH
Barbara Nutini, R.N.
THE LONG WAY HOME
George R. Drew, D.O.
COLOSTOMY
Richard A. Oyler, M.D.
YESTERDAY
Michael M. Knott, M.D.
THE SPECIMEN
B. Tomkiw, Jr., M.D.
DO NO HARM
Hugh F. Hill III, M.D.
OUT OF STEP
Kirk V. Dahl, M.D.
PERSEVERANCE
James Dougherty, M.D.
SHORT TAKES II
Kenneth A. Wallace III, M.D.
THEFTPROOF
Chris Pfaendtner, M.D.
REGISTRATION
A. L. Jenkins, M.D.
PART V
Anita Jones, R.N.
NURSING
THE SAVE
THREE BROTHERS
LIFE AFTER DEATH
WHAT MIGHT HAVE BEEN
ID
USO
THANKSGIVING DINNER
TRAUMA
DO EVERYTHING!
FOUR HOURS IN TRIAGE
WHAT AM I DOING HERE?
INTIMATE STRANGER
SCREAMING
OOPS!
LAB TECH
WINTER MORNING TRAUMA
THEY JUST KEEP COMING
PART VI
SPUD
James Augustine, M.D.
DOGGIE-STYLE
Carmen Diaz, R.N.
LIFE AND DEATH
James Weber, D.O.
PISSED OFF
B. Richard Stiles, D.O.
ADOLESCENCE
Gerald O’Malley, D.O.
SOUR GRAPES
Michael Heller, M.D.
GUESS AGAIN
Charles Hagen, M.D.
PLASTIC SURGERY
Donald Graham, M.D.
THE HEALER
Keith N. Byler, D.O.
CPR
Jerome R. Hoffman, M.D.
IN THE FAMILY
Gary M. Flashner, M.D.
ALONE
Robert D. Herr, M.D.
PART VII
TURF
David B. Levy, D.O.
OWL’S WELL
David J. Simon, M.D.
THE ANGEL OF DEATH
Douglas Lindsey, M.D.
SAY WHAT?
Myka Clark, R.N.
SO WHAT ELSE IS NEW?
Brenda Hill, R.N.
BAPTISM
Edward T. Dickinson, M.D.
AT THE MOVIES
James Dougherty, M.D.
A LITTLE PRICK
Michael S. Zbiegien, M.D.
THE PRONOUNCEMENT
William Maloney, M.D.
SHORT TAKES III
Sharon Wise, R.N.
PLAYING CHICKEN
Brent D. Amey, M.D.
PART VIII
BURNING OUT: THE LETTERS OF QUINN
Campion E. Quinn, M.D.
FRANK
Rhoda Goodman, M.D.
PART IX
HARD RAIN
Kent Benedict, M.D.
COMMUNICATING IN THE ER
Rhonda L. Perry, P.A.
DOWN THERE
Michael Ericksen, M.D.
KEEP ON SMILING
John Dente, M.D.
JUST BEING THOROUGH
Marilyn J. Gifford, M.D.
BRIAN’S STORY
Brian Coakley, R.N.
OPEN LETTER TO THE ER STAFF
Dan Caliendo, M.D.
IN MEMORY OF J.W.
Valerie Norton, M.D.
MULTITRAUMA
George L. Higgins III, M.D.
EPILOGUE
THE VOCABULARY OF THE ER
ACKNOWLEDGMENTS
About the Author
INTRODUCTION: THE DOORS
Emergency rooms have no windows. They have doors. The pneumatic type, that open unexpectedly with a hiss. Inside the doors is a family of specially trained people who work, prepare, and wait. They wait to see what the doors will bring. Pain, fear, anguish, irritation, and embarrassment are some of the visitors. They come at any time, with any intensity, in any number. There is no order to their arrival. Those entering all have one thing in common—they need help from the people inside.
The business of the world outside is unseen until a soft hiss announces the arrival of the world’s business gone bad. The doors bring cute kids with splinters right after cute kids covered with blood from gunshot wounds. Basketball players with swollen ankles precede grandmas gasping for breath. Poor people with colds enter with SIDS babies and screaming drunks.
The doors also take people out. Sometimes the people are relieved and comforted. Sometimes they are angry. Sometimes they leave with unknowable grief. Sometimes they leave dead.
The emergency room is a cauldron of human emotions. The anguish, fear, need, and gore is wearing. As the protective layer of the self is weakened, the pain seeps through and begins to stain the soul. The protective layer grows thicker. But the patients’ needs call out to a sensitive heart, and a balance is struck. Survival in this place requires a deep kindness nestled in a very dark sense of humor, and a strong faith tempered with cynicism. The people who work in this place refer to it as the Pit.
What follows is a collection of true stories from all over the country about what the ER doors bring. These stories are irreverent, funny, horrifying, and heartbreaking. They will buffet you.
These stories are presented randomly, not neatly categorized as one might desire but in the disorderly manner in which the doors might bring them. They are written not by writers and reporters but in the words of the doctors, nurses, and paramedics who were there.
I hope these true stories give you an appreciation of what goes on behind the doors.
MARK BROWN, M.D.
Malibu, California
PROLOGUE:
ON BECOMING A DOCTOR
I might never have become a doctor but for a visit I made to my brother more than twenty-five years ago. He was a medical intern in Madison, Wisconsin, and I, well, I wasn’t much of anything. I was getting ready to quit my job with The New York Times, and had no idea what to do with the rest of my life. I really wanted to be a writer, but in some fundamental way I knew I wasn’t yet ready to write: I hadn’t lived enough, or experienced enough, to have anything important to say.
As the intern in the ER (all of about one month out of medical school), Robert was the only doctor in the department. He could, of course, call for help (but only if he were willing to admit he was such a wimp as to need any). His supervising resident (all of one year his senior) was nearby in the ICU.
I went to the hospital about midnight, when things were expected to be quiet and Rob could show me around. Until about 4 A.M. there were almost no patients to be seen, and I enjoyed the chance to schmooze with my brother. I was well ready to go back to his apartment and get some sleep, though, when a patient in his forties came in by ambulance. I have no idea today what was wrong with this man, but I remember with absolute clarity what transpired in the early hours of that morning.
The man apparently had some sort of reversible lung disease, which was manifested by frequent life-threatening acute episodes, each of which, however, resolved quickly with simple medical therapy. The problem was that during the episodes he often needed to be intubated (a tube passed down into his windpipe) and placed on a ventilator. Once that was accomplished, everything would improve, and he could be sent home within a few days. The underlying condition, whatever it was, was expected to resolve gradually over a year or two, leaving this otherwise completely healthy man free to lead a long and normal life.
Standing by the cubicle in which the man was placed, I could see that he was having great difficulty breathing. I watched as my brother, after wasting very little time on a physical examination, attempted to pass the tube through his nose and into his airway. I understood this would be no easy feat for my brother, who had done it only once or twice before. I also understood that if he succeeded the man would be absolutely fine, while if he failed the man would die.
The few minutes during which Robert made his couple of attempts passed very slowly, and the man seemed to be getting worse. When the resident was called he raced past me into the room, his face almost as white as my brother’s. I saw him motion toward me and ask, “Is that the son?” He was obviously relieved to find out that I wasn’t.
The resident was also unable to pass the tube, the man kept turning bluer, and I could almost palpate the anxiety of my brother and his colleague. After briefly considering whether there might be any other (more manly) alternatives, they decided to wake the anesthesiologist on call, and I heard Robert quickly explain the situation over the phone. She was at home, “only” a few minutes away, but though she evidently responded at first, the line soon became silent, as if she had fallen back asleep. There was no way to reach her again, since she hadn’t hung up the phone.
While Rob and the resident agonized, the patient was suffocating and beginning to lose consciousness. As for me, I felt strangely separate, as though I were an observer of something bigger than just ordinary life. Perhaps this should be a Bergman film, I kept thinking, where the appropriate ending, whether tragic or happy, would help us understand something profound, or move us to tears. But who was writing this script, and with what moral?
Suddenly the anesthesiologist dashed into the room, apologized for having momentarily dozed off, and in one motion intubated the patient. And then, almost as quickly as she’d arrived, she was gone. (Who was that masked woman?)
In an instant, with the touch of her hand, everything had changed. The patient rapidly awoke, Rob and his resident congratulated themselves on their escape from this near disaster, and I was left to ponder: life, death, careers.
It seemed such a good thing to do, this medicine. If you just mastered the skills, you could save people’s lives. No muss or fuss, no deep thoughts, no complexities, subtleties, or ambiguities. Just the act of cheating death, assuming, of course, that you could do it right. Which would only require training and diligence, neither of which seemed any real obstacle at all.
Perhaps if I had known then what I know now: that physicians rarely save (really save) even a single life. That it is almost impossible to be competent, no less masterful, given the complexity of what we do. That we routinely fail despite our best efforts. That almost all our decisions are shrouded in uncertainty. That even our most perfunctory acts are troubled by extraordinary moral questions. Perhaps if I had known, I would not be writing this now.
But I didn’t. And twenty-five years of medicine have given me enough experience to fill too many books. Nowhere else could I have dreamed up such a gold mine of life at its most naked—the tragedy and the comedy, the outrageous and the banal, the grace and the anguish, the courage and the terror, and even, occassionally, the joy. It’s all there to borrow, if I should ever decide to become a writer after all.
JEROME R. HOFFMAN, M.D.
Los Angeles, California
PART
ONE
When I was a medical student at Dartmouth, a young man was brought in whose heart had stopped following a high-impact collision. I watched as the trauma surgeon “cracked” his chest by slicing a smile-shaped gash between the ribs on the left, then prying the chest open with a mechanical rib spreader that works like a car jack. The ribs popped as they were jacked apart. Within sixty seconds of starting, the surgeon had his hands inside the chest cavity, feeling for blood and massaging the heart. The young man died, but I was dazzled at this surgeon’s skill.
I saw him later in the doctors’ changing room. “It must be hard to learn to do that so fast and effortlessly,” I said admiringly.
He looked at me sadly for a moment, and then said, “Opening the chest is the easy part. Telling the parents is the hard part.”
TRAUMA CENTER
Friday night in the South Bronx. It’s the middle of summer and the beginning of my twelve-hour night shift in the Emergency Department of a level one trauma center. The day had been warm, and I knew this
would mean a busy night for major trauma. Warm days had everyone out on the streets. Mix this with the alcohol, drugs, and handguns in the community and you’ve got a violent combination.
The action began with a bang: A young man shot in the chest over an argument about drugs was taken to the operating room. A husband and wife who had stabbed each other followed; he was moved into the backup trauma room for observation of a superficial chest injury, while she had to go to the operating room for her abdominal stab wound. The trauma room was just cleared when we were called by paramedics bringing in a Hispanic male with a gunshot wound to his head. Another drug deal gone bad, I thought, and we began to set up for his arrival.
The paramedics moved his motionless body onto our trauma gurney. There was no spontaneous breathing or movement. He was already on a ventilator, and IVs were in place. The bullet had entered his head on the right side, just above the ear, and exited on the opposite side in nearly the same location. We monitored his blood pressure and heart rate. There wasn’t much else to do.
The neurosurgical resident and I agreed we should get a CT scan of his head for completeness and then call the organ transplant team.
I left the trauma room and was writing up his chart when security informed me that the young man’s family had arrived. I never get accustomed to breaking the bad news to families, but, after doing it so many times, I didn’t even hesitate and headed for the small waiting room at the end of the hall. I entered the room and was surprised to find only one middle-aged man quietly sitting on the bench.
I shook his hand as we introduced ourselves. I told him I had bad news and explained the injury and the poor prognosis. After a brief pause, I asked him if he would like to see his son. He nodded, eyes closed, and said, “Take me to Louis.”
We entered the trauma room where Louis was covered to mid-chest with a white sheet. After closing the door to the noise of the Emergency Department, the trauma room became quiet. The stillness was interrupted only by the steady swish of the respirator and the quiet beeping of the cardiac monitor. I left the room to give Mr. Ramirez time alone with his son.
Outside, I quickly sutured a patient with a scalp laceration and checked a sore throat before returning to the trauma room to bring up the question of organ donation. As I entered the room, Mr. Ramirez was kissing Louis on the forehead. He slowly turned to me and I could see the moisture in his eyes.
“Doctor,” he said with a thick accent, “did you hear how this happened?”
Emergency! Page 1