THE UNEXPECTED MIRACLE
It’s the usual Friday night scene in a county hospital Emergency Department. All that remains of another drive-by shooting victim is splotches of blood on my shoes. A swearing, spitting drug abuser is held down by security guards while being placed in four-point restraint. Quiet crying comes from behind the curtain hiding a woman who has painful gallstones. A young AIDS patient stares hauntingly from sunken eyes, his gaunt face distorted by the purple blotches of Kaposi’s sarcoma. Three patients with their EMT entourage lie on gurneys by the door, like planes waiting to land, vainly hoping for an empty bed. All around the room are the sullen, resigned faces of those who have waited up to twenty-four hours to be seen for their sore throats or sprained ankles. The stench of an unwashed homeless man in the corner, ravenously consuming a brown-bag hospital-issue lunch, permeates the atmosphere. Walls display reminders of the season: cardboard candy canes, blinking minilights, and grinning Santas bearing sacks of gifts, the likes of which no patient in this department will see.
In the midst of the chaos, I hear the manic chatter of a giddily cheerful middle-aged woman. She greets everyone in passing with a jolly “Merry Christmas” and an endless stream of meandering conversation. She is in the Emergency Department for a chronic infection in her lower legs. While I examine her, she talks on about living on the streets, peppering her narrative with references to life before homelessness. Her eyes take on a sparkle as she describes her prior home: two stories, five bedrooms, three-car garage. Her unwashed hair falls in clumps across her forehead as she proudly speaks of three successful sons. She describes her husband, a prosperous banker, handsome as a movie star. A shadow crosses her face when the nurse asks where her husband and sons are now. After a pause, she ignores the question and continues her chronicle.
Her lofty tales extend to her own life. She boasts of being a Juilliard scholar, of playing violin in New York City’s philharmonic. Her hands wave grandly as she describes standing ovations, velvet curtains, black satin dresses, and postperformance parties. We humor her with tolerant smiles and give one another knowing glances. As she is wheeled from the room, she beams magnificently and promises to come back to play her violin for us. We nod patronizingly, then forget as we turn to yet another patient in need.
A week later, the scene is the same. More sullen faces, another psychotic patient screaming incessantly, more shooting victims, more pain, more endless need. Patients and staff alike are stretched to the limits of tolerance. Doctors snap at clerks, patients swear at nurses. A general murmur of discontent pervades. I feel pulled in all directions at once, working as fast as I can while falling more and more behind.
No one notices her come into the room. No one notices her take the rolling stool and position herself in a doorway. No one notices her take out the violin, place the cloth to her chin, and rest her cheek gently against the instrument. No one notices her raise her right arm and carefully place the bow to the strings.
The first pure, sweet notes drift softly into the confusion, taking everyone by surprise. Out of her violin flows phrase after phrase of perfect sound. Her musical repertoire is as disjointed as her conversation: a bit of Bach, a few show tunes, a little Gershwin, Mozart interspersed with carols of the season. Her technique reflects the Juilliard years. Her face is composed, peaceful, almost beautiful. I wonder if her mind is in another time, a time of black satin dresses, handsome husbands, and loving sons.
Her concert lasts four continuous hours, no musical phrase ever repeating itself. The first person affected is the psychotic man. He becomes quiet, pauses to hear her music. Patients waiting in chairs listen intently. When their conversations resume, frowns are eased and they chat amiably in hushed voices. Two patients stop weeping, their attention drawn to the music. The staff members slow their pace a fraction, and smiles replace the angry tension in their faces. I find myself humming snatches of music I recognize. A calmness settles on the Emergency Department, muting the continuing bustle. Peaceful feelings of the holiday blossom and, for four hours, tranquillity reigns.
The last note hangs in the air as she lowers her arms and looks around the room. She blushes, startled out of her reverie by the faces focused on her, and carefully places the violin back in its case. She stands slowly, shuffles over to me on her painful, swollen legs, and murmurs, “I just wanted to thank you.” Having worked her magic, she departs quietly, leaving me in awe of the unexpected beauty and dignity of life.
DIANE BIRNBAUMER, M.D.
Lomita, California
PART
TWO
When I was an intern at San Francisco General, a bag lady came in saying she was falling down on occasion. Since she was in her sixties, we worried about heart problems or transient strokes. She reported no other medical problems or symptoms.
We helped her undress, which took time because she was a mummy of clothing layers interspersed with layers of newspaper. When we got down to the last layer and uncovered her leg, it was alive with thousands of maggots wriggling in what was left of her flesh.
I felt a visceral stun. There was a moment where my brain could not absorb the information my eyes were sending to it. It had to make some adjustment before moving on.
I think of this now as I watch a coworker bite a doughnut while working on a mutilated trauma victim, and I wonder if as the bizarre becomes commonplace there is a hidden cost to the self.
MAN’S BEST FRIEND
On a clear, crisp Sunday morning in late June, we were ready to end our shift in the trauma unit. The call schedule at Cook County Hospital runs twenty-four hours, but the summer months seem to tug and pull until they blur into a long stretch of gunshot wounds, broken bones, and assaults.
We were waiting for the morning report when the call came in: A stab wound was coming up the elevator to the trauma suite. The door crashed open and the paramedics stood there with a bloody mound of angry sheets twisting on their cot. They rolled into the room, followed by police, ambulance attendants, and hospital staff. They huddled around the cot and, with shouts and awkward laughter, heaved the body over on to the trauma cart.
It was a drunk.
He was out of it and could barely answer questions. His vitals were stable, but even now there was a fine spray of blood and fluid arcing up and out of him.
He had no penis.
He lived alone in a rooming house with a ratty little poodle. He had a history of both alcoholism and depression. The night before, he had gotten drunk and gone to the kitchen in search of a knife. He found one, a big carving knife, and used it to saw off his penis and testicles. Then he staggered in to the bathroom, trailing blood and urine along the way, and ran the blade into the bathroom wall through a photo of his mother.
He reeked of stool and urine and beer. He was in his mid-fifties but looked ten years older. His hair was caked off to one side with grime, and a thick stubble erupted around a mouth of peglike teeth. He kept trying to say his name but could only manage a whispered slur. He denied any pain or injury. The bleeding was stopped with pressure, and the urologist was called to the ER. After examination, he thought surgical reattachment might be successful, depending on the condition of the genitals.
The paramedics had not brought in the body parts, so the police were dispatched to recover them.
An officer soon returned. Somewhat out of breath, he began his report:
“In twenty years on the force, I’ve never seen nothing like this. The apartment was filled with stench and garbage. The little mutt was yappin’ and runnin’ around and bitin’ at our ankles. Blood and urine was everywhere: on the floor, on the walls, on the kitchen table. But nowhere could we find the guy’s pecker. All of a sudden I hear this gagging sound and I look over in the corner and this little mutt is choking up the guy’s pecker. The dog had eaten it.”
To prove it, he held up a McDonald’s sandwich bag and took out a shredded penis and scrotum, testicles bobbing like yo-yos, chewed up and covered with saliva and hair.
No one knows what happened to little Fifi.
BLAINE HOUMES, M.D.
Cedar Rapids, Iowa
GOT MILK?
I was working in the trauma area of Detroit Receiving Hospital. I was a third-year emergency medicine resident. A young black woman was sitting quietly on the stretcher, waiting to be seen.
“Hi, I’m Dr. Vassallo. What’s the problem tonight?”
“I’ve been shot in the head.” She said it matter-of-factly, indifferently.
“You look good for having been shot in the head,” I said.
“I’ve been shot in the head,” she said again. This time she elaborated nonchalantly: “I was on my way to Kentucky Fried Chicken and somebody shot me in the head.”
“Where are you shot?” I asked. She pointed to a spot on the back of her head. I touched it with my finger and felt an almost imperceptible laceration through her thick hair.
“OK, we’ll get an X ray and see,” I said.
I returned a little later. “You’re lucky,” I said. “You have been shot in the head. The bullet is flat like a pancake against the bone of the skull. But it didn’t go in or even crack your skull.” I reported this enthusiastically.
“I drink a lot of milk,” she said.
At that moment her friends joined her at the bedside. They had all been together when the whole thing occurred. Hoping to get a reaction, I announced that their friend had been shot in the head and it was a wonder she hadn’t been injured.
“We know she was shot in the head. That’s why we brought her here,” they said. “It’s her birthday today.”
With everything explained, they went home.
SUSI VASSALLO, M.D.
New York, New York
TREASURE HUNT
A morbidly obese woman was brought to the Emergency Department for shortness of breath on a tarp dragged by six firemen. After positioning two gurneys side by side, we somehow managed to lift her up. She was in respiratory failure due to her weight, which we estimated to be approximately five hundred pounds.
Attempting to undress her, we lifted her arms up to pull her very large blouse over her head. To our surprise, an asthma inhaler fell out from under her right armpit. It had been enveloped in the skin.
Reviewing her chest X ray, we noticed a round density in the left chest. With the help of an assistant, we lifted up her massive left breast to find a shiny dime. No telling how long it had been there.
Finally, a nurse and two technicians attempted to place a Foley catheter in her bladder. After spreading apart one tree-trunk leg at a time, they found a handful of industrial paper towels, apparently being used as a sanitary napkin. But they also found an even bigger surprise in her crotch—a TV remote control.
When I gave a report about the patient to the unhappy admitting physician, I tried to cheer him up by reminding him that if he did a thorough exam, he too could find buried treasure. We nicknamed our patient The Human Couch.
The patient’s family was very happy that we found the remote.
WILLIAM MALONEY, M.D.
Evanston, Illinois
ODE TO A JOHN DOE
An old man walked out the front door of his house on a lazy, sunny Sunday afternoon, looked back at his wife, and said, “Ahorita regreso, mi vieja. Voy a traerte tu comida favorita.” (“I’ll be back in a minute, honey. I’ll get you your favorite food.”) He started down the street to their favorite seafood restaurant. The warm sun felt good on his face. His arthritis was not hurting him and he had not been to the hospital for chest pains in six months. He was eighty-seven and thoughtful about his health.
As he reached the busy intersection, the first car stopped for him and he took it as a signal to walk across the street. After several steps he looked again to check on the car in the next lane. As he turned his head, the thud of car hitting human was heard—the muffled sound of bones giving way as the car struck him and sent him through the air.
That same afternoon, I was entertaining friends at home. As we began eating, my phone rang. It was Lourdes, a nurse from the ER where I work.
“Doctor Lopez, sorry to disturb you but your aunt is here looking for your grandfather. He went out for food over two hours ago and has not returned. When your aunt went to the restaurant she heard that an old man had been in accident and she came here. He’s not here, but I heard that a traumatic full arrest was taken to L.A. County Hospital.” A tingling came over me. As I thanked her and hung up the phone, I felt the strange weight of death.
“What’s wrong?” asked my friend Jorge.
“My grandfather is missing. He may have been involved in an accident. There is a John Doe at L.A. County. It could be him. I’m sorry, but I have to go.”
Jorge drove me to the hospital. On our way there, I talked to him about Grandpa. He had come here at the age of ten with his mother and father. By seventeen he had begun working for Sunkist, and he stayed with them until he retired as a plant supervisor at sixty-five. He met my grandmother when they were youngsters working in the fields. Her father would not let him marry her until he had saved eight hundred dollars. They had children, grandchildren, and great grandchildren. When I was admitted to medical school, he gave me tuition money from his savings. When I told him I would pay him back, he waved me off and said, “You will pay me back when you do the same for your children.”
When we arrived at the Emergency Department, I introduced myself to the chief resident there, who told me about the John Doe as she walked me to the trauma room. “Elderly Hispanic male in traumatic full arrest with massive head injuries, multiple lower extremity and rib fractures. We got back a blood pressure but it’s shaky. Right now he’s comatose, has a blood pressure of sixty, two large-bore needles going full speed, two chest tubes, and a clean abdominal tap.”
As we walked into the room, my eyes scanned the bruised, splinted, swollen legs and the exposed chest full of tubes and wires, still hoping that it might not be Grandpa. I looked up to see the face. The intubated, swollen, bloodied head with scant grayish hair took seconds to come into focus. I knew that this mangled John Doe was my grandfather. The resident’s voice became distant, and all I could hear were the rhythmic noise of the respirator, the beeps of the monitor, the shuffling sounds of people around him.
My voice was tight as I talked to the resident and the attending physician.
“I am afraid you have been much too skilled for my grandfather’s good. You have done a wonderful job, but if he goes into another cardiac arrest, please let him go. He is eighty-seven years old and has had a good life.”
Grandpa died a few minutes later.
I thanked the doctors and went to call my family. When I came back to see Grandpa, his body had been covered with a white sheet and moved aside. In his place there was another full arrest being worked on. John Doe number one was making way for John Doe number two.
I did not want my family to see him here and in this way. I wanted a place of quiet and privacy for this final meeting.
I asked the charge nurse if she could help. She told me how sorry she was and gave me a hug. Then she found an empty booth where my family could view Grandpa with some privacy. She helped me clean his bloody, battered body. She also called in a priest to give him the last rites. After seeing a thousand shattered families, she could still care.
When Grandma arrived, she asked me, “Cómo está mi esposo?” (“How is my husband?”) I told her with a hoarse, whispering voice: “Lo atropelló un carro y se murió, Abuelita.” (“A car ran him over and killed him, Grandma.”) Her wrinkled face aged even more and she let out a long, sorrowful cry. I led her down to the booth where Grandpa’s body was waiting. She touched his face and said, “Esta muy frío.” (“He’s very cold
.”) She was crying and kissed him. I lost my composure and hugged my mother and grandmother as we cried and cried. It was an emotional catharsis that as a doctor I never allow myself. In this grief I was able to retrieve some of the feeling that I had become insulated from in the role of physician.
A priest came and gathered the family for prayers. A visible sense of calm came into Grandma’s face as we prayed together. After a short while, we took her home and made all the preparations to retrieve Grandpa’s body. A few days later, hundreds of people came to remember him, and the line of cars that accompanied the funeral procession stretched for several blocks.
When I look back at this painful experience, one thing stands out. I will always remember the nurse who helped me start the painful process of grieving. Her kindness helped remind me to reach out from my heart to the survivors of the dead. I will always remember that a John Doe is somebody’s father, brother, or grandfather. Even my own.
AL LOPEZ, M.D.
Los Angeles, California
EL HOWIE
I was a fourth-year medical student rotating through an academic Emergency Department in the southwestern United States. There was a first-year resident, Howie, from the Midwest, who was struggling to learn Spanish. Spanish did not come easily to him, but that didn’t stop him from attempting to communicate with Spanish-speaking patients. Howie was one who believed that any lack of skill could be masked by a loud, authoritative voice.
One lazy Saturday afternoon, a car drove up to the Emergency entrance. A young man ran into the Emergency Department screaming, in Spanish, that his wife was having a baby. Also in the car were several soon-to-be grandparents. Howie, hoping for a delivery, ran to the car and found the head of the baby beginning to show. He positioned himself between the mother’s legs, among a sea of grandparents, and urged her to push by yelling, “Puta! Puta! Puta!” The grandmother began to cry and the husband needed to be restrained.
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