It took her four days. She had tried begging, stealing, and selling herself. She had been beaten twice; once by a territorial prostitute and once by a man demanding a refund when she choked. Finally, a kind soul had befriended her and bought her a bus ticket to Moses Lake. She cashed the ticket in. Over the next several months the cycle was repeated. The bus ticket scam became more polished. The beatings and demands for money became more frequent.
“Sometimes I wish I’d’ve just taken that first ticket and gone back to Moses Lake,” was her lament.
“Why don’t you go now?”
“I’ve been a whore and lived with a drug dealer. My parents would never take me back. They’d kill me.”
“If you don’t leave, he’ll kill you.”
Much to the consternation of the other diner patrons, I removed the sutures with my Swiss army knife. We left just as the waitress was about to request our exit. I bought Christine a ticket to Moses Lake with my Visa card and handed it to her as we parted. She asked for my address, so she could send my money back. I chuckled and scribbled the address on the ticket envelope. “Just send me a postcard from Moses Lake telling me you’re back in school and the bruises are healing.”
“I don’t think they’ll ever heal.”
“You never know,” I said as I took my fish and walked off.
I finish the story for the interviewer by telling him of a Christmas card I received from Christine. “She’s back in school at Moses Lake, and she thinks she may still graduate with her class this spring. She tells me she wants to go to college and study to be a lawyer.” I smile and pause at the irony. “Anyone who can lie like she can ought to be a damn good lawyer,” I say.
Actually, the story ended a few days after the bus station.
The paramedics came in, all lights and sirens, with a stabbing victim. As part of the on-call surgery team, I was back in the ER. My job was to get blood from the femoral vessels and then assist another student with the Foley catheter.
There was a medic kneeling astride the patient performing chest compressions as they rolled into the trauma room. The patient had three stab wounds to the neck and upper chest. “We lost pulses three minutes out,” he gasped.
“Get the chest tray open!”
“Do we have a line? Start the O negative.”
“Give another milligram of epi.”
I managed to get some dark blood from the groin. It became a pointless exercise. The residents had opened the left chest and were desperately trying to stop the blood loss. The attending surgeons gathered around and looked in. A sternotomy was discussed. A shunt of the lacerated carotid was attempted, but there was no blood flow. Shortly before they called it off, the chief resident grabbed my hands and stuck them inside the warm chest cavity. With his hands surrounding mine he demonstrated open cardiac compression on the lifeless heart.
It was not until the room had emptied, leaving me and another student to sew up the thoracotomy, that I noticed the houndstooth overcoat in the pile of clothes, and then the scar on her face. I heard ringing. Sweat beaded up on my brow and the walls closed in.
I was sitting outside on the stairs when the intern found me. There was a light sheen of drizzle on the pavement. “That was that girl you sewed up in the ER the other night, wasn’t it?”
“Yeah.”
“The cut healed up real nice.”
“Yeah.”
“Sometimes you have to go for the little victories.”
As for the question “Why emergency medicine?” some days I’m not sure. It’s just what I do.
ROBERT G. RIPLEY, M.D.
Anchorage, Alaska
PART
THREE
After my internship, I read Samuel Shem’s book The House of God, about internship. One of the laws the interns were taught was “The patient is the one with the disease.” I didn’t yet know what that meant.
On my first night ever as a full-fledged doctor on duty, I was the only doctor in a small hospital. It was very quiet and I had plenty of time to sleep, but I stayed awake all night, terrified that I might be called Code Blue to resuscitate some patient who went into cardiac arrest. Toward dawn, I began to question why I was so scared. I wasn’t going to have a cardiac arrest. I wasn’t even sick. I was fine. The patient is the one with the disease. I felt reassured with that and was able to get a couple hours of sleep.
DO YOUR BEST
It’s 1984. I am a newly trained doctor. I work in a small urgent-care facility contained within a trailer twenty miles from the nearest hospital in a small suburb comprising relatively rich people who subsidize its existence. The trailer clinic has a staff of three: a young man who takes X rays, puts on splints, and cleans the floor; a young woman who is nurse, receptionist, and billing clerk; and me, the doctor. Minor medical problems are our specialty.
This evening, one of the smattering of neighborhood movie stars drops by because he is feeling skipped heartbeats. I evaluate his symptoms and check his heart rhythm. All appears normal, but we keep him on the cardiac monitor for a while.
An attractive young couple arrives, dressed for a night on the town. She is having an asthma attack. She has fear in her eyes—not a good sign. I give breathing treatments. She doesn’t improve. I give intravenous drugs. She gets worse. Panic slides over her like a shadow. She can’t get enough oxygen. She begins to lose consciousness. Now I’m scared. The staff is scared. Even the movie star is scared. The patient’s husband is sweating, screaming, “She’s dying! Do something!”
We lay her back on the gurney. She’s combative, pushing us away. She’s delirious, fighting. From two feet away the husband keeps screaming at me, “She’s dying! Do something!” Over and over. “She’s dying! Do something!” Then she stops breathing. Do something! I need to intubate her.
Intubation is a procedure requiring skill. I’ve done it many times. It is performed standing at the head of a patient who is lying on her back. A blade is used to push the tongue to the side while the jaw is lifted until the vocal cords are visible. Then a tube is slipped between the cords and into the trachea, allowing air to be forced into the lungs with a bag. Sounds simple, right? But often the cords are difficult to see. The patient may be gagging and thrashing, and the cords can be obscured by vomit or blood. Intubation, which can be a life-saving procedure for a patient who has stopped breathing, needs to be done right now and done right. It is used in an extreme emergency. Like this.
The woman continues thrashing. My two assistants are holding her down. The husband continues screaming at me. The blade and the tube are in my hands.
In an instant, I recall all the times during my training when I’ve intubated old people whose hearts have stopped and who are no longer breathing. I think of the dead and the near dead who have undergone intubation at my hands as part of that last dance of resuscitation. All the Code Blues. Full arrests. Although it seemed urgent at the time, I now realize that all those intubations were just practice for this moment. I must now do this procedure right or she will die. I also note how badly I have to pee. I think, This is why people wet their pants when they’re scared.
The screams grow distant. The room fades away. Events slow. There is just me, the blade, the tube, her throat.
I flash on an image from college. A dog caught a squirrel and crushed its chest. A bunch of us watched as the squirrel lay gasping, dying. An anguished young woman yelled at us: “Do something!” Do what? I thought. We’re just kids. I am now called back to that moment. Do something! Now I’m a doctor but I still feel like a kid. I wish a grown-up would arrive and take over.
The tube slides in easily. I squirt medication directly into her lungs and ventilate her with a bag. She begins to improve. Her husband stops screaming and clutches her hand.
The movie star has been watching from his monitored bed. He is the only one without a job to do. I ask if he would please call 911, which he does. He must wonder about his own safety, having just been asked by his doctor to call 911. The ambul
ance arrives, and the woman and I ride to the hospital. She is much better now, awake and calm. She’ll do fine.
As I drive home that night, I’m depressed. I wonder why I’m not elated. I just saved a life. I had prepared for this moment for years and tonight it all came together. I should be elated, but I am not. I am depleted. Drained. I realize why.
I never want to be that scared again as long as I live.
MARK BROWN, M.D.
Malibu, California
LASTING IMPRESSIONS
It was, as Saturday afternoons go, fairly typical. Busy but in control. I barely noticed as one of the local paramedic units rolled in with a healthy-looking young man, his knee propped on a pillow, his mother close behind. Within a few minutes, one of the nurses requested that I see him because he was in quite a bit of pain. Obligingly, I went to his room. David was a handsome, athletic high school kid. In spite of his discomfort, he stoically explained that during an afternoon game of pickup basketball he felt his knee go out of joint. Indeed, he did appear to have an obvious dislocation of his patella.
I approached him with confidence and enthusiasm. After all, his problem was simple and straightforward. “We’ll give you a little something for pain, and after a screening X ray of your knee, I’ll just pop it right back in place,” I informed him. My reassurances were met with a look of skepticism and panic. His mother, standing by the bedside, frankly and calmly informed me that she was a nurse. She asked if I would consider performing the treatment under conscious sedation, a short-acting anesthetic that would place her son in a tranquil, comfortable state during which he would be undisturbed by the minor procedure.
At this point in my career I had had limited experience with conscious sedation. As I was of petite, feminine stature, I decided that anything which would assist my finesse would be an asset and agreed to Mom’s request. Following a discussion of the pros and cons, and after obtaining consent and administering a generous dose of narcotic, the nurse and I began to prepare for the procedure.
Within twenty minutes we were poised and ready. IV, monitor, and pulse oximetry were all in place. The anesthetic was given and we waited for him to settle into twilight. In about five minutes he seemed appropriately out. The nurse and I quietly moved into place. My plan was simple enough: Remove the pillows; extend the leg and simultaneously apply pressure to the lateral side of the patella. Presto—patellar reduction!
I quietly spoke some reassuring words to David as I began to lift his leg and cradle it in my arms. Suddenly his placid demeanor was replaced by moaning. Low and plaintive at first, his moans soon changed character. The tempo accelerated and the volume began to crescendo.
Criminy, I thought, I haven’t even removed the pillows yet. I braced myself and continued.
“Mmmmmm. OH! Ohhhhhh! OOOOOHHHHHHH! OH! OH! OH!”
I felt a little flushed and looked up at his mother. “I know this all sounds quite awful, but David really can’t feel much and he won’t remember anything after we’re finished,” I assured her. She nodded quietly. Determined to get on with it, I slowly and purposefully resumed the procedure. This time my efforts were met with more animation and louder vocalizations. One could not help but notice that they were beginning to take on the distinct tone and cadence of the soundtrack from a pornographic movie. I glanced across the bed at the nurse. She had the pained expression of someone straining to maintain professional composure.
“OOOOOhhhhhh … OH! OOOOWWWWWW! OH! OH! OH!” By now he was sitting straight up on the gurney, eyes wide open, howling wildly. “Oooooooh. Oooooow! Oh, God! Oh, God! OH! OH! OH!” As squeamish as I am about causing pain for my patients, I was becoming even more uncomfortable with the scene being created, and I was acutely aware of turning a deeper shade of red. As his bleating continued, I felt perspiration forming on my upper lip and brow. I was grateful to feel the patella suddenly settle into its proper position.
“Wh-Wh-WOW!” he shouted, then dropped back onto the pillow. For a moment he lay there quietly, eyes half closed, with a peaceful countenance. Then, slowly, he opened his eyes and met my gaze as a lazy grin spread across his face. “Got a cigarette?” he asked in a loud baritone voice.
My blush was now complete. I was sweating and my hair was tousled. I allowed an embarrassed chuckle to escape and turned to his mother. She stood with arms crossed, gazing at the ceiling, her foot tapping in nervous agitation.
Sensing her discomfort, I decided to exit. I slid open the exam room door and looked out at the nurses’ station. My gaze was met by a gallery of slightly open-mouthed faces quietly staring at our room. Slowly the stares gave way to contorted smirks and grins. I glanced around the department. From nearly every exam room door there peered a curious head. I drew a deep breath and strode with pseudo-confidence to the nurses’ station. “I guess they think we run a full-service department here!” the charge nurse said.
SUSAN K. SUCHA, M.D.
Omaha, Nebraska
HARD TO SWALLOW
An attractive couple in dinner attire came in to the Emergency Department, both holding extremely bloody towels. The male was clutching his towel over his groin, and the woman had hers wrapped like a turban around her head. Both were very uncomfortable.
They were reluctant to talk about what had happened. Physical exam of the man revealed several deep lacerations of the penis. The woman’s physical exam showed multiple puncture wounds to her scalp that were oozing blood. After some coaxing, they told their story.
They had been enjoying a candlelit dinner together and after several glasses of fine wine, they were feeling romantic. For a special dessert treat, she slipped under the table, unbuttoned his trousers, unloosed his penis, and took it into her mouth. Suddenly, in the midst of the act, she had a full-blown grand mal seizure: her jaw clamped down tightly and her head shook back and forth like a dog with a rag. In a frenzy of pain and terror, the man grabbed his dinner fork and began hacking at her head until the seizure stopped and she relaxed.
RANDAL P. DEFELICE, M.D.
Spokane, Washington
PICTURE PERFECT
One Friday night the paramedics brought in an unconscious woman from a terrible car crash. We feared the worst and began searching her purse for the next of kin. While cataloging her personal items, we discovered a stack of pictures featuring the woman and a man in various revealing poses, costumes, and acts. The staff loved them and swapped them around like baseball cards. The secretary came back and said that the woman’s husband was at the desk asking for information. Wanting to get these embarrassing pictures out of circulation, I gathered them together, put them in the woman’s purse, and told the secretary to give it to the husband. I would be out to talk with him in a moment.
I went out to see him, expecting to recognize him on sight from his photo spread. The husband, however, was not the man in the photos.
I told him that his wife’s condition was critical and that she would need to be in the intensive care unit. He listened intently, clutching the unopened purse. At this time the husband’s friend came in from parking the car. I immediately recognized him from the photos.
I left them there, these two friends, and returned to care for the woman. She was admitted to the ICU and soon recovered and went home. I don’t know what happened to her marriage.
As for me, I finally understood why my mom told me always to wear clean underwear.
NAME WITHHELD AT REQUEST OF AUTHOR
GOOD FELLOW
In the great state of Texas there lives a nasty little poisonous asp called the coral snake. It has three bands of color for easy identification: red, yellow, and black. In the same area lives a copycat snake hoping to garner respect from predators by looking like the coral snake, but the copycat snake has not one whit of venom. Its bands are also red, yellow, and black, but in a different sequence. Texans, a crafty lot, have developed a little rhyme concerning these bands of color to help them distinguish the poisonous snake from the harmless one.
Red on yellow
, kill a fellow.
Red on black, venom lack.
A man soon to be our patient, his wife, and their two children were out on a picnic. The kids discovered a multibanded snake and excitedly called the parents over. The snake was about eighteen inches long and banded alternately red, yellow, black, yellow. Mom dutifully recited her best recollection of the poem: “Red on yellow makes a good fellow!” So Dad, not in the habit of disagreeing with his wife, picked up the Texas coral snake to show his kids proper snake handling. The coral snake, although normally quite timid, was alarmed at this intrusion and chomped Dad between the thumb and forefinger. Dad screamed but had the presence of mind to drop the snake into an empty ice chest and bring it with him to the emergency room.
Dad did well with only a swollen and painful hand to show for his trust. Mom seemed a bit sheepish and the kids were alert but quiet. The emergency room staff was thrilled to have a visit from Mr. Snake and put him on show-and-tell in a plastic canister for the day before releasing him to the care of the forest service.
Red on yellow can take a life
Despite a well-intentioned wife.
BILL DAVIS, R.N.
Austin, Texas
PLEASE TAKE A NUMBER
It was our usual busy summer Saturday evening in the Emergency Department. Accident victims, strapped down to backboards with neck collars in place, lined the halls. A young male accident victim was being comforted by a fiftyish woman who spoke soothingly to him as she stroked his cheek and kissed his forehead. The young man looked rather anxious but lay quietly immobilized.
Before long the woman began complaining about the wait for attention. A nurse patiently explained that we were very busy, and that although it is frustrating and uncomfortable to wait, they could safely do so until a physician was available. The woman seemed not to fully understand this explanation, and went on to complain more and more loudly and less and less coherently. Finally, she announced that it was not the young man she wanted treated, it was she herself. Indeed, she did not even know the young man she was stroking, but was a registered patient herself wanting to see a psychiatrist. With one final shriek, she dramatically left the Emergency Department, climbed into an empty ambulance, and sped off into the night.
Emergency! Page 5