When I finished, the nurse prepared the injection and I found Grandma still simmering. I sat down and offered her coffee. She declined and lit a cigarette.
“Well … she’s pregnant, ain’t she? Lord Jesus, I know that son of a bitch got her pregnant. You know that he waited for her mother to be at work and for me to be out shopping. He waited for an empty house and got that girl pregnant.”
“She’s not pregnant.”
“She’s not?”
“No. We did a test.”
“Thank the Lord for that.” She smashed the cigarette out in the ashtray, gave a long sigh, and folded her hands in her lap. She no longer appeared angry, she just seemed tired.
“She has an infection.”
“Gonorrhea?”
“Maybe. Probably. Listen, I know that you’re angry, but don’t be angry with her. She made a mistake. She needs you now. If you need to be angry with someone, take it out on the guy that did this to her.”
“Can I get him arrested?”
“I don’t know.”
Grandma thought for a minute and lit another cigarette. I sipped my coffee and wrote up the chart. The fluorescent lights buzzed noisily overhead and drowned out the din of the Emergency Department down the hall. “Damn fool girl,” Grandma said. “I could’ve killed her when she told me about it.”
“But she told you anyway.”
“Yeah.”
As my patient walked down the hall, she limped slightly, sore from the gluteal injection. At first Grandma walked behind, oblivious to the girl’s gait, but as they neared the exit doors I watched carefully as my patient offered her denim jacket to the old woman. Grandma put on the jacket and gently led my patient by the elbow out the door, into the softly falling summer rain. Then they took each others’ hand and walked out. I felt the tightening of goose bumps on my arms and turned back into the fray.
GERALD O’MALLEY, D.O.
New York, New York
SOUR GRAPES
It was a Friday in the summer of 1973 and the gastroenterologists had a new toy: a fiber-optic flexible scope, which allowed for a periscope view of the inside of the colon. It was equipped with a biopsy forceps. They let it be known to the ER staff that they would be willing, even happy, to evaluate and treat rectal bleeding in the ER. In fact, they added an incentive—a six-pack of any domestic beer—for the house officer who recruited an “appropriate” (i.e., insured) patient.
Enter Mr. Simmons. He had blood in his stool, and a GI series showed a polyp in the transverse colon. He was stable, cooperative, and insured: the perfect recruit. Three gastroenterologist attendings and a gastroenterologist fellow performed the colonoscopy in the ER pelvic room. It was not a short procedure, and there was joyful shouting when the polyp was finally located (not exactly where it seemed to be on the X ray, but then again, we were reminded, the colon is a mobile organ). The polyp was snared and gingerly extricated. I held the formalin container as the stool-coated growth was deposited during smiles and self-congratulatory handshakes. The fellow took it up to pathology himself, not trusting the precious specimen to some anonymous orderly.
The pathologist evaluated the “polyp” and issued his report on Tuesday morning. I was alone when I read the formally phrased and very brief report. I knew I’d be buying my own six-pack.
The pathology report said: “Normal grape.”
MICHAEL HELLER, M.D.
Pittsburgh, Pennsylvania
GUESS AGAIN
The seventy-year-old female patient had a history of frequent urinary-tract infections. She had a fever and slight back pain, so I ordered a catheterized urine specimen to be sent to the lab. I went on to other patients, but the nurse soon returned and said she had tried to cath the woman but couldn’t find her urethra—the opening to the bladder. She had asked several other nurses to help her cath the lady, but no one could find the urethral opening. I decided to help, and went to the patient’s bedside. I found an elderly, pleasant woman who told me about the history of frequent urinary problems and told me she was childless.
I examined the woman’s perineum and identified the larger orifice of what appeared to be the vaginal vault, and searched above this for the urethral opening. I couldn’t find an opening either, but as I looked, some urine trickled out of the vagina. Suspecting a fistula connecting the bladder to the vagina, or an embedded urethral meatus, I decided to look inside the vagina with a speculum. As I readied to do this, however, I noticed something underneath the vagina, on the perineum, and looked closer. I found the patient’s vagina and intact hymen under what I had assumed was the vagina. I realized that the upper opening she was using as a vagina was in fact the patient’s urethra. I asked the woman if she had any problems with sexual relations with her husband.
“Not really. It hurt the first year or so, but it was fine after that.” She had been married for fifty-two years.
CHARLES HAGEN, M.D.
Auburn, Alabama
PLASTIC SURGERY
On a Sunday evening we received a call from a paramedic who said he was bringing in a woman with some nasal trauma. The patient arrived in the Emergency Department, a gauze pad covering her face. When the gauze was removed, it was noted that her nose had been removed as well—flush with her cheekbones. This included the amputation of both the soft tissues and bony tissue of the nose. The nasal concha were completely visible. Remarkably, there was absolutely no bleeding.
When the patient was asked what had happened, she told the following story:
No longer in love with her husband, she had found, and now loved, another man. She and her lover had gone to her home and explained to her husband that she was leaving and would not be back.
Her husband, who had been drinking, got up silently from the sofa, went into the bedroom, and came back into the living room with a .30 caliber rifle. The husband had the wife tie the lover’s hands behind his back and lay him facedown on the living-room floor. The husband tied up the wife in the same fashion. The husband then shot the wife’s boyfriend in the rectum, the exit wound nearly blowing off his genitals. The husband then proceeded to lift his wife’s head off the floor by her hair and took a serrated knife and sawed the patient’s nose off her face. He flushed the nose down the toilet. The husband then notified the police.
DONALD GRAHAM, M.D.
Boring, Oregon
THE HEALER
I had a friend in school
thought he could save the world.
Always said he wanted to do general practice
in some hillbilly place
like the Appalachians or something.
Said he’d take chickens, or hams, or vegetables
in return for his work.
Said he’d still make house calls
and birth babies and such.
I used to laugh at him a little
although I thought he was a nice guy
with good intentions and all.
But the rest of us knew that our payoff
would come someday.
A big house with three garages
a Porsche
maybe a Rolex
and of course, respect.
Somehow chickens and hams
just didn’t cut it for what they put us through.
One time late at night
when we were bone-tired from hunching over our cadavers
tired of trying to find nerves and vessels
tired of that formaldehyde smell
that seems to stick to you wherever you go
and kills your sense of smell for anything else,
one time he told me why he wanted to be a doctor.
I can’t remember it word for word
but it was something about being a healer
about knowing that he was one.
He said he had a sixth sense about things
that he knew how to help people.
He said that when the spirit allowed
that he knew just how to touch them with his hands<
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and just where, and how hard, and how long.
So he decided to become a doctor
figuring that it might be something new and powerful
to combine his heart for the metaphysical
with a head full of scientific knowledge
of anatomy, and physiology, and modalities and such.
He hoped for a kind of synergy, he said,
some sort of 2 + 2 = 8 thing
where he could diagnose and treat in two dimensions at once
and really do the job right.
I thought it was a bit naïve
not to mention a little eccentric.
But as I’ve said, he was nice enough and all.
And he worked hard and learned his stuff
and did fine in school.
Although he did comment from time to time
that it was crushing his right brain
and that a certain spark seemed to be dying
and that he hadn’t felt the power in his hands
for quite a while.
As the semesters rolled on
he settled in, though,
and became more like us
and told gross jokes
and laughed at some of his patients
and talked about buying a nice car someday.
And after a while he stopped talking about his sixth sense
and just got into the work
and sweat blood over the next set of exams
just like the rest of us
and sometimes was happy just to get by
just like the rest of us.
I wonder what he’s doing now.
We’ve lost touch.
The last time we talked
he said that he was working
in some Emergency Department in Illinois
and that he was trying to find himself.
KEITH N. BYLER, D.O.
Edwardsville, Illinois
CPR
When you do CPR you get some blood flowing, but usually not enough to do more than keep the heart and brain alive for a few extra minutes. In rare cases, though, for reasons no one quite understands, you can actually provide almost normal blood flow just by pumping rhythmically on the chest.
We had such a patient once, a sixtyish man who was brought in by the paramedics in cardiac arrest. There were no family members, and we knew nothing about him.
His heart monitor showed ventricular fibrillation, which was a relatively good sign, since VFib is the only “rhythm of arrest” from which people really ever survive. Not that good, though, as only about 10 percent of people with VFib ever leave the hospital.
Shortly after he arrived, with CPR in progress, we were startled to see him open his eyes. With a breathing tube down his throat he couldn’t talk, but he was clearly conscious. The CPR was keeping enough blood moving to his brain.
We checked the monitor just to be sure, but it really did still show VFib, and in fact, when we stopped CPR in order to do the check, the patient passed out again. Once we started up again, though, he rapidly responded and even seemed to make eye contact with the people above him.
CPR must be painful, but it’s nothing compared to defibrillation, the big jolt of electrical energy we use for VFib. Ordinarily this doesn’t seem relevant, since patients we shock like this are already comatose (if not, in some way, already dead). But this man was looking at us!
We had to do it, though, because VFib is not compatible with continued survival. And we didn’t think it would be smart to give him any sedatives or pain medicines, because they all have suppressive effects on the heart. So we stopped CPR, and thankfully, while we were positioning the paddles, his eyes rolled back into his head and he went out before we shocked him.
Most patients respond to defibrillation by getting better (developing useful electrical activity) or getting worse (losing all electrical activity), but this man stayed the same, with VFib still on the monitor. We shocked him repeatedly, ultimately using the maximal current, and trying all our adjunctive drugs as well, but no matter what we did, his heart stayed in VFib.
And he stayed in the same extraordinary place not only between life and death, but between consciousness and death. Every time we did CPR, he opened his eyes and seemed to look into each of our eyes. And every time we stopped, even for a few seconds, he died.
With each shock the smell of his burned chest increased, and we were sure he was in agony each time he awoke. Although we usually call off our efforts if they’ve failed for a half hour or so (since when we succeed it’s invariably in the first few minutes of CPR), we kept trying, and shocking, for two hours.
We had to keep going, because unlike so many patients in whom the sense of humanness is lost as they go through the act of dying, this man kept looking at us. He couldn’t communicate or answer our questions, but the more we worked on him the more obvious it was that he was alert and even seemed to know that he was dying. And the more we worked on him, the more each one of us felt, as we acknowledged later, that he was looking right at “me,” that he was depending on each “me” among us to save him.
But none of our efforts worked, and over time it became more and more obvious that saving him just wasn’t going to happen. If we changed positions so someone could get a breather from doing CPR, he died, and when we started up again, he was reborn! There was a temptation to stop on purpose for a few seconds, almost like a game, to witness this remarkable event. We also felt, with each successive effort, an increasing dread of subjecting him to another defibrillation.
Finally, with the whole team exhausted, the ER backing up with other patients, and hope of success completely gone, we had to stop the resuscitation. We couldn’t keep this up forever; it was futile, it was crazy. So we had to stop pumping on the chest of a man who was looking at us, knowing that when we did he would be dead. We could just stop, and he’d be dead soon enough. Or we could tell him.
One of the hardest things in medicine is telling a parent, or a spouse, or anyone, that someone he or she loves is dead. It’s particularly hard in the ER, because you usually know neither the one who died nor the survivors. This was the first and only time, though, that I had to tell a patient himself. That I had to say, “We are going to stop trying, for reasons of our own, and you will die.” I didn’t use those words, of course, but I couldn’t keep from feeling that that was the underlying message, pure and simple.
I touched him, and said the most comforting things I could think of (even while someone else kept whaling on his chest so he could live through these eerie last moments). I tried to get him to communicate with me, to tell me if he wanted something, to forgive me, to curse me. Anything. But he didn’t. He just kept looking at my eyes. Finally, I told him one more time, and then, a few seconds later, we stopped the CPR.
I’ve always wondered what he was thinking. Did he really understand what was going on? Was there something he wanted to say before it was over, or someone he wanted to say it to? Was he terrified that we’d stop, or terrified that we’d continue? Were his eyes begging me to keep him alive, or, please, just to let him die?
Twenty years later, I still think of him from time to time. And I still don’t have a clue.
JEROME R. HOFFMAN, M.D.
Los Angeles, California
IN THE FAMILY
From 1984 to 1991, I served as staff physician and medical director for the Yosemite Medical Clinic in Yosemite National Park. Although not a hospital, the clinic is the sole source of medical care for almost all of the twelve thousand square miles that make up Yosemite.
The summer is the busy season. I was on duty with one of my associates on a typical July day in 1988; we had only just begun and already there was a three-hour wait for nonemergency problems. We received a call on the radio that park medics were en route by helicopter from the Tenaya Lake campground with an unresponsive infant. CPR was in progress for the three-month-old female, who was not breathing and pulseless.
She was one of
four children—the daughter her father had always wanted. She seemed fine that morning when she had been put down for a nap in the family tent while her parents made breakfast. They were only a few feet away and had been out of the tent less than five minutes when her mother returned to find her cold, pale, and lifeless.
The father was a well-established cardiologist with a group practice in Southern California. The mother was an ICU nurse. They immediately started CPR on their little girl while someone ran to call for assistance. The child was still apneic and pulseless as she was being loaded into the helicopter for transport. Flight time to our clinic was five to ten minutes. Flight time to a hospital of any size from Tenaya Lake was a minimum of thirty minutes.
We set up our one-bed ER with all that the clinic had available for an infant resuscitation. One of the nurses came to me and said, “They’re here,” and I vividly recall the gut-wrenching feeling I experienced knowing I was walking into a disaster. The child was mottled, cool, pulseless, and the monitor showed flatline. Intubation went smoothly, but we could not establish an IV. Dad arrived as I was working on a cutdown.
He was a large man—five to six inches taller than me and at least fifty pounds heavier. He could best be described as being in a state of controlled panic. When he realized that an IV had not been successfully established, he picked up equipment and made several attempts to start central venous lines himself. There was absolutely no way to persuade him to leave the room. We could not physically remove him—there was no one big enough to do so. After about twenty minutes, he finally gave in and joined his family in the waiting room. Resuscitation was terminated about forty-five minutes from the time of arrival.
The local priest had been called. After we stopped the resuscitation, I went out to look for the father. He was wandering around outside the building followed by the priest. My associate had gone back to start seeing other patients. Park medics had already been called away to another incident. I finally caught up to the father and he asked, “Is she gone?” When I said “Yes,” we hugged each other and cried together.
Emergency! Page 11