To this day, the thought of a priest administering the ritual of baptism to a tampon never fails to bring a smile to my face.
EDWARD T. DICKINSON, M.D.
Menands, New York
AT THE MOVIES
About 1 A.M. I took a radio call from one of our paramedic units, at a downtown theater. The paramedics described a middle-aged male who had been struck in the head and robbed while in the lobby of the theater. All throughout their report I could hear low moaning in the background. At the conclusion of their evaluation they recommended to treat and release because the patient “was in no distress.” Puzzled, I said that it didn’t sound like the patient was in no distress because of all the moaning that I was hearing. They replied, “That’s not the patient. We’re at an X-rated theater and that’s coming from the screen.”
JAMES DOUGHERTY, M.D.
Akron, Ohio
A LITTLE PRICK
I was treating a very scared twenty-year-old female with an inflamed vaginal cyst. The nurse, Pat, was holding her hand and trying to comfort her as I was preparing to cut and drain the cyst. With her spread legs up in the stirrups, I positioned myself between them. As I was about to inject a local anesthetic with a small syringe, Pat told my patient, “OK, now you’re going to feel a little prick between your legs.” After a pause, the three of us started laughing, which was just the medicine needed to get the patient to relax.
MICHAEL S. ZBIEGIEN, M.D.
Farmington Hills, Michigan
THE PRONOUNCEMENT
Emergency physicians are frequently asked by police and funeral home personnel to examine and pronounce someone dead. A quick listen with the stethoscope to confirm absence of heart sounds, a look at the dilated pupils, and a feel for rigor mortis is all that it usually takes to complete the physician’s task.
But on this particular day, the police grabbed everyone’s attention by announcing that they had twin fetuses for pronouncement in the back of their paddy wagon. They were found lying together underneath a park bench. Reactions from the Emergency Department staff ranged from sorrow to disgust to curiosity. As the physician on duty, it was with a combination of these emotions that I followed the officers out to their vehicle.
The big steel doors opened, and there, wrapped in a sheet, were two lifeless little bodies appearing to be of approximately five months gestation.
“Who could have done such a thing?” one of the officers said. “We’re looking for the mother.”
I examined them a little closer and noticed something peculiar. They had hair on both sides of their noses. Also, their fingers and toes were not well formed. Finally, each had a long appendage near the buttocks.
“Gentlemen,” I said, “the mother you should be looking for is a cat.”
WILLIAM MALONEY, M.D.
Evanston, Illinois
SHORT TAKES III
Since we are a teaching hospital, it’s sometimes necessary for the same exam to be done repeatedly by medical student, resident, and attending physician. After the third rectal exam on a trauma patient, the patient stated, “I’m beginning to feel like I am in prison with my face to the shower wall.”
A nineteen-year-old female was being triaged. She stated that she and her boyfriend were having sex and the condom came off but she wasn’t able to retrieve it with her fingers. She went to the bathroom and “gagged myself to vomit but couldn’t vomit it up either.”
A Vietnamese girl who was obviously pregnant came into the ER unable to speak English and voice her complaint. The doctor rushed the patient into the GYN room and did a pelvic. When the translator was on the phone, she let us know that the patient had come in about her cough.
SHARON WISE, R.N.
St. Louis, Missouri
PLAYING CHICKEN
About ten years ago I saw an intoxicated, obnoxious, elderly woman with a fracture-dislocation of the shoulder. After diagnosing her problem, we parked her gurney in the hallway and called the orthopedic surgeon to come in and take care of her. After some noisy, drunken complaining, she dozed off for a couple of hours.
The hospital blood bank had started a blood drive that day with the motto, “Don’t be chicken, donate blood.” A large chicken, similar to Big Bird of Sesame Street, came through the Emergency Department with a group of people, including the press and the administration. The chicken walked up to this lady and patted her on the shoulder and said, “Hi!” From her drunken stupor, the lady looked up at the chicken and yelled: “I’ve waited two hours for an orthopedic surgeon and all I get is a fucking chicken?”
BRENT D. AMEY, M.D.
Odessa, Florida
PART
EIGHT
Emergency physicians leave their specialty at a higher rate than any other specialty. They burn out. A major reason they burn out is the wearing effect of being on the receiving end of a stream of human misfortune. They have no control over the rate of flow—sometimes a trickle, sometimes a flood. Whatever the doors bring.
Another reason is the nights. The Emergency Department never closes. No other medical specialty spends half of their practice at night. Ask a cop or janitor. Nights grind a person down over the years, pushing against the body’s clock, locking one out of step with family and friends. Sleep deprivation.
Also, the unique population of patients seen in an Emergency Department takes its toll. If a person is too sick, or too drunk, or too nasty, or too stupid, or too crazy to get medical care in a doctor’s office or clinic, that patient ends up in the emergency room. We reserve the right to refuse service to no one.
As the years go by, the skin gets thicker, the nights get longer, and the patients get meaner. In response, the jokes get louder, the sarcasm becomes harsher, the care becomes business.
Burnout.
BURNING OUT:
THE LETTERS OF QUINN
I
Dear Larry,
I’m typing this letter to you on the train to work, using my new laptop. It takes about an hour on the Long Island Rail Road to Penn Station. A shorter subway ride takes me to the doors of the emergency room at St. Alban’s Hospital. It’s hard to believe three years have passed since my move from the city to the suburbs. Even with the commute, I still prefer it to living in Brooklyn. I think it was the fifth break-in in one year that helped me decide to leave. The dual forces of rising income and rising crime are very effective motivators to move to the suburbs. It is sad, though, to be driven from your birthplace.
I know the city well and still enjoy it, but somewhat less than when I came to work in this emergency room. Sometimes I feel my job’s like that of a cop. My employment brings me in regular contact with the worst New York has to offer, and it makes me rethink the romance of the city and its citizens. Right now we’re fully staffed with five attending physicians (including me), two surgical residents, three medical residents, and a variable number of interns and medical students. It’s hard to imagine that we see over eighty thousand patients per year, though lately it often feels like more.
When I enter the ER in the morning, I always ask the night shift, “How was it?” This is both out of courtesy and augury. The ancient Romans would look to the flight of birds (remember that high school Latin bonis avibus or avi sinistra) or the entrails of animals to predict the coming day. A quiet night shift augurs well; a busy night shift means pain and suffering through the day. By corollary, if someone were to say, “Gee, it’s quiet today,” everyone would groan, knowing that this statement is sure to bring several ambulances full of very sick “train wrecks.” These beliefs have no logical basis but are firmly held dicta by most of the staff. It’s an ER thing.
A couple days ago, I started my morning with a rape exam. This sixteen-year-old girl from the Midwest got off the train at Penn Station and within fifteen minutes had met a middle-aged man. He told her he was a musician and offered to give her a free guitar lesson. I guess she felt lucky because she had heard that New Yorkers were cold and unfriendly. And here she was, just off the train,
and already she had a new friend. So she followed her new friend to an abandoned building … and guess what? No music lesson! Just rape, sodomy, and beating. It was sad, but I really couldn’t believe that someone could be so naíve. The first person she met she followed to an abandoned building? Doesn’t she watch television? This isn’t Kansas.
This morning I see one of my fellow attendings on the train. He is engrossed in an LSAT review book. It is his notion that if he can go to law school, the MD/JD combination will spell easy street. He wants a nice office, with a nicer salary and not as many headaches and heartaches as the ER. He is not alone in his quest. Most everyone harbors fantasies of leaving for a less stressful job. Many colleagues are consultants to the pharmaceutical industry, advertising agencies, and Wall Street analysts. I feel that one job is enough for me right now, although from time to time, when I want to give myself a headache or need money for approaching holidays, I work per diem shifts in another ER. But usually the work at St. Alban’s is so overwhelming that I need every day off to recover.
More later,
Campion
II
Dear Larry,
Remember what I said about avi sinistra (evil birds) and asking the night shift how it was? Well, today the belief proved true. I had arrived at work about as carefree and lighthearted as I can get. (My mother always said, “Better presumption than despair.”) That was soon to change.
I said good morning to Dr. Sanchez from the night shift. He is a recent graduate of St. Alban’s internal medicine program, and is still filled with the energy and enthusiasm that left me years ago. He has a wife and a pretty little daughter that he mentions a lot as he shows her picture all around. He is generally a very happy man—but not today. Needing a shave and a remedy for dark circles, he barely mumbled a good morning. I looked over his shoulder to the code room. A body was being wrapped in a shroud by the night shift nurses. The floor and walls were covered with blood. Used chest tubes and Pleurevacs were floating in IV fluid on the stained linoleum. Dr. Sanchez had the same blood covering the bottom of his shoes and splattering his pants. I asked, “What happened?”
Sanchez washed his hands in the sink, muttering under his breath about the soap containers being empty again. “That asshole in there got himself shot,” he said flatly.
“The story is, he was just standing on the corner, minding his own business, and was shot six times in the chest and neck at close range. His friends show up an hour later and swear that he was a clean-living guy and didn’t have an enemy in the world. They asked if they could spend some time alone with him.”
“Was he really an innocent bystander?” I asked.
“Are you fucking kidding?” His laugh was humorless. “He had over three thousand dollars in fives and tens, a bag full of crack vials, and a nine millimeter pistol stuffed in his jacket pocket. No doubt a business competitor shot him. His friends were carrying pistols. They wanted the time alone to lift his merchandise. They were all dirt-bags,” he spat. “If not for this,” he jerked his chin toward the body covered in the white plastic shroud, “I could have gotten an hour’s sleep.”
We made rounds after collecting the day’s residents, interns, and medical students. Sanchez mumbled comments about the patients lying on the stretchers. Although the ER director describes these as “teaching rounds,” there is little or no teaching going on. This is work, and the sooner we finish rounds the sooner the night people can go home. A typical report goes, “This is an AIDS player with PCP, treated with AZT and DDI in the past. He’s presented with SOB, and tempt of thirty-nine C. We did a CBC, UA, CXR, started IV Bactrim, and are waiting for a bed. [Doctors love abbreviations.] The floor residents were assholes all night and said they couldn’t find him one.”
The patients are seen first in the waiting room by a triage nurse who interviews them from behind bullet-proof glass. On the basis of this assessment they either wait or come in immediately. It’s not a great system. People are often reluctant to shout the intimate details of their medical problems to the nurse in the middle of a crowded waiting room. As a result, it is difficult to get an appreciation for a case when you first read the chart. We are often surprised by the differences between the stated complaint and the real complaint.
We often have several homeless residents of Penn Station in the waiting room. After being triaged for various complaints, they find one of the more comfortable straight-back cushionless plastic chairs that are bolted to the floor in the waiting room and fall asleep. Intoxicated as they are, they sleep soundly across several chairs, not hearing when their name is called for treatment, or conversely they wake and answer to their name or a name that sounds like their name, or to any name for that matter if they are drunk enough. As a result, we get false histories on many of them, pull all the wrong charts, and order all the wrong lab tests and X rays. It creates quite a mess and wastes a lot of time. When we ask why they responded to the wrong name, the usual answer is, “I dunno,” or “I didn’t remember my name,” or “I was in a hurry.” Ain’t it sad.
Many people like this come to the ER in the cold weather. Hoping to avoid the homeless shelter, they present themselves with some complaint that they hope will rate an admission. Some are quite adept at malingering, and know just what to say to gain a night in the hospital. Some favorites are, “I have crushing chest pain.” Or, “I can’t see out of my right eye.” And, “I have kidney stones.” These require CT scans, IVPs, and a host of other expensive tests, not to mention physician and nurse time. There is no disincentive for them when they come to the ER. Some of them will try several times a night in different hospitals or on different shifts in the same hospital. This allows them to work on their story, hoping that a new complaint will be the open sesame to a warm hospital bed and free meals. They know that once in the hospital it is difficult to get thrown out, with the Patient’s Bill of Rights posted everywhere and the Patient’s Rights Advocates ready to do battle against staff who have the temerity to try and discharge someone just because he doesn’t have a medical problem.
Actually, I’m getting well acquainted with all the residents of Penn Station. After I’ve Kwelled them for lice, sutured their head cuts, pumped their stomachs, etc., we meet several hours later in the station when they ask me for “a dolla.” When I remind them I’m the doctor who just treated them for free, they say, “Oh, how about five dolla.”
Just before I left to go home tonight there was a shoot-out in Chinatown that kept me overtime. Apparently a gang-related incident. The paramedics told me they had to step over many bodies to get to the people who were screaming. One member of a rival gang had entered a disco and shot an Uzi into the crowd in hopes that one of the bullets would find an opposing gang member. Three were DOA. One head injury died in the OR. Two chest wounds and several minor extremity wounds did OK. The police arrived in force with radios going and pads and pens out. As usual, they asked for my name but wouldn’t tell me why. They always take control of all the phones and desk space in the ER, which makes it impossible to do any work.
I received a response to my inquiry about the Royal Flying Doctor Service. They said I would first have to register with the Australian Medical Service. I discovered they are completely funded by charity, so the rumor of big bucks is groundless. I don’t know how I’d do in the air. I’d be permanently on Dramamine, I’m afraid. Anyway, Cathy and I are becoming more intertwined, so Australia doesn’t look as inviting.
Write soon,
Campion
III
Dear Larry,
Yesterday while working in the ER, I had the pleasure of dabbling in another related field: the fascinating world of dentistry. Mr. Rangoon, formerly a native of Sri Lanka, now a denizen of Washington Square Park, came into the Emergency Room with the right side of his face quite swollen. Being an astute physician, I was aware of some indisputable facts. He was poor, uneducated, hungry, and unwashed. His long shaggy hair was the home to an entire civilization of lice, and his veins wer
e thrumming with alcohol and cocaine. He had the wild-eyed stare of those wakened suddenly from a sound sleep. A few sentences of garbled communication, and all my suppositions were confirmed. His breath was truly fetid. In the past I have not flinched at the rancid odor of tampons lost for months in cavernous vaginas (toxic box syndrome). I have confronted rotting feet of the homeless that have not seen the sunshine (let alone soap and water) for years (toxic sock syndrome). But just talking to him in an enclosed space brought tears to my eyes. He was febrile and perspiring like the proverbial pig. He looked sick and was in pain. He admitted that the cocaine was wearing off, and he no longer had the resources to replenish his supply. My empathy threatened to increase my flow of tears.
As he spoke in his interesting version of pidgin English and home-boy argot, my attention was drawn to his mouth. His teeth were cracked and yellow-brown, and looked like rotting wharf wood. They moved in their sockets as he spoke, to and fro with every breath or movement of the tongue. I told him to sit down. There were no empty chairs, so he sat on top of the garbage can. I put on a pair of latex gloves and examined his mouth with a flashlight. It was a sight to give a periodontist nightmares. His teeth (such as they were) were surrounded with angry red mounds of gum tissue, each mound issuing gouts of green pus with little or no provocation. This sight, added to the overpowering stench, nearly had me running to the bathroom.
I wondered: His teeth look so loose, will they come out if I give them some encouragement? Ever the intrepid doctor, I looked at my gloved hand, considered the mess that was his mouth, and put on another glove. I asked him to open his mouth and told him not to bite. I promised myself that I would stop if he started to scream (or I started to scream) and call a dentist. (Though I knew of no dentist who was likely to leave his lucrative practice to rush over here and look at this mess.) I thrust my hand into his festering maw and firmly grasped his remaining front teeth. I could feel how loose they were, though they felt like they were connected with string. I gave a solid, confident yank, and out came three teeth with several cupfuls of pus and blood. Boy, was that satisfying! His facial swelling was going down already. Mr. Rangoon sat calmly, seeming to take all this with equanimity. Encouraged by his lack of objection, I continued to pull the remaining teeth from his head. They all came out with little problem except for one stubborn molar in the top back. I looked around the ER for something like a set of pliers that I could use to remove it, but in a rare lucid moment, I stopped to think, and changed my mind.
Emergency! Page 13