Authors: MD Mark Brown
Copyright Â© 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.
is a registered trademark of Random House, Inc.
mergency 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 commonâthey 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 disorder of arrivals creates tensions inside as the workers are buffeted by suddenly changing needs. Maintaining a high level of readiness is tiring, and efforts of the specialists may appear wasted on scraped fingers and colds. The very ill bring their own emotional charge, which must be matched in order to maintain control. The patient must never smell fear. Nights bring their own punishment: The self is screaming for sleep; the patient is screaming for help. What at four in the afternoon seems challenging, at four in the morning is grueling.
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.
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
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 nakedâthe 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