Emergency! (3 page)

He kept breathing.

“He'll stop soon,” I said. “Let's get back to the others.” Disconsolate, we all shuffled out. My drunk was on a warming blanket. His temp was up. We told the mother about her baby. She didn't care. I wrote up a couple of charts, and then looked over to the room.

He was still breathing.

And he kept on breathing. Dear Lord, was the scale wrong? If I, like a fool, rushed back in and reintubated the kid, wouldn't I just be resuscitating someone with severe brain injury? I gritted my teeth, and wrote up another chart. I looked over again.

Still breathing.

Word began to spread. First, it was a few ward clerks who came and stood in a circle around the stretcher. The next time I glanced over, it was some nuns. One chart later, and a collection of paramedics stood there. Then, some beat cops. No one gawked. No one spoke. All had seen life wasted, wasted daily, wasted badly. They had numbed themselves to that pain. This was somehow worse. This little baby did not want to waste his only chance. He struggled, and struggled, heart continuing to beat at the too-slow rate of sixty, chest muscles continuing to try to draw air into fluid-filled lungs.

I noticed that the policemen had their hats off.

I couldn't stand to keep looking over there. I vanished to suture a long laceration. When I returned, my eyes were drawn inexorably to the room. His room. To my relief, it was empty. It was over. Now they could take his little body to the morgue, or the funeral home, or wherever they put small dead people who gave life their best shot.

I looked down at my chart. A large plastic bag was in front of me with the now dead baby sealed inside.

It was labeled
TISSUE SPECIMEN FOR PATHOLOGY
.

I never knew the baby's name. They never gave him one. A pity. He deserved better.

H
e had a handsome face. I could see that, even though half of it looked like mush.

He was fifteen years old. He came in with his mother, a quiet woman, who sat patiently by his side. He had tripped while playing basketball and fallen onto the jagged edge of the Cyclone fence, ripping open the left side of his face.

The wound was awful: stellate, deep, and with enough twists and turns, flaps and layers to challenge a plastic surgeon. This was out of my league. This required someone with more expertise than I had. I was going to have to get the plastic surgeon on call. Foolishly, I told the mother that. Then I called the plastic surgeon.

“Medicaid patient? I'm not coming in for that,” he said.

“But it's his face,” I pleaded. “He has to wear that face for the rest of his life!”

“Transfer him to Cook County. An intern will stitch him up there.”

“That's just it. That's all he'd get: an intern. I can do a better job than an intern and I don't think I can do a good enough job.”

“I'm not coming in for a Medicaid.”

“But you're the plastic surgeon on call. You've got to come in and take these cases on your call days. Besides,” I added, foolishly trying to reach a heart that wasn't there, “it's his face!”

“I'm sick of Medicaid, sick of endless paperwork, hostile bureaucrats, mindless lawsuits, and no pay. Medicaid is a joke. I'm not coming in.”

“I'll call the hospital administrator. You are obliged to come.”

The plastic surgeon, who must have taken the Hippocratic oath at some point in his life, blew up. “I'm retiring at the end of the month. I'll call the hospital administrator and submit my resignation right now. I'm not coming!” He hung up.

I was stuck. No other plastic surgeon would come in. They were not on call. I went back in to face the mother. She took the news calmly. I told her that I was not the best person for the job. I told her that I would do the best I could. I told her that it was her choice: I could transfer him to Cook. She might find someone better there.

She looked at her son's beautiful face. No, she said. She would take a chance on me.

I did my best, but that's all I can say. I still think of him, now. I wonder what he is doing, down on the South Side of Chicago with a mother who loves him and half a beautiful face.

H
e did not have a beautiful face. It was all doughy and acne scarred. It didn't help matters that his eyes were two red puffs and his mouth was held in the rigid contortion of trying not to cry. At eleven, he was almost as big as the cop who brought him in.

“We just need to confirm the abuse,” said the cop, looking equal parts embarrassed and bored. “Well take the pictures down at the station.”

The boy had called the police himself. He called not to report his own abuse, which was of long duration. That was evident. The scars on his back and chest and legs were classic electric-cord whip injuries: the narrow hairpin loop marks that look a bit like a brand. He had hundreds of scars of different ages. I could see the shiny, flat, well-healed ones that he probably got at six. The scars that were still red were acquired at age ten. The fresh ones looked less than a week old.

He had not called to report this. He had called because, on this day, his mother had started to beat his younger brother.

He sat there silently crying. He cried because he felt rotten. He sobbed because he had turned in his mother. He cried for his little brother. He cried for himself.

I wrote up the chart. I went to the vending room and got some microwave popcorn. I brought him the bag. We sat together eating the popcorn, he and I, and I felt as I watched him munch in silence that I was wrong. He had one of the most beautiful faces I had ever seen.

TRACEY GOESSEL, M.D.
   

Hunt Valley, Maryland

Like ripe fall fruit from a wild apple tree, babies tumble from the wombs of careless and innocent unnoticing young mothers. In contrast is the agony and yearning of the barren and infertile woman. And when the mind is weakened by mental illness, the power of this deep and primitive reproductive urge becomes seen as it forces its way up into the light of daily behavior
.

I
n an upper-income community hospital Emergency Department, a fifty-year-old matron complained of mild abdominal pain and fever. The patient was on an antidepressant, but she had no other significant medical history. Her physical exam was unremarkable. Lab tests did little to further the diagnosis. I decided to proceed with a pelvic exam. A female nurse set the patient up in the GYN room.

As I approached the room, the nurse shook her head in disbelief suggesting we were getting close to a diagnosis. The pelvic exam revealed that the patient's labia were pinned together with three large, rusty safety pins.

The patient apparently had a long psychiatric history, including obsessive behavior focused on her inability to bear children. Two weeks earlier, the patient had purchased a small chicken at the market and had inserted it, piece by piece, into her vagina. She had pinned her labia to keep the chicken in place and was waiting for it to develop into a baby.

The patient was subsequently admitted to the psych unit, but not before she was washed out with two liters of Betadine douche and the entire chicken carcass was accounted for.

GREGORY DAVID POST, M.D.

New York, New York
       

KEITH N. BYLER, D.O.
 

Edwardsville, Illinois

I
t'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