Emergency! (6 page)

Suturing of the wound would have been dangerous to us both were it not for a passing nurse who procured a mirror and appealed to Krystal's vanity. “If you don't hold still and let the boy do a good job of stitching that up, you're going to look like you chase parked cars in your spare time.”

Krystal lay still and silent for the forty-five minutes it took me to close her wound. As I finished, the intern returned to chide me for using too many sutures and to take me back upstairs. I had not been responsible for her discharge instructions, but looking at the ten-day-old wound, I knew that she had not kept her follow-up appointment for suture removal.

“Even if you could just give me a ten or a twenty, I'd be that much closer to home,” she implored sweetly.

“OK,” I distractedly mumbled, “let's go to the bus station.” Again she thanked God. The walk to the Greyhound terminal was short. I preferred her previous obscenities to her current saccharine effluence. As we neared the window, she held out a hand for money to buy the ticket. When I pulled out a credit card, she became suddenly tense.

“They don't take credit cards here.”

“The little sign says they do.”

“Well, maybe they do, but they don't like it,” she warned.

“They'll get over it.”

“There's a bank machine around the corner; you could just get the cash and wouldn't have to use your card.”

The apathetic woman in the window ignored our dialogue and asked, “Where are you folks going today?”

I turned to the girl, “Well, where do you want to go, since you know you can't cash the ticket the moment I walk out?”

“Bastard!” She pivoted and stormed out.

“Sorry.” I shrugged to the cashier, and left.

She was walking slowly back up the sidewalk. I matched her gait. “Get the fuck away from me or I'll scream.”

“When was the last time you ate?”

“What do you care?”

“I care. Why don't you let me buy you lunch and take the stitches out of your face?” Her hand came up and her ring finger worried one of the tiny blue filaments at her brow. She stared at me. “Can you do that?”

“Why not? I put them in.” She looked surprised.

We sat at the counter and she wolfed three hamburgers. Between bites she told me a different story. Her name was Christine, and she was from Moses Lake. Her father taught shop and coached football at the high school where she had been a junior. Her mother sold cosmetics, and spent the rest of her time “trying to ruin my life.” She couldn't stand the farm-boy jocks her parents wanted her to date. She found school tedious and frustrating, and her sharp tongue landed her on probation all too frequently. She'd run away from home with her boyfriend, an older, notorious, small-town coke dealer with a black Trans Am. They were going to make the big time: live in a nice house, own a ski boat, and throw wild parties for all their friends. They'd laugh at the hicks living back in Moses Lake. The competition in the city cocaine trade had proved too much for her friend, however, and soon he was sampling more than he was selling. One morning, after the money ran out, her boyfriend slapped her around and pushed her from their room. She was to come back with a hundred dollars or not come back at all.

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
     

I
t'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 ambulance 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

I
t 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.