Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (13 page)

And there goes the grace theory right out the window.

I looked up from the chart to the girl. She wasn't particularly large, but she was fleshy—fleshy enough, apparently, to hide a first pregnancy even at term.

I'm a scumbag; worse than the worst lawyer. My only thought now was lawsuit, damage control.

The girl was here with her parents. I told someone to put them in the grieving room, the room where we put families whose relatives have died, and I would be right out.

So there I was and there they were, West Virginia hillbillies of the first water. Mother, middle-aged, dressed in pants she bought twenty pounds ago; father, skinny, almost scrawny, with a raggedy black beard that didn't quite mask a protruding chin, cigarette pack in his shirt pocket, dirty undershirt visible underneath, tattoos: anchor, naked woman.

“Your daughter was pregnant,” I said simply. “We've delivered the baby, but I'm afraid the baby is dead.”

“How's Suzy?” Mom asked.

“Suzy's okay. Suzy's fine.”

They both sat for a minute taking this in, then the father scratched at his beard and rubbed his nose. Mom cleared her throat. “I thought she was putting some weight on, and I asked her one time…but…” She trailed off. She was thinking. “How long has the baby been dead?”

“I don't know,” I said.

“She had that seizure last week. Did that seizure have anything to do with the pregnancy?”

“I'm not sure,” I lied.

They thought for a minute more, then the mother nodded. She was analyzing the situation. “She told me she was still having her periods.”

Wishful thinking. “Apparently she wasn't.”

“Can I see Suzy?” the father asked. The mother thought for another minute, then said: “Can I see the baby?”

Wrongful death. The worst kind of malpractice case. Accusations started flying the next day.

Family Medicine, which had admitted her into the hospital for observation the week before, claimed that it was the ER physician's responsibility to make the diagnosis. After all, the ER saw her first, while she was seizing, no less. The ER doctors countered that Family Medicine had the patient for two days. They should have caught it. It became a pissing contest conducted in the shadow of a recent local malpractice suit: An internist saw a patient once for a few minutes, a patient under the care of a neurosurgeon for a neurosurgical problem. The internist was sued for a poor neurosurgical outcome even though he had taken no active part in caring for the patient. The plaintiff was awarded $1.5 million (in addition to the several million dollars from both the neurosurgeon and the anesthesiologist). Professional prejudice aside, this was clearly excessive. But it was reality, we all lived and worked in this shadow. I was at risk as well for a number of things: not attempting to resuscitate the baby, for the episiotomy, for any gynecological problem the woman might develop.

I knew all this that night. When the ER finally slowed down enough for me to think, I sat and reviewed my decisions. I walked through the thrash a couple of times in my mind. There was absolutely nothing I would have done differently. There was never a question in my mind that the woman needed an episiotomy and that the baby was clearly dead. Nothing would have brought that baby back. But I could already hear some lawyer at a deposition asking me if it was possible that the baby did not die the week before during the seizure but had actually died because I did not attempt resuscitation.

It stayed quiet. At some point I picked up a book one of the nurses was reading,
The Healers,
by someone with an intensely Anglo-Saxon name. The cover showed a beautiful nurse, with a nurse's cap, of course, staring deep into the eyes of a handsome young doctor in a white lab coat. The blurb on the back said:

Beautiful neurologist Dr. Nan LeBaron and Emergency Room chief Dr. Steven P. Winstead III [where do they get these names?] are fighting for their medical lives. They are codefendants in a malpractice suit after their best efforts failed to save a patient's life. But neither of them can deny the physical chemistry that flares between them.…

Inside there was a listing of “The Lovesick Women of the Emergency Ward.”

Ann is on the brink of realizing her dream of power at Chandler Medical Center, only to find herself back in the arms of a doctor who could turn it into a nightmare.

Lisa
has one last chance to break the hold that drugs have on her body and that a diabolically domineering dealer has on her flesh.

Avon
discovers that wearing her white uniform will not make people in power forget the color of her skin.

Rosa
is torn between her determination to be the perfect doctor and her desires as a woman.

Meredith
can deal with patients' mental disorders but not her own guilt about her heritage.

This is Chandler Medical Center, where contagious scandal stalks the corridors in crisp and spotless uniforms and hides behind a medical mask.…

I opened the book at random:

Chapter 6

Patrick studied the exposed surface of the brain where the skull had opened.…

How did it open, I wondered idly as I tossed the book aside. Like a clam?

I glanced around the doctor's desk where we wrote our reports. There were multiple Styrofoam cups of cold coffee; crumpled pop cans; a two-year-old
Physicians Desk Reference
with the cover torn off; magazines (an old
New England Journal, Sports Illustrated, Glam-our);
someone's half-eaten sandwich covered by a paper plate with MINE written on it; a cheap stethoscope missing an earpiece, a reflex hammer with a broken handle—stark fluorescent light, worn linoleum floor.

Reality.

5

H
OW TO
C
RACK A
C
HEST

“T
HIS IS AMBULANCE THIRTEEN.
We're bringing in a John Doe-trauma victim, boarded and collared. We've got a pulse of one-sixty and a BP of eighty over palp. He's disoriented but…”

“What kind of trauma?”

“Uhhh…we're not sure.”

“What do you mean you're not sure?”

“Well, there's a lot of trauma here.”

“I don't get you.”

“You will.”

The patient was a mess. Some kind of large-caliber weapon had taken out his right shoulder and much of his lower left leg. He had several stab wounds to the chest and a crushed pelvis. You pronounced him dead within ten minutes of arrival. It took longer to reconstruct what had happened to him. It seemed he had been shot, stabbed and run over several times by a car.

The resident whistled. “Someone wanted that sucker
dead
.”

Donna, one of the nurses, leaned over the gurney and said, “Yeah, they wanted him dead
stat
.”

Stat. In the ER, after a few seasons of watching various versions of the job on television, everyone started running around ordering things “stat.” It was an ER in-joke: Get me that IV STAT! Make some coffee STAT!! Get out of that chair! I need to sit in it STAT!!!

You all watched that stuff on the TV in the nurses' lounge on the occasional slow nights in the ER. The quick-thinking paramedics! the compassionate nurses! the dedicated doctors! The most hilarious part was watching the procedures—actors intubating, suturing, doing brain surgery. (“I want that chest cracked STAT!” someone shouted from the rear.)

One show had the paramedics bring in a trauma victim. Within seconds, the TV doctors had made the decision: they needed to perform a thoracotomy on a patient—that is, “crack his chest.”

Cracking a chest—the mother of all procedures—involves opening the chest wall to get at the heart and other vital organs. It is the most dramatic and least effective procedure in medicine. Occasionally, though, it can save a life.

On TV everyone looked as if they were playing the piano or some board game. The actors—all dressed up as doctors—lined up around the hospital bed, the patient groaning thoughtfully as they stared down at some middle distance where a chest, presumably, was really, truly being opened.

“Can you see the aorta?” one superserious senior-statesman doctor asks. Everyone is standing as if they were innocent bystanders who had happened upon a minor traffic accident.

“Yes, I see it.”

“Now take this and clamp it.”

“I can't. I tried to, but I can't.”

“Then let's have this other [more photogenic] physician do it.”

“There, I did it. Do we have a blood pressure?”

“Yes, we now have a normal blood pressure. You can take him upstairs to his room, Nurse.”

That is the fantasy. This is the reality. It's five-thirty in the morning. You are standing in the trauma room when two breathless, frightened-looking paramedics sweep in with your next patient strapped to their gurney. They had radioed ahead, but the scene was such a thrash that they could only transmit three pieces of information: gunshot wound to the chest, two bullet holes, thready pulse.

Three or four firefighters accompany the paramedics. The bad news: one of them is doing CPR; another is holding the man's endotracheal tube in place. That means the patient doesn't have a heartbeat and is not breathing on his own—signs of bad trauma.

“We lost the pulse,” one paramedic says. “He had one when we left the scene, but we've lost it. We've got nothing.”

Donna, charge nurse for the evening, says, “Okay.
Party time
.”

You are in the midst of the golden hour, the hour that follows a trauma or other medical emergency. Each minute of the golden hour is a last chance, the last chance to do a procedure or temporize an injury, to patch the patient back together enough to at least get him to the OR, where the surgeons can do a definitive repair. The golden hour, though, started thirty minutes ago, when this patient was shot. It takes that long for EMS to arrive, stabilize and transport to the hospital. Not much gold left over.

J. T., the other physician on, has followed the stretcher into the acute room. “Gunshot wound to the chest? Five in the morning?” he says. He's shaking his head. “It's gotta be drugs.”

You catch a quick glimpse of a boy's face, a bloodsoaked T-shirt and a pair of oversized jeans. But before you can really examine him, you and everyone else on the team must do these things:

Check the airway. The paramedics have intubated the patient, but is the tube in the right place?

Check for a pulse.

Hook patient up to the monitor, establish heart rhythm. Connect patient to blood pressure cuff and pulse oximeter (which checks the amount of oxygen in the blood).

Start IV lines, big ones, to get fluids into the patient. The paramedics have started one, but Donna, looking down at it, says, “It's blown.” The patient will need several peripheral lines and, optimally, a central line—an oversized IV plugged right into one of the main veins. First, you'll give him regular IV fluid—blood comes later, if the patient lives that long.

J. T. pulls the central line kit out of a closet. He points to it, looking at you, and you nod.

Next you must cut the patient's clothes off to look for hidden injuries. If the universal symbol of a physician is the caduceus, then the universal symbol of an emergency medicine physician would be the trauma shears. These are tough-looking scissors used to rip open the clothing of drunks, car crash victims and critically ill patients. (Note: There is always room for surprises here—most recently you saw a well-respected male judge in the ER with severe chest pain and discovered that he was wearing under his business suit black satin underwear, garter belt and pantyhose.)

You help cut off the jeans. All that's revealed tonight is bloody underpants.

Get blood samples: for hematocrit, chemistries, drug screen, blood typing, HIV testing.

Call for four units of type O blood. Tell them you want another four of type specific, pronto.

Call the thoracic surgeon on call; alert the OR. You've got a gunshot wound to the chest.

Only now can you get a quick look at the patient.

“Hold CPR,” you say. The firefighter pauses and wipes the sweat off his forehead.

You check what's on the monitor. There is a sinus rhythm: rate 128. Recheck pulse. Donna does that.

“I got nothing here, gang,” she says.

The firefighter looks up at you.

“Restart CPR?” he asks.

“No, stop for a minute.”

Now for the first time you look at the injury. The patient has two bullet holes clustered over the sternum, right where the paramedic had placed his hands for CPR. Blood is trickling from each one. Are they entrance wounds? exit wounds? You can never be $$$.

“Restart CPR,” you say.

You look up at the patient's face. It is hard to see with the endotracheal tube in place and blood smeared everywhere, but he looks to be a kid, maybe sixteen at the most, with a ratty goatee and acne. You look him over. He's dressed like a punk—his enormous pants, now filleted open, are barely hooked up over his hipbones. There is a homemade tattoo on his right arm that looks like a dragon or maybe a serpent. Someone has carved an outline into the skin with something sharp and then filled it in with ink. It's amateur gang stuff, not something you see too often here. This is a quieter part of a quiet town; the last drug-related shooting you saw was over a year ago when you did a few shifts in the big city. But, ER doctor that you are, you have a working familiarity with the local kids who hang out on the curbs outside the convenience stores, the tough guys who think they're hot stuff, who think they can play hardball as well as the big-city boys. You peer over at the kid's face. At least you don't recognize him.

“You're right,” you say to J. T. “It's gotta be drugs.”

J. T. is setting up to start the central line in the groin. He has a pair of sterile gloves on so that, to stay sterile, he has to push his glasses into place with the back of his wrist as he looks up at you. “You going to crack this kid's chest?” he asks.

You don't answer him. You are still thinking—two gunshot wounds to the chest…You need to look at his back to see whether the bullets went all the way through the body.