Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (22 page)

82 percent…82 and holding.

When you run a code, everyone moves as if they are running through water. Time dilates and what only takes a minute seems like hours. All that time. Alisa finally returned bearing the bottle of sux aloft.

“A hundred milligrams,” I told her. The problem with sux is that it causes the stomach muscles to contract. More aspiration. There were ways to prevent this, but they all took time.

81…80.

The patient was still seizing, head thrown back, face contorted, arms jerking. Charcoal was everywhere.

Sux in. Pulse ox 80 percent, an oxygen level low enough to cause brain damage.

80 percent and holding.

Slowly, slowly, slowly, the jerking became more pronounced but less frequent. Finally, after one last spasm, Marilyn lay still.

Her jaw moved easily in my hand.

Now I had to get the tube through the larynx, past the voice box and through to the trachea. To do this, I used the blade of the laryngoscope to lift the tongue and part of the voice box out of the way to see the narrow tube, the trachea, and, within it, the twin shutters of the vocal cords.

“I need suction,” I said. The respiratory therapist handed me the Yankhauer. I tried to vacuum up the charcoal as best I could, but even so, as I pulled the tongue out of the way with the laryngoscope, I still couldn't see the larynx. I readjusted the blade. Nothing. No vocal cords. The only thing to do was to poke the ET tube in the general direction of the larynx, and hope for the best. I did this. Again. Nothing. The ET tube was hanging up somewhere. I couldn't get it in.

76…75.

I threw the tube on the floor. “Get me a smaller one,” I shouted.

Somebody scrambled for one. We bagged the patient as best we could, but the pulse ox stayed at 75 percent. She was not going to last long here.

I looked again. More charcoal. Please, dear God, I prayed. Just this once. (I know I always say, Just this once.) Someone handed me a narrower tube. I flexed it, inserted the long wire stylet and bent over once again to pass the tube into the dim, charcoal-coated reaches of Marilyn's pharynx.

“You in?” Alisa asked breathlessly as I straightened up.

“I don't know.” I pulled out the stylet and attached the Ambu bag. The respiratory therapist gave her a breath. Her stomach rose and fell, not her chest. I was in the esophagus. No good. I pulled the tube out. “No,” I said.

I looked down her throat again with the laryngoscope. I could see only the tip of the epiglottis—the sentinel of the larynx. I made another pass, roughly where I had passed it before.

Once again I pulled out the stylet. We reattached the Ambu bag. One breath, two. The chest rose and fell this time, a good sign. I managed to find my stethoscope to listen for breath sounds as the respiratory therapist bagged madly.

Breath sounds. Good breath sounds. We were in.

As I straightened up, I realized that my back was killing me. I clasped my hands together; they were trembling.

We all looked down at the patient, at Marilyn. The respiratory therapist was in the process of wrapping tape around the endotracheal tube to hold it in place. What next? I thought wearily, looking around the room. What fresh disaster awaired me now?

Marilyn's fate was sealed anyway. Destination: ICU. Diagnosis: overdose, seizure, aspiration. I called the medicine service down. Two internal medicine residents arrived, glanced at the patient and then huddled for twenty minutes with the lab reports. Great, I thought, they get to take hours to go over a decision I had to make in seconds.

The senior resident came over to me.

“You know,” he said, trying to look casual, “you probably should have intubated her before you gave her the charcoal.”

“I know that
now,”
I said. “But there was no way to predict when she came in that she was going to seize. I can't intubate every overdose I see. Most aspirin overdoses do okay.”
You idiot,
I thought.

The resident shrugged and gave me a look that said, if
he
had been here…

I turned my back on him, wondering. Should I have known? Did I miss some clue, something somebody else would have easily seen? I wasn't sure, and the uncertainty made me feel sick inside.

An hour later Marilyn finally went up to the ICU. Afterward I stood in the empty room for a moment bathing in a transient sense of relief. She was now someone else's problem. I looked around the acute room. It was a disaster. Charcoal everywhere, blood on the floor, ET tubes, plastic stuffing, packaging material scattered all over, a garbage bin turned on its side. I stooped down, uprighted the garbage bin and began stuffing trash into it. I didn't think I could handle a task more complicated.

I could hear the recrimination already: the Monday morning quarterbacks, doctors whose specialty is second-guessing any decision involving a patient that goes sour. It's an occupational hazard of the emergency room doctor. This case was particularly bad. After all, I had been one of the doctors who complained about Dr. Daiquiri's prescribing habits. He had already complained to the ER director about me. He was gunning for me in a major way, and I had just handed him a whole boxload of bullets.

But nobody ever said a word to me. Perhaps it was the nature of the case, or that long list of medications on the face sheet of the chart. Other ER shifts intervened and I went on to fresh disasters. Marilyn's and my brief therapeutic relationship was over—or so I thought.

Not quite. My life touched Marilyn one more time and that, surprisingly enough, was in the Medical Records Department. Well, perhaps not so surprisingly. The ghosts that haunt doctors are all housed in medical records. They haunt us because every day minions from Medical Records comb through these charts looking for “incompletes.” Signatures not entered, procure notes absent, discharge summaries never dictated. All these missing pieces are tagged for doctors to complete, to sign or dictate—which, of course, the doctor never wants to do because the only thing more boring than signing charts is dictating them. Some doctors will be in arrears with over a hundred charts at any one time. You find scores of them in the Medical Records Department, a heart-stopping pile of records in front of them. They are only there signing charts now because the hospital has suspended their admitting privileges.

It's as if some kind of giant medical mom has told her kids they are grounded.

One night, though, I sat alone in the department. I was working my way through a stack of charts when I found myself opening Marilyn's. It had been six months since everything happened, and I had entirely forgotten her. Now, though, I felt that old rush of nausea.
The charcoal, the charcoal,
I thought again.
Should I have known she was going to aspirate?
Then the nausea subsided and I grew curious about what had happened to her. I started paging slowly through the chart.

She arrived in the ICU and immediately went into ARDS—adult respiratory distress syndrome, a toxic reaction involving the lungs. Then she became septic—bigtime septic—the medicine service thought so, anyway. She was started on three different antibiotics but kept spiking fevers through them. Nobody knew why. Then one of the antibiotics damaged her kidneys so much they almost completely shut down. She was on renal dialysis for weeks.

It occurred to me, as I paged through this chart, that Marilyn had come perilously close to getting what she wanted. She didn't want to die, she had told us, but she didn't want to be alive either.

At last things evened out. Her kidney function returned. Her lungs cleared up. The team transferred her out of the ICU to the floor six weeks after she was admitted. There was another setback, though, a small stroke. She ended up in the hospital rehabilitation unit and had been discharged only a few days ago. Hence her chart was here for my signature.

The weird thing, though, was that after my initial ER dictation, nowhere in the chart did anyone say anything about Marilyn's drug problem. The suicide attempt was taken care of by having a psychiatrist visit her once for twenty minutes. His consult note said she was no longer suicidal; she was depressed secondary to problems in her marriage and would benefit from marital counseling. Nothing about all the drugs. Nothing about the massive amount of painkillers and sedatives Marilyn required during her stay. The doctors had saved Marilyn's lungs, her kidneys, her guts and her brain, but they ignored her addiction, the problem that had brought her here to begin with.

The last progress note in the chart stated that Marilyn was now off dialysis, tolerating an advanced diet and able to ambulate without assistance. Vital signs stable.

Patient discharged in good condition. Referred back to her primary doctor.

Patient to follow up with: Dr. Daiquiri.

9

H
OW TO
B
URN
O
UT

Y
OU NEVER KNOW
you're burned out. When the stress of the job starts destroying mental software, the capacity for personal insight is the first to go. At the onset of
your
great burnout season, the scorched-earth years of
your
life, the only thing you really notice is that just about anything that happens gets on your nerves. The other symptoms: the hair-trigger temper and ferocious mood swings, the trembling hands and the uninterrupted string of hangovers; none of that really registers. You just go on as you always have, pushing through too many shifts, too many patients, too many sleepless nights and harrowing days. Meanwhile, your marriage goes to pot, your kids get screwed up and that nagging back pain gets so bad you start prescribing yourself painkillers for it. A few T#3s can take the edge off any bad day. Face it, though, how can you complain? What are your little tragedies compared to the carnage of bad luck you see at work every day?

Finally, though, one day, you see that you are falling, falling—but you have no idea why. Even now, after you have moved to a sleepier life, there are still moments when, say, some particular song comes on the radio. Or a smell, or the distant sound of an ambulance siren, lonesome as a train whistle. Then, suddenly, there you are again:
Icarus.

Why should this ever come as a surprise? On the first day of your internship, the surgeon who ran the Trauma Department told you and your fellow interns that by the time you all finished your residency, “The divorce rate in your class will be a hundred and fifty percent. That's because some of you will get divorced, remarry and get divorced again.” The surgeon was proud of that. And from that first day on, you went to work in terra incognita. A land unlike any place you had ever seen.

During the worst years it was like getting up in the morning and going into war. Things happened in that small clutch of examining rooms that no one else had ever seen. And if you tried to talk about it, to your spouse or your few friends who did not work in ER, you would get the fisheye—a look of suspicion and disbelief. They didn't really want to know; they certainly didn't want to believe and you couldn't blame them. Even if they were interested, they didn't have the right mind-set to understand what all of you working in the pit relearned every shift. The dead end of rage, the sordid stupidity of drunks and addicts; the awesome destructive power of bad luck. Everyone in that other world, the “real” world, lived in a cocoon of safety. You didn't want to be the one to tell them how much of an illusion that cocoon is.

Only cops seem to know these things. There is a secret fraternal order of people on the front lines. Members include the ambulance drivers who scrape up pedestrian victims smeared across a roadway by hit-and-run drivers; orderlies who wheel the dead bodies down to the morgue late at night; strung-out, exhausted nurses; the even more strung-out ER doctors on the tenth shift in a row. Only insiders could take for granted the casual lunacy of, for example, the patient you saw last night. He was a seventeen-year-old kid—acutely, horribly psychotic—but no drugs, no alcohol—just out there on his own personal pathway to destruction. The police took him into custody after he had set the garage on fire and then tried to stab his little sister. This loopy kid was brought to your Bedlam and, amidst all the other chaos, everyone had to stop what they were doing to get him tied down. As you did, the kid fought back like mad, and all the while he
barked—
barked like a dog. Not just random barking, either. He was barking, of all things, “Frère
Jacques.”
Bark, bark,
bark,
bark, bark, bark,
bark,
bark. Nothing would shut him up. You tried sedating him, then you stuck him in a side room with the lights turned out. Nothing worked. He just kept barking, barking, barking, until, finally, the boys from the state psychiatric institute arrived to cart him away. By then you were ready to go with them.

Or that case last month when a sixteen-year-old driver struck another car that was driven by a woman who was eight months pregnant. It was just a fender bender, neither of them more than just shaken up. When the police arrived a few minutes later, the kid told them, “It was my fault,
my fault.”
Ambulance 19 brought the woman into your ER, where you watched her for a couple of hours and then released her. The kid refused ambulance transport, went home, shot himself in the head and came in, just as the woman was leaving, as a traumatic arrest. He had left a suicide note that you found pinned with a safety pin to his plaid flannel shirt. The note read in its entirety: “Brain dead.”

There was the thirty-four-year-old mother of three whose mild right-hand weakness on admission evolved into a massive stroke that left her completely paralyzed, but—and this was the saddest part—still alive. You were in the grieving room for what seemed like years that day, sitting across from the husband, watching him sob helplessly, while next to him the three kids, the oldest only eight, watched him and cried as well, although they didn't know why…

There was the beaten baby, dying as you tried desperately to get an IV in somewhere, anywhere…

And there was that mother of a gunshot victim, a kid shot by the police in a drug raid. You went out to talk to her, and she stood there in the middle of the ER waiting room, screaming right up in your face that she would kill you, you motherfucker, she'd kill you if anything happened to her son. And you were
pissed.…
“For Christ's sake,” you screamed back at her, “why are you yelling at me?
I
didn't shoot him. I'm just trying to save his fucking life.…”