Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (38 page)

The poor drug reps. We get a visitation every day. Once upon a time they were unsmiling men dressed in cut-rate brown suits, carrying stodgy sample satchels. Now they are attractive young women, well dressed and elaborately coiffured, the clip, clip, clip of their high heels a marked contrast to the soft padding sound of the usual ward sneakers. They come bearing gifts: drugs—often hundreds of dollars' worth of samples—for the doctors to pass on to their patients, friends and family. Then the added inducements: notepads, calendars, expensive pens, refrigerator magnets, ice cream scoops, flashlights, clinical guides, business card holders, boxes of tissues, timers, T-shirts, canvas bags, key rings, decks of cards.

The problem is, of course, that in order to dispense these gifts, those well-dressed, well-heeled young women have to actually come into the ER and see this life firsthand. Yesterday, for example, the pleasant, terminally blond Abbott drug rep stood giving her usual speech (“This drug extends the spectrum of coverage to include Varicella and
Yersinia pestis”)
while opposite her in room 10 a pathetically manic woman, who an hour before had set fire to her hair, sat up on the gurney screaming at her: “Fuck me, fuck me, fuck me, you Teutonic goddess.”

This is the real world of the ER. And tonight it's all around, evanescent yet eternal, lit only by cold fluorescent light, the sole illumination for this nightless place.

I glance at my watch. Ten after two; the trauma phone should be going off shortly for our first drunk-driving accident of the evening. Meanwhile there are a stack of charts in front of me that need to be dictated, another stack that needs to be signed, yet I just sit here, not reading the magazine in my lap. I should really be thinking about my future, my life post-emergency medicine. After all, I've done this now for over ten years. Isn't it time to stop spending my life hunkered down over screaming, manic burn patients and start thinking about a career? But try as I might, I can't imagine life without this place—the crazy hours, the screaming babies, angry mothers, the bizarre drunk William Burroughs look-alikes, the respectable businessmen wearing nylon stockings and panties under their suits, the psychotic rap poetry issuing from an out-of-control schizophrenic tied down in the psych cubicle. I could leave them all behind and return to the world of the living, a world where no one could ever imagine that this other world, almost an anti-world, existed.

Over the years I have tried to tell people about what life is like in these little rooms. The best I have done is to come up with this analogy. Imagine you are standing in a field somewhere, a brightly sunlit field with flowers, trees and birds. There is also a rock at your feet. You bend down and pick the rock up to look at the ground underneath it. There you see worms and bugs and slimy slugs and things that scurry to get out of the light.

That's what life is like in the ER. Every day at work is like picking up a rock just to see what's underneath. And whatever it is, it's pretty much guaranteed not to be a pretty sight.

Two weeks ago I was asked to appear on a panel, a presentation about emergency medicine for a medical student “Career Day.” There were five of us official emergency medicine physicians sitting in a row at a table in the front of a lecture hall. Three dozen students gazed down at us as we each gave a little rundown on our lives and our “lifestyles.” Most of it was party-line stuff. During the question-and-answer period, though, one of the students startled a panelist into an honest answer. “Why did
you
” he said, looking at the doctor sitting next to me, “go into ER?”

My colleague thoughtfully searched the ceiling. Everyone sat very still; even we panelists wondered what he would say. Wasn't this the most important question?

“Because I have a very short attention span,” he said, scratching the back of his head and smiling.

There was silence and then a number of students started coughing. Nobody laughed. Remember—this was a group obsessed about their future. Then the question was passed down the line of panelists. The woman to the left, a director of a large suburban emergency room, said she got into ER in order to get out of an impossible surgery residency. An academic physician next to her said he liked the trauma and liked the research questions that could be asked about trauma.

After the last of the others on the panel trotted out his or her answer, they passed the microphone to me. I held on to it for a moment, trying to compose my thoughts, what thoughts there were. As I did so, I stared across at the sea of faces in front of us, all so young, so splendidly well educated, so wealthy, privileged and impossibly naive.

“Well,” I said, trying to smile, “my mother was an alcoholic.”

All sound evaporated. The room became perfectly still, not another cough.

“And my grandfather, my dad's dad, was an alcoholic.”

No one moved.

“I know this doesn't answer your question in any way that applies directly to you—everyone has to find his own way. But in some ways, for me ER is all about family baggage, the stuff I dragged into adulthood with me.” I could feel myself groping for a moment. “Like my granddad.” I made a gesture meant to evoke a distant prairie. “It's funny, because I never met him. He was my dad's father. Dad was raised on a farm on the plains in eastern Montana which is the poorest, most godforsaken piece of tundra you ever want to see. In the thirties it was the northernmost reach of the Dust Bowl of the Great Depression. You can't—none of you sitting here can really quite imagine it. That land was bitter cold in the winter, and it was winter up there pretty much all the time. Martin—my grandfather—tried to farm it all the way through the Depression years, but he was a man who never had a bit of luck. There was no water—no rain—nobody to sell anything to, no nothing, for over ten years.

“You know those courageous settlers who came here from the old country with just a dream and ended up in a new world rich beyond their imagination? Well, Granddad wasn't one of them. At the tail end of the Depression he gave the farm up. In 1940, or thereabouts, his youngest daughter died and my grandmother left him. A year later his three boys went off to fight in World War Two. Granddad was left alone up there in the badlands with nothing but drink to keep him company.

“The last time my dad saw him was after the war. It was the middle of another bitter-cold winter. Granddad was working on a dam project down south of Bozeman. He was in his fifties by then, living out of a little wooden shell he had built himself on the back of his pickup truck. He was pouring cement all day and drinking two pints of whiskey a night. By then he was coughing so bad he could scarcely smoke a cigarette. So Dad took him up to Missoula to a tuberculosis sanatorium. And Granddad died there of advanced TB: a drunkard's death. Nobody knows where he's buried.”

I paused.

“That was my granddad.” I shrugged. “And my mother…”

I stopped again. The room remained ghostly quiet. I could hear myself breathing. I was afraid of what I was going to say next.

“Every day,” I said, “every day I go to work and I see my granddad. I see the drunks and the addicts, the people who have fallen right off the edge of the earth. I see people who have made every bad move anyone could make, made every major mistake there was to be made, and by the time I see them, they are paying for it, sometimes with their lives. That's why they came to the ER.

“When you work in emergency medicine, you are seeing patients who are the least common denominator as far as human beings go; people who are heartbreakingly stupid and ditty and drunk and high and obnoxious—unbelievably obnoxious. These people have all flowed out of the darkest side of life. And when you are finished with them, that's mostly where they'll return. So each of you who is thinking you want to go into emergency medicine will have to ask yourself, ‘Do I really want to do this?’” I tapped my chest. “I know the answer for myself—every day I work I'm taking care of someone who is just like my grandfather, someone just like my mother. But everyone in this room needs to ask himself or herself, ‘Do I want to spend the rest of my life with addicts and idiots and drunks and psychotics? Is this what will make me happy?’ “

I peered at all of them over the top of the microphone. “Very few sane people answer yes.”

I passed the microphone on. I had said my piece and made a complete fool of myself to boot. I scanned the faces in front of me. Everyone was staring toward me, but not actually at me, each face with mouth slightly ajar. I had a feeling deep in my bones, a not unpleasant and faintly snobbish feeling, that of all the young students sitting in that room that day, not one would go into emergency medicine.

B. now sits down next to me, steeples his bloodless hands and picks up his paperback. Next to him on the desk is a thermos-style coffee cup with a drug company logo on its side. There's the reality issue again. I lean forward. “You should put that in your book,” I tell him, pointing. He looks at the cup and then back at me. “You mean…the coffee cup?” I look at him and realize that he isn't my problem. I am my problem. Just as I think this, the trauma bell goes off.

“I'll take it,” I say, patting him on the back as I stand. Better to keep busy. B. nods, absentmindedly tapping the Dictaphone in his breast pocket. A man without demons.

I head out toward triage looking for Donna. From the hallway, I can see her sitting at the triage desk, musing over the electronic blood pressure monitor. Digital readout is 123/99.

“What's coming in?” I ask her as I reach the door.

“Trauma-wise?” She shrugs. “No idea.”

“Who took the call?”

She shrugs again. I lean a little further into the triage room and can now see the patient whose blood pressure she is taking. He is a middle-aged man in a business suit, the suit coat folded carefully on his lap, and he's wearing aluminum foil. He has an aluminum foil hat perched on his immaculately bald head, aluminum foil tents on each shoulder and rings fashioned from aluminum foil on each finger of his right hand.

“Well, the thing is,” Donna is telling him, “when they talk about safe sex, what they really mean is
condoms
…”

I walk on. I don't want to know any more. Another inexplicable patient.
Inexplicable.
This was the second one tonight. Donna had triaged one just hours before. She told us the story. A man brought in a very pregnant woman, clearly far into active labor. He ran up to the triage window and screamed—panic stricken—
“She's gonna have a baby right now.
”

Donna barely looked up.

“You the father?” she asked him.

“Of course I'm the father.”

She pulled out a triage form. “What's the patient's name?”

He turned to lean over the mother of his child and asked, “Honey, what's your name?”

Donna gave me the look she gave him: deadpan incredulity. “He didn't know her name,” she said, shaking her head. “Didn't know her name…”

There was another inexplicable case yesterday, a trauma that did not go well. It was the worst kind of case, tragic and, well, weird. A man of thirty-five came in via EMS—gunshot wound to the abdomen. He had an innocent-appearing injury, a single, small jagged hole in the right lower abdomen from which a small tongue-like piece of fat extruded. The patient was alert and awake, but his blood pressure wasn't so great. As I checked him over, I started my usual trauma history routine.

“What's your name?”

…Jamie Something…

“How old are you, Jamie?”

“Fifty-two.”

“You have any medical problems?”

“No.”

“Take any medicines?”

He looked at me. “Yeah.”

“Yeah, what?”

“I took a lot of pills.”

“You
took?
”

“Yeah, I took.”

“Today?”

“Yeah, today.”

“What did you take?”

“Aspirin, man, I took a bottle full of aspirin. Then I drank bleach, you know, bleach for clothes.”

“Were you trying to hurt yourself?”

He looked at me, scowling. “I was trying to
kill
myself.”

“And then you got shot?”

“Yeah.”

I gazed at him, confused. “Did you shoot yourself?”

He gave me another look. “Are you crazy?” he said. “Why would I shoot myself?”

I opened my mouth, closed it and opened it again. I was trying to figure out what to ask him when Donna said, “Oh boy, guys. We're losing his pressure here.”

There it was: 62/40. While we were chitchatting, the patient was drifting away.

“I got a bad feeling,” Donna said as she prepared a second line.

The patient's words echoed in my head. “…aspirin, man, I took a bottle full of aspirin.” I had that same bad feeling. This guy was going to die

I put a central line in, put down an NG tube to wash out the aspirin, started blood, clotting factors, everything. The surgical team arrived, took one look at the patient and whisked him immediately (stat!) to surgery. There they found that the bullet had transected the right iliac artery, one of the twinned vessels that reaches down to supply the legs. Also there were by now several liters of blood in his gut. All this was fixable; what he needed was blood transfusions and a vascular repair. But even with transfusions at maximum volume, he remained severely hypotensive—and even after an uneventful vascular reanastomosis and a quick closure, he was just barely hanging in there. And then he, quite undramatically, faded away—died—the next day, at noon, twenty-three hours after he arrived. Everyone knew what he died of: diseases with lots of initials (ARDS, DIC, ASA OD) but no one I talked to had any idea how a man who wanted to kill himself with an overdose of aspirin somehow came to be shot by somebody else.

And so it always goes, the life of a doctor—stories, stories, stories. Some that end in a great denouement and a life saved. Others that fade to nothing or fade to death. And each story takes place in a setting of complex banality—the ER with the triage desk littered with coffee cups and streaks of dried blood, the dingy linoleum floors, the posters: Y
OU HAVE THE RIGHT TO A SCREENING EXAM
and S
EATBELTS SAVE LIVES.
The zombie paramedics, surly nurses smoking out in the well light of the ambulance bay, breath smoky from the cold alone.