by Will Smythe
The emergency room in any metropolitan academic medical center is a busy, quirky place. It is set physically apart from the remainder of the hospital, its location often at the figurative and literal edge, or “fringe” of the institution.
During the day, these places might have the feel of a clean and efficient factory – one where patients are evaluated and treated by the cheerfully caffeinated daytime crew, busily shipping them, like new cars, into and out of the facility.
However, at night they can seem something more akin to a neighborhood Irish pub – walls removed but everything and everyone else left intact, dropped into the middle of a battlefield. At these times you will likely find there a predictable group of “bartenders, servers, patrons, bouncers and combatants” – emergency room specialists, surgeons, nurses, technicians and orderlies along with the intoxicated and / or somewhat deranged local “regulars”, interspersed with the real wounded. All of these people gather in big city emergency rooms around the country each night to provide for, or to seek, solace and relief.
It was almost midnight in one of these very places – the downtown emergency room in Philadelphia where I was training as a surgical resident, and it was Christmas Eve. I was sitting at the long, low chartreuse Formica covered nursing desk facing the main intake door – where the ambulances and fire rescue vehicles entered the covered area just outside, and emergency medical technicians and orderlies moved patients on stretchers into the facility. Sitting was actually unusual for me when on call in the emergency room, but I was enjoying an unusual break in the surgical consult action, and talking with two nurses that were sharing with me the intermittent, but unavoidable health care employment pleasure of another holiday away from home.
One of my more self-admiring professors of surgery had once informed me a few years earlier, with his deep bass voice and in a tone that suggested that he felt he was imparting some secret, profound knowledge, “you know son, people get sick 365 days a year, and disease never takes a holiday.”
Once I had recovered from this shocking revelation, I thought about the fact that although disease may be averse to celebrating anything, my professor obviously was not – he told me this as he was leaving the hospital to go to his home in Bryn Mawr, a stately Philadelphia suburb, to enjoy his own uninterrupted Christmas dinner.
The Christmas dinner I was looking forward to on that particular night, if lucky enough to find the time, was a turkey hoagie from “Bucky’s Lunch”. Bucky was a tough guy from South Philly, about my age, who had inherited his food truck, a year or so earlier, when his father was no longer able to cut the mustard, or the cheesesteak to which it was added, due to the ravages of diabetes. Bucky was there every night, parked outside the emergency room entrance, a cigarette dangling precariously from his mouth, his short dark hair slicked back, sporting a yellowing wife-beater tank top – one that was often freshly spattered with something that looked as if he had tried to stab one of his famous marinara-covered meatballs to death.
“Hey! You want oil an’ oregano on that Christmas ’ toy-kee, doc? Yo! How ‘bout some red peppers, huh? Yeah! Hey! Imagine ‘em like cranberries! Cranberries! Get it, doc? Get it? Yeah! Roasted reds! Red peppers, red cranberries, ya know?… Damn, I’m crackin’ myself up here”…
I wondered whether or not Bucky himself, unlike disease perhaps, would be taking a holiday tonight, on Christmas Eve, or if he would be in his usual place. It was cold out, but not too bad for December in Philly, and there was probably a short wait in the food truck line as the hospital was staffed more efficiently during the holidays. Bucky would be unlikely to be serving up wassail or fruitcake, but a hot cup of his (perpetually bacon-flavored, for some reason) coffee and some cheese fries didn’t sound half bad.
“Bucky out there tonight?” I asked the nurses.
“Don’t know, but I’ll tell you what, it’s quiet in here – real quiet.” the one sitting closest to me replied, without looking up, as she paged mindlessly through a magazine.
“Yeah,” I replied, smiling and wincing at the same time, “don’t jinx us!”
“Too late,” the other nurse sitting next to her commented laconically as she flipped through a patient chart, “we’re probably screwed now.”
It’s common medical lore that a comment regarding a light clinical load; especially at night, can invite an onslaught of illness and activity – ER visits, patient admissions, and transfers from other facilities, etc.
I thought to myself – It has been a quiet night, especially for Christmas Eve. No trauma since earlier in the afternoon – only a couple of cardiac patients in the last couple of hours…
I thought about the last cardiac patient that had been brought in. I watched the emergency room physician defibrillate, or “shock” him several times, as he had come in with an obvious heart attack, or “MI” as we call it, and an associated arrythmia, or abnormal heartbeat. I stood off to the side of the bed, behind the nurses in attendance as the ER doctor placed the shiny metal paddles with faded yellow rubber handles on the elderly man’s chest, his worn red plaid flannel shirt unbuttoned and opened wide to expose his the bony, white, hairless surface.
“Everyone clear!” he had yelled out. The patient’s body rocked quickly from the left and then to the right, convulsing as the electricity instantly flowed from the plug in the wall, to the box with the heartbeat displayed in green fluorescent lines on a little black screen, to the hand-held metal plates, and into his frail-looking and previously lifeless form.
The familiar aroma of slightly singed human skin and hair mixed with metallic electrical discharge wafted up from the bed and hung in the air – thick, yet invisible. I could smell it from several feet away. After four shocks, the patient’s normal rhythm returned, and with my hands shoved deep into the pockets of my long, wrinkled labcoat, I walked slowly back over and returned to my perch at the desk, watching the double set of sliding glass doors expectantly – this is a little too good to be true for being on-call during a holiday…, maybe I should sneak down the hall to the call room and try to get some sleep?
One might think of much of illness, and certainly death, as relatively uncontrolled and somewhat unpredictable occurrences with no volitional component whatsoever. However, those that have taken care of the acutely ill and dying with any appreciable repetition know better. Patients have a habit of throwing in the figurative towel on “anniversary” dates – their birthdays, birthdays of spouses, wedding anniversaries, and other days that hold some sort of significance – holidays perhaps, like Christmas Eve.
It is unlikely, for the purpose of example, that the departure of John Adams and Thomas Jefferson, two deaths that occurred in different places, but on the same day of the same year – a day that just happened to be the fourth of July, can be explained as a random coincidence. These anniversary dates are milestones that the mortally ill aspire to see and live through – prior to giving in, or giving up, on life. There is obviously much more to willing oneself to live, or at times to die, than molecular biology in all its cold rationale complexity can explain, because this phenomenon is reproducible.
However, in addition to this unexplained testimony to the human spirit, another more mundane set of general holiday-related circumstances can lead to the demise of those teetering unsteadily on the edge of good health, or good sense. The relatively immobile and variably infirm elderly often decide to suddenly become mobile around these times – to visit relatives and shopping malls, for example, with predictable consequences. In addition, the relatively immature and variably deluded of no particular age often decide in good holiday cheer to drink or use other mind-altering substances well above baseline, often combined with other activities such as operating automobiles or perhaps handguns.
As a third year surgical trainee, I spent most of the year as the “ER resident” – a common rite of passage at this level then, and now, in general surgery residency programs. By the third year, you have figured out how to manage most of what we term “floor” issues associated with caring for patients that are about to undergo, or have completed surgery.
The term “floor” indicates the area where patients end up once they no longer require the intensive care unit, or have left the emergency or operating rooms, and have been admitted to what one might consider a normal hospital ward. A common dictum among surgeons is “cut well, sew well, do well”; however, you can certainly cut, sew and do most everything in surgery perfectly, or as close to perfect as possible, and still be dealing with a substantial problem a few days later. One never truly masters all of the needed skills to deal with these issues, but by the time you have handled several hundred, perhaps a few thousand of them, it’s time to move on to other things – time to leave the “floor” to the first and second year residents, and move “down to the ER”.
The nurses sitting at the desk fell silent, once again engrossed in their reading and enjoying the unusually quiet interlude. I was unaccustomed to this sort of inactivity, and it made me vaguely uncomfortable, perhaps due to the fact that it gave me the opportunity to think about what residents-in-training and prison inmates refer to as “life on the outside”.
I put my head in my hands, stared blankly ahead, and pondered the fact that my little girl would wake up on Christmas morning without my being there – again. I thought back to two years earlier, when as a surgical intern, what we call a first year resident-in-training, I was introduced to the concept that holidays were at best considered optional. The most senior trainees on this service were the cardiac surgery residents, those that had finished general surgery and were now in their sixth or seventh year of clinical training following medical school. On this service, it was only interns, and cardiac surgery residents. Unlike other services, there was no hierarchical buffer (mid-level residents training in years two through five) via which to send questions up and down the ladder anonymously. We were working directly with these guys, and for the most part, they despised us and our lack of knowledge and experience – both of which made their jobs more difficult. It didn’t help that the cardiac surgery residents were usually surly to begin with – their patients were sicker than most, their hours were longer than most and they were both tired (perpetually) and ready to finish training.
The other intern on the service, Boyd, was an oral surgery trainee, and due to the fact that oral surgery training was phase-shifted a half-year when compared to general surgery, to allow for the completion of the dual D.D.S. and M.D. degrees, this was his first clinical rotation to my sixth. Boyd was a tall, gangly-looking guy with a head that seemed too large for his body, a somewhat fake-looking black pencil-thin moustache, a Buddy Holly hairstyle and heavy-framed retro looking glasses. He had a heavy Brooklyn accent, and his first words to me after the usual introductions were, “Hey, I’m a surgeon, okay? I’m not a gum-gahdener, and don’t fuggitit”. Unfortunately, Boyd might not have been a “gum-gahdener”, but he wasn’t much of a cardiac surgery intern either.
The Chief of Cardiothoracic Surgery, an athletically built man with a thick shock of prematurely white hair, would walk briskly through the cardiac floor each day, checking on his patients. He always had his pastel button-down long sleeve shirts rolled up to above the elbow, exposing muscular forearms, with his preppy striped tie always slightly off center at the collar, suggesting motion even when he was standing still. He discerned fairly quickly that Boyd was a little over his head, remarking to me after only a few days, his Jason Robards look-alike countenance smiling as he spoke, “looks like Boyd is going to struggle this month. I suggest that you do whatever you need to do to make sure that the patients get the same care”, the smile leaving his face at this point, “whatever you need to do, son.” I was pretty sure that this meant that I needed to work harder than usual, rather than a request that I murder Boyd, but I wasn’t sure.
Despite his challenges, Boyd had two redeeming qualities, at least in my eyes. First, he was a very kind man, and cared a great deal about the patients and their problems, despite the fact that he often did often did not recognize them as problems until the nurses or I pointed them out to him. Second, the cardiac surgery intern rotation would span the month of December, Boyd was Jewish, and I was a Southern Baptist. At that time, prior to the work hour restrictions that medical trainees and programs have to adhere to at present, we took “call”, or worked and slept in the hospital every other night.
Boyd and I discussed the upcoming holidays, and decided that we would each take two nights of call in row so that each could have one day off.
Boyd had a family as well, including two small children – but he graciously offered to structure things so that I could have off both Christmas Eve and Christmas day. Once we came to this agreement, I told him that I would inform the cardiac resident. During a lull on the floor the next day, I walked up to the operating room area and found him in a hallway talking to an attractive young nurse. I had not met him, as another cardiac resident had been responsible for supervising the care of the floor patients and working with the interns the first couple of weeks. However, I recognized him from the early morning teaching conference we attended each week, where as interns we tried, with great ambition, to hide on the back row and consume as many doughnuts as possible.
They were laughing, and as I approached. the nurse waved coyly at me, her hand raised slightly from her waist, and smiled. The cardiac resident; however, didn’t turn to acknowledge my presence.
“Dr. Rose,” I said tentatively, “I’m one of the cardiac surgery interns on the service this month.”
“So?” he replied, still with his back to me.
“Uh, we, uh, the interns that is – you know, Boyd and I, wanted to ask you if it was okay for us to double up on call for the holidays – to take two days in a row, so that each of us could have one day at home with our families”.
He now turned quickly, and looked at me. There was no expression in his face at first, but as he spoke, he developed a smile – no, a smirk, I thought, a little confused.
“Absolutely not… Absolutely not,” he said, flatly, but forcefully, “let me put this in terms that even someone as stupid as you can understand.” He stopped and glanced at the nurse to insure that she was listening.
“If you wake up at home, you sleep in the hospital. If you wake up in the hospital, you sleep at home. You got that?”
My mind faded back to the present. At least I don’t have to put any toys together tonight, I thought, and smiled sadly. I imagined my daughter’s excitement, regardless my absence, as she crawled into bed.
I had spoken to her on the phone earlier, right before bedtime, at which time she had asked me, “does Santa Claus come to the hospital, Daddy, to see the sick people, and the doctors?”
“You never know, honey,” I replied, “I hope so. Sure, I bet he will.”
I imagined my daughter curled up in her bed, and the curved, “apostrophe” shape her little figure always made in under the covers once she drifted off to sleep. About that same time, I noticed something flashing over by the ER doors. The now familiar swirling red lights begin to rhythmically reflect off of the shiny metal frame of the outer doors and then the glass, followed then by the frame and glass of the second set of doors leading directly into the ER – indicating that an ambulance had arrived.
“Another one coming in”, I mumbled. Neither of the nurses even looked up.
“Probably another MI,” said the nurse rummaging through the magazine.
“Yeah,” I said, “seems to be tonight’s theme”.
The outside, then inside doors opened, and I could make out the usual forms – two emergency medical technicians, and the shiny tubular rail bars of a rolling stretcher carrying a patient. I noticed that they were moving at a slightly increased pace, a pace that indicated that this might be someone in need of more urgent attention. I lifted my head up out of my hands, and sat up from my slumped position for a better look.
As the stretcher entered the ER proper, I tried to make out the patient’s appearance, but it was too difficult, as the doors were about thirty or so feet from where we were sitting.
There was a third EMT, trailing the other two, holding something down on the patient’s body – back, or front? – I couldn’t make out which. There was a lot of red on the stretcher,… was that blood? Was that a lot of blood?
I stood up now, and the stretcher moved toward the desk rapidly. They’re heading to trauma, to the trauma bay, I thought.
To get to the nearest “medical” ER beds, the stretchers would turn right immediately after entering the ER, where there was a row of beds separated by curtains ready to accept patients with chest pain, shortness of breath, etc. However, if they were trauma patients, they were wheeled right past those beds, toward this main desk, and then a right turn would be made directly in front of where we were sitting to the “bay” or large enclosed room outfitted with all the necessary accouterments, where trauma patients were taken.
The EMTs obviously knew where to go without having to be directed – they were in here frequently, and knew their way around.
“Trauma?” I muttered, loud enough for the two nurses to hear, and they both looked up simultaneously.
As the stretcher drew nearer, I was able to make out that that red wasn’t blood after all. A somewhat obese patient was lying on the stretcher face down. He was wearing a crushed velvet red stocking cap, topped and trimmed in white fur, and a crushed red velvet long-sleeved waistcoat, also trimmed in white fur and with a wide black patent leather belt. His hair was white, and long, as was his full, long beard.
He was also, I noted with some muted interest, having seen many unusual sights down here, completely naked from the waist down, and the EMT that I had seen toward the back of the stretcher was now obviously seen to be holding large gauze dressing on the patient’s right buttock.
As the stretcher turned right in front of us to head toward the trauma bay, the patient shuffled quickly up onto his elbows, flipped the two nurses and myself off with his left hand, and said in a growling voice, red-faced, and smiling…
“HO! HO! HO!, YOU SONS OF BITCHES!”
I stood there motionless, my arms hanging limply at my sides for a long moment. I then turned and looked at the two nurses sitting next to where I was standing. The one nearest me was staring past me at the receding generous naked paired buttocks and feet of the patient, her reading glasses askance on her face, one lens partially on her right cheek, the other almost completely situated above her left eye.
The other nurse was slowly standing up, “what the hell was THAT?” she asked, nervously, “WHAT WAS THAT? “WHO… WAS THAT”
I turned again to see the stretcher disappearing into one of the trauma rooms, and one of the emergency room physicians in close pursuit. Right before he went in, he turned to us and yelled, “call a trauma alert!”
“Calling a trauma alert” meant that the surgical team on call for trauma would be mobilized to the ER. On most nights there was a faculty trauma surgeon, a fifth year chief surgical resident, and two or three other more junior residents on call for the trauma service.
All of the surgical residents in the hospital received the trauma page when the system was activated, and my beeper went off accordingly a few seconds later. The sound reminded me that it was my responsibility to go and begin the patient evaluation until the trauma team assembled, which normally took five to ten minutes. I reanimated, and ran over and into the trauma bay.
Just as I entered, I heard the EMT begin the familiar hand-off sequence, “white male, sixties, found down at approximately 2350, obvious gunshot wound to the left buttock, unconscious in the field – question alcohol-related, but vitals stable”.
The curiosity immediately overcame me, and I asked what could only be construed as a completely inconsequential question, at least medically, of the nearest EMT, “did you guys remove his pants in the field?”
“No doc,” he replied, “this is how we found him, no pants, no boots, no socks – nothin’ below the waist.”
A couple of nurses quickly entered the room, and the trauma alert “dance” would now begin. Everyone in the room had a particular task, or tasks, to perform in a pre-scripted fashion. This regimented, reproducible approach was important – it was what usually saved the life of the patient as it insured that the likelihood of missing something or not doing something important in a confusing emergency situation would be minimized.
The EMT’s would now transfer the patient to the trauma bed and remove the stretcher, one nurse would slap a blood pressure cuff on the patient’s arm, and the other would start an IV in the other arm. An emergency medicine resident, or a third nurse, would either remove or cut off all clothing necessary to complete these tasks, as well as to facilitate the physical examination to follow, and another nurse would stand at the entryway to the room and begin to record all data on the trauma flow-sheet.
My job, until the trauma team arrived, was to act as the “primary assessor”. The primary assessing physician started first by quickly evaluating the “ABCs” – which stood for “Airway”, “Breathing/Bleeding” and “Circulation”. The thought process here was that someone with a blocked-off airway, who wasn’t breathing, was bleeding massively, or had no blood pressure would require an emergent intervention to preserve life, and that these things should be evaluated immediately.
If the ABC’s were okay, then a focused head to toe physical examination would follow, and during the entire process the primary assessor calls out aloud the findings so that the team assembled, and the nurse recording will know what the issues are, and document it.
I knew that the patient’s airway was okay, and that he was breathing. If you can talk, I thought to myself, or Ho! Ho! Ho! you can obviously breathe. The EMTs turned the patient on his back and moved him over off of the stretcher and onto the trauma bed. I moved up to the top of the bed above the patient’s head, my designated position, as the nurses began their work below.
I leaned over and looked down at his face, which was contorted and angry.
“GODDAMNIT! THAT HURTS!” the patient yelled as his backside made contact with the hard surface of the bed.
His eyes were shut tightly, and the skin around them wrinkled concentrically in pain. His breath reeked of alcohol. I quickly removed the red velvet and white fur trimmed hat, and started to call out my exam to the recording nurse.
“Airway patent! Patient breathing! Normal rate!”
I felt around under the white thick hair on his head, “no cranial injuries noted!”
Just then, the patient’s face relaxed, as if a sense of complete calm had suddenly come over him. He opened his eyes, which were light crystal blue (and a little bloodshot), and looked up at me.
In a very measured, quiet, matter-of-fact voice, and with no expression, he said to me…
“they shot Santa in the ass.”
I stopped for a moment and looked out of the corner of my eye at the nurses assisting me. Did they hear that? They were working away normally. I refocused, and continued my exam. I reached under his neck, feeling the spine, and watched his face for signs of pain, at which time he winked at me, and smiled…, “uh…, no neck tenderness!” I yelled to the nurse.
Normally, at this point I would move down to the chest to feel the patient’s collarbones and shoulder joints quickly, for signs of instability, followed by feeling the ribs and breastbone, to rule out fractures. You never know when a patient who had been shot might have been also been beaten with a baseball bat by more thorough assailants at the same setting, or run over by a car – just in case the bullets weren’t sufficient.
However, I couldn’t stand it any longer – I reached down and tugged on the long white beard.
“OUCH!” he yelled, the calm replaced once again by the contortion and plethora, “SON-OF-A-BITCH! WHY’D YOU DO THAT?”
It was real.
One of the nurses looked up from the foot of the bed, and asked, “What hurts now, sir? What hurts?”
“It’s okay, it’s okay,” I replied quickly.
At this time, the trauma team arrived, and another resident stepped in to finish the exam. As I walked out, I turned to look and see the team “log-rolling” the patient’s body to evaluate his backside, “no lower spine tenderness!”, I heard my replacement call out, as he beat sequentially downward on the center of the patient’s back with his closed fist, then “gunshot entry wound, central right buttock!”
The red velvet white fur trimmed cap, and now shredded jacket were lying in the corner of the floor, and not even noticed by the new team.
“DAMN YOU! GOD-DAMN YOU”, the patient yelled when he was placed back to his original position.
I walked back out into the main ER, toward the desk.
The two nurses seated with me earlier walked up, neither had been in the trauma bay.
“So?” the first asked, “what the hell was that all about?”
I suggested that we go back over and sit down at the desk. We did, and the two of them sat at rapt attention, staring at me. I was trying to be as serious as I could possibly muster, under the circumstances.
“So?” the other asked, “are you going to tell us?”
I hesitated for a moment, and then replied, with a completely straight face “yes, I am. I have bad news for both of you, I’m afraid.”
“They shot Santa – they shot Santa in the ass.”
We all three erupted in laughter. The nurse that had been reading the chart earlier put her head down on the desk, and when she lifted it back up, it was obvious that she was laughing so hard that she was crying.
As I and the other nurse got momentary control of ourselves, the nurse with the tears on her cheeks exclaimed, “what am I going to tell my kids?” The juxtaposition of the tears, and this comment set all three of us off again.
We were laughing convulsively and wiping our eyes, at which time the sliding glass doors to the ER again flew open, and a dangerously thin black woman dressed in tattered dirty loose clothing, with a soiled dark blue bandana wrapped around her head ran into the middle of the room, right in front of us.
I immediately recognized the look – a crack addict. The bandana, or something like it, was always there, it was part of the uniform – there to hide the fact that due to the replacement of calories with the drug which so effectively stimulated the pleasure center of the brain (obviating the desire for food), hair began at some point to fall out in clumps.
She was holding the left side of her face, just below her left ear. Blood was spurting out of the other side of her head, at about the same location. It was literally shooting out of the side of her neck several inches into the air with each heartbeat, and out onto the floor, making a sickening “splischt” sound each time it fell there.
She stopped a few feet away, opened her mouth, and a torrent of blood ran out in a gush onto her chest, like a macabre, B-movie special effect. She somehow managed to scream through the fluid, spewing a fine spray now of blood out of her mouth as well onto the charts and papers in front of us, her eyes open wide – wild and panicked…
“THEY SHOT ME IN MY FACE! THEY SHOT ME IN MY FACE!
HELP ME, PLEASE! PLEASE! THEY SHOT ME IN MY GODDAMN FACE!”