Emergency! (2 page)

F
riday night in the South Bronx. It's the middle of summer and the beginning of my twelve-hour night shift in the Emergency Department of a level one trauma center. The day had been warm, and I knew this would mean a busy night for major trauma. Warm days had everyone out on the streets. Mix this with the alcohol, drugs, and handguns in the community and you've got a violent combination.

The action began with a bang: A young man shot in the chest over an argument about drugs was taken to the operating room. A husband and wife who had stabbed each other followed; he was moved into the backup trauma room for observation of a superficial chest injury, while she had to go to the operating room for her abdominal stab wound. The trauma room was just cleared when we were called by paramedics bringing in a Hispanic male with a gunshot wound to his head. Another drug deal gone bad, I thought, and we began to set up for his arrival.

The paramedics moved his motionless body onto our trauma gurney. There was no spontaneous breathing or movement. He was already on a ventilator, and IVs were in place. The bullet had entered his head on the right side, just above the ear, and exited on the opposite side in nearly the same location. We monitored his blood pressure and heart rate. There wasn't much else to do.

The neurosurgical resident and I agreed we should get a CT scan of his head for completeness and then call the organ transplant team.

I left the trauma room and was writing up his chart when security
informed me that the young man's family had arrived. I never get accustomed to breaking the bad news to families, but, after doing it so many times, I didn't even hesitate and headed for the small waiting room at the end of the hall. I entered the room and was surprised to find only one middle-aged man quietly sitting on the bench.

I shook his hand as we introduced ourselves. I told him I had bad news and explained the injury and the poor prognosis. After a brief pause, I asked him if he would like to see his son. He nodded, eyes closed, and said, “Take me to Louis.”

We entered the trauma room where Louis was covered to mid-chest with a white sheet. After closing the door to the noise of the Emergency Department, the trauma room became quiet. The stillness was interrupted only by the steady swish of the respirator and the quiet beeping of the cardiac monitor. I left the room to give Mr. Ramirez time alone with his son.

Outside, I quickly sutured a patient with a scalp laceration and checked a sore throat before returning to the trauma room to bring up the question of organ donation. As I entered the room, Mr. Ramirez was kissing Louis on the forehead. He slowly turned to me and I could see the moisture in his eyes.

“Doctor,” he said with a thick accent, “did you hear how this happened?”

I shook my head. I didn't know any details, but working where I did, I guessed it had to be related to drugs or a gang fight.

“Louis was on his way home from night college. He is the first one in our family to finish high school and the first one ever to go to college. He is only nineteen. He works during the day in the bodega on 149th and Third Avenue and twice a week at night he goes to City College. We are very proud of him. His mother is still in Santo Domingo with his two sisters. Only he and his fourteen-year-old brother came with me to New York. Tonight on the way home, he saw his little brother across the street fighting with some other kids. When Louis crossed the street and pulled the kids apart, one of them drew a gun and shot him. Doctor, he did nothing wrong.” His voice began to crack. “Please help him.”

His pleading eyes stared at me and I had to look to the floor to escape them.

“I know we don't have insurance,” he said, “but here … maybe this will help to pay for a special test or to call in a specialist.” With those words he opened a wrinkled envelope he had taken from his pocket and offered me ten one-hundred-dollar bills. “This is all the money I have saved. I have nothing else.”

I gently pushed the money back to him and placed my hands on his shoulders. “I am so sorry, but there is nothing that anyone can do.”

The grief welled up in him from that deep and shadowy reservoir that runs back through our ancestors. As it overtook him, it pulled his face into the contortion of crying he had probably last known when his own father died. Beneath my hands he began to physically deflate like an air mattress with the plug pulled.

Overhead, I heard an announcement about an ambulance coming in with trauma. I knew we would need the trauma room. I started to guide him back toward the waiting room. He stopped and went back to Louis. He held the young man's face in his hands. Tears now freely ran down his cheeks.

“Adiós, hijo mío. Que Dios te acompañe.”

He touched his forehead to Louis's forehead.

I wished without hope that I would never have to feel this man's pain.

The overhead speaker: “Squad Eighty-four for Trauma One. ETA eight minutes.”

I gently took Mr. Ramirez by the arm and led him away. He was now compliant. I left him in the waiting room. His younger boy was there now. A volunteer would help them through the business of death.

I went back and sat down at the nurses' station. One of the nurses told me that the ambulance was here with the victim of a gunshot wound to the abdomen. I heard myself say, “Move Ramirez to the backup trauma room and get ready for the ambulance.”

My plug had been pulled too. I felt drained. So much injury to the spirit. When will it ever end?

JERRY BALLENTINE, D.O.

New York, New York

W
e were in the midst of an unusually busy shift in the ER when I examined a girl of sixteen or seventeen who was seated in a wheelchair. Her anxious parents had brought her in with a sprained ankle. I ordered an X ray of the ankle and said to my most aggressive and efficient nurse, Eileen, “Put some ice on the patient in room six, she's on her way to X ray.” Eileen grabbed a disposable rubber glove, filled it with ice, and entered the treatment room, seemingly in one fluid motion.

Once in the room, Nurse Eileen took immediate note of the bulbous and oversize nose on my adolescent patient and slapped that ice pack right on it. “We'll get you to X ray right away,” she said as she quickly moved on to her next patient.

Somewhat confused, the parents moved the ice pack from the abnormally shaped but uninjured nose and placed it on their daughter's swollen, tender ankle. Eileen, seeing this, ran back into the room, snatched the ice off the ankle, and replaced it on the now tearful patient's nose.

“Leave it there,” said Eileen menacingly as she jogged off to the next patient. The family, now wondering if they had taken their pride and joy to the right hospital, quietly removed the ice pack from the cold nose and replaced it on the injured ankle.

Enter Eileen one last time. Seeing the family interfering with her attempts to ease the patient's suffering was the final straw. Eileen looked the parents right in the eyes and told them, “If you don't leave the ice where it belongs, the swelling will never go down and your daughter could end up with a funny-looking nose for the rest of her life.”

MICHAEL I. GREENBERG, M.D.

Wayne, Pennsylvania
         

A
new intern was nervously taking a detailed history from a prim elderly woman concerning her abdominal pain. She was nearly deaf, and the questions from the intern were being relayed by this lady's grandson, who would lean over and shout in her ear. As the intern went through a long list of standardized questions, the entire ER listened in—not only to the shouted questions but also to the answers given in this nice old lady's piping voice.

Finally, in an effort to determine if the abdominal pain was from an obstructed bowel, the intern asked, “Are you passing any gas?”

The grandson dutifully leaned over and yelled in her ear, “Grandma, have you been farting?”

The old lady drew herself up and replied in a voice that penetrated every corner of the department, “Not me, must have been the doctor!”

BRADFORD L. WALTERS, M.D.

Royal Oak, Michigan
        

T
he rescue squad arrived with a twenty-eight-year-old male. He was badly bruised about the face, neck, and upper torso, with a fair amount of generalized swelling and abrasions. He was clearly despondent, and the paramedics confirmed that he was extremely depressed. Apparently he had taken an overdose of pills several hours prior to his arrival in the Emergency Department.

When asked about the type of medication he had taken, the patient admitted to using a fifth of vodka to wash down several nitroglycerin tablets in an attempt to kill himself. In response to questions about the bruises on his head and chest, he became even more despondent and described how he had repeatedly and quite forcefully rammed himself into a wall in an attempt to make the nitroglycerin explode.

ROBERT G. POWELL, M.D.

Ashland, Virginia
         

I
never knew the baby's name. This was not due to an oversight on my part: No one ever
gave
him a name. A pity, for the baby was a fighter and deserved better.

It happened during the mid-eighties at St. Barnard's emergency room on the South Side of Chicago. It was a rough neighborhood—and a correspondingly rough ER. If it was nasty and it happened in our neighborhood, it came to us. I remember treating paramedics bleeding from facial lacerations caused by bricks thrown through the windshields of their ambulances.

I was a moonlighting resident. I needed the money. I needed the experience even more. The Barnyard, as it was known to all other hungry residents, provided both. This particular night I felt especially blessed: We were double covered. Charlie was out of his residency, boarded, smart, and willing to teach. I remember feeling that with him behind me, the shift couldn't go wrong.

Then, they all came in at once: an unresponsive, hypothermic drunk; a screaming, bleeding man who ended up on the receiving end of a disagreement conducted with kitchen knives; a scared, hypotensive seventeen-year-old who had just delivered herself of a pregnancy she had up to now kept secret; and the seventeen-year-old's just-born baby.

Charlie and I looked at each other. Welcome to the Barnyard. “I'll take the stab wounds, you take the baby,” he said. “Then you take the drunk and I'll take the mother.”

The baby. My God, he was a little peanut of a thing, laying on the stretcher and gasping. I had never put a ventilation tube into the lungs of a newborn, much less a preemie. The baby laryngoscope blade barely made it in his mouth.

I said a there-are-no-atheists-in-foxholes kind of prayer, and the tube fit between the vocal cords. We had him ventilated, and we had a pulse. But the pulse was too slow for a neonate: sixty. So, we did chest compressions, and I put in an umbilical line and started pushing the drugs. I tried to guess a weight. How can you guess the weight of a smidgen-sized soul?

Still, the baby held its own. He was stabilized. Time to call the neonatologist and arrange for a transfer. They got her on the phone for me. Her first question: “How much does the baby weigh?” I didn't know. “Well, get a weight. If he's less than five hundred grams, there is no point in continuing the resuscitation. They can't survive at less than five hundred grams.”

So we all stood around and stared at our baby, the baby we had got back from death, while the nurses rounded up a nursery scale. It felt like the whole ER staff stood there as I lowered him onto the scale. The neonatologist stayed on the line, and even Charlie strayed in, having single-handedly saved everyone else in the department in the meantime.

Less than five hundred grams. Not even close enough that I could fake it. A roomful of faces fell simultaneously. “Just pull the tube and forget about it,” said my neonatologist. Easy for her to say. She wasn't looking at the kid. I hung up and walked over to the baby, turned off the line, pulled the tube from the lungs. In my naïveté, I thought that would be the hard part. We all stood there, mute, watching him.