Authors: MD Mark Brown
Emergency! (24 page)
8:35:
The tube has been secured with tape and the child is hooked up to a ventilator. O-negative blood has arrived and is hung. A catheter has been placed in the child's urethra to drain her bladder. I snake an orogastric tube into her mouth, past the endotracheal tube and into her esophagus to empty out her stomach. The surgeons are worried, because the child's belly is firm and slightly distended. The neurosurgeon would like to get a CT scan of her head, but the trauma surgeons suspect they'll have to explore her belly in the operating room first. They are arguing politely. The senior resident is looking at X rays of the chest, pelvis, and cervical spine as they come out of the developer.
8:42:
A second hematocrit comes back significantly lower than the first. Even though the patient's blood pressure is stable, everyone agrees she must be bleeding into her belly and needs to go to the OR. We begin “packaging” herâtransferring the IV bags, monitors, oxygen, etc. to the gurney for transport.
8:50:
The patient is wheeled out of the room with the surgeons at her side, leaving miscellaneous trash in her wake. The floor is strewn with needle caps, IV bag wrappers, gauze pads, and small pools of blood.
8:51:
I go see a new patient.
10:23:
The charge nurse has heard through the grapevine that the child had a double operation: The surgeons opened her belly while the neurosurgeons put a tube into the ventricles of her brain to relieve the pressure there. When they got chunks of brain matter back through the tubes instead of clear cerebrospinal fluid, they knew her brain was hopelessly damaged. The surgeons closed her belly back up without trying to find the bleeding site. The parents saw her for the first time in the recovery room and agreed to have her removed from life support.
11:45:
I am writing up another patient's chart when I find a loose computer label with the child's name on it lying on the counter. Under her name is a ten-digit hospital number and her birth date.
My eyes fill with tears and my throat begins to burn. I go to the computer room to make an entry into the procedure log.
11:50:
When I come out five minutes later, I am more composed.
VALERIE NORTON, M.D.
 Â
Los Angeles, California
I know you are coming.
The voice over the airways warns me.
A voice which shares so much more
than facts and vital signs
(it tries not to).
Panic, fear, anger, frustration
overpower the static
and tear across the miles to my ears.
You are coming, the voice says,
and you are dying.
Preparation by rote.
Multitrauma coming.
Open fractures, sucking chest wound, bad head.
Pedestrian, kid on a bike, no helmet.
Hit head-on by a car.
How old?
Maybe ten or eleven.
Force out the image that forms.
How far out?
Five minutes, no more.
I stand and wait quietly among assembled colleagues
and glistening instruments of resuscitation.
Arms folded, head slightly bowed,
eyes focused on the gray tiled floor.
I experience a strange detachment
from the activity taking place around me.
The trauma team.
Nurses focus on readying infusion sets and cut-down trays.
Technicians discuss the never-ending business of their day.
Residents, looking dog-tired,
gown up in silence, pulling on gloves and adjusting goggles.
Medical students and junior residents,
wanting to appear in control,
are betrayed by body language
and pressured whispers.
Their affected indifference only emphasizes
their not so hidden emotions.
I am moved by this assemblage.
But I fear that no matter how well prepared,
we will not be able to save you.
“Patient in the trauma room.”
The matter-of-fact, unemotional overhead speaker voice
announces your arrival.
Worse than expected.
Intubated, CPR in progress.
Long board, collar, sandbags, two lines running.
Well packaged.
Paramedics sweat from their efforts,
their eyes and voices telegraphing
their disappointment and stress.
The ABCs of trauma care are welcome friends.
I immerse myself in the ritual
of this incredible process.
Protect the spine.
Secure the airway.
Central lines.
O-negative blood stat.
Crystalloid challenge through fluid warmers.
Emergent thoracotomy.
Cross-clamp the aorta.
Open-chest cardiac compressions.
We perform your last rites
in our way.
When it is over
and there are no more tasks to perform,
no more traditions to uphold,
no more heroics to attempt,
your humanness
and the tragedy of your death
force their way back into my thoughts.
For the first time I see you,
not as another victim of blunt vehicular trauma,
but as a child.
Fine features.
Sun-bleached hair.
The smooth, unblemished skin of youth.
Lean, muscular, an athlete's build.
Two colorful braided friendship bracelets
tied about your left wrist.
A handsome boy.
We quietly and gently clean your body
and prepare the room,
absorbed in our own thoughts of
personal mourning.
Your parents are nearby
expecting news of a miracle.
I am unable to comprehend the devastation
my visit will bring them.
I will share my own sorrow,
offer an embrace of understanding,
and be there to answer questions of Why?
and assuage guilt.
As I cross the hall to the grieving room,
I am again awed by the profundity
of this very precious responsibility:
bringing the message
of sudden and tragic loss
to those who must carry on.
I count myself among the survivors,
forever changed in some immeasurable way
by each untimely death I witness.
So much injury to the flesh.
So much injury to the spirit.
Multitrauma.
GEORGE L. HIGGINS III, M.D.
Cape Elizabeth, Maine
    Â
I looked at the doors today. They were quiet, closed. Resting. Waiting
.
Earlier this morning they had brought in a ninety-two-year-old man. As he lay on the gurney, looking up at the ceiling in the glare of the treatment room, it suddenly occurred to me that someday this would be my son. My father would be a slight memory to him. I myself would be long dead. There would be grandchildren he'd played with that I knew nothing about
.
The doors will have brought him in on this final occasion to the people inside. What will they know of him, those people caring for him on that distant day? Will they see in that old man's face any of the young boy that I look at now? Will they know that he was once wildly cherished and that every single day he was in someone's most tender thoughts?
They won't know that. And he won't need them to know that. What will he need, I wondered?
Just their kind presence
.
T
he following is a collection of words used in the emergency room. Some are simply medical terms that appear in the stories and might be helpful to have defined. But they are interwoven with the slang of emergency medicineâwords and phrases that do not appear in the text or in any medical text whatsoever. The slang is included for your information and perhaps your amusement. Some of the language may seem degrading if not outright nasty. In that respect it reflects the ongoing process of using humor or sarcasm to blunt the emotional impact of working in the Pit.
A
GONAL
: Just before or accompanying death, as in: “The heart was in an
AGONAL
rhythm.”
A
MBU
B
AG
: Device used to ventilate a patient who is not breathing.
See
BAG
.
A
NEURYSM
: An abnormal and dangerous ballooning out of a vessel, especially an artery.
A
RREST
:
See
CARDIAC ARREST
.
A
RTERIAL
L
INE
: An IV inserted into an artery rather than a vein for the purpose of continuous monitoring of blood pressure.
A
SYSTOLIC
: Without a heartbeat.
See
FULL ARREST
.
A
TTENDINGS
: Full-fledged doctors who, after training, teach in Emergency Departments that train new doctors. (Often referred to as “offendings” by the
HOUSE STAFF
.)
B
AG
: To ventilate a patient with an
AMBU BAG
.
B
LADE
: A nickname for a surgeon. Surgeons are known to be bold and arrogantâoften wrong but never in doubt.
B
LEEDING
A
LWAYS
S
TOPS
: Need we say more?
B
OXED
: Put in a pine box (i.e., died).
B
UG
J
UICE
: Intravenous antibiotics.
C-S
PINE
: The cervical spine (the neck bones).
C
ARDIAC
A
RREST
: When a heart stops pumpingâi.e., the patient has dropped dead. Also
ARREST; FULL ARREST
.
See also
CODE; CODE BLUE
.
C
AROTID
A
RTERIES
: The two big arteries supplying blood to the brain.
CAT S
CAN
: Computerized axial tomography. A fancy X ray that shows the inside of the body. Also
CT SCAN
.
C
HANDELIER
S
IGN
: In the diagnosis of
PID
during the pelvic exam movement of the cervix produces pain so severe that the patient has to be scraped off the chandelier.
C
HARTOMEGALY
: From “chart,” referring to the medical record, and “megaly,” meaning large or exaggerated in size. Refers to the chart of a patient who comes to the hospital very frequently or is a
FREQUENT FLYER
.
CHF: Congestive heart failure. When a heart gets weak and sick, it can't pump blood very well, hence the blood does not circulate well and the blood pressure drops. In addition, the blood returning from the lungs to the weak heart tends to back up into the lungs, making the patient very short of breath. When the blood pressure drops and the lungs fill up with fluid, the patient is called
SICK
. Expect a
CODE BLUE
.
C
ODE
: To go into
CARDIAC ARREST
.
C
ODE
B
LUE
: Announced with a specific location, it means someone has gone into
CARDIAC ARREST
and needs resuscitation
STAT
.
CPR: Cardiopulmonary resuscitationâthe practice of squashing dead people's chests in hopes of squeezing enough blood to the brain to keep them alive for a few more minutes until help arrives.
C
RACK THE
C
HEST
: To open the chest in order to stop massive bleeding or perform open-heart massage.
See
THORACOTOMY
.
C
RASH
: When a
SICK
patient turns bad and starts to die.
See
DUMP
.
C
ROCK
: A malingering patient with bogus complaints, as in, “Every time the train goes by, my feet get numb.” Order a
STAT PORCELAIN LEVEL
.
CT:
See
CAT SCAN
.
CTD: Circling The Drain. A very
SICK
patient not doing very well.
See also
FTD; PBAB; STBD
.
C
UTDOWN
: When it is impossible to successfully stick an IV through the skin and into the vein, it becomes necessary to cut open the skin and dig down to the vein.
D
ASH FOR
C
ASH
: Helicopter transport of critically ill patients. These helicopters are often owned and run by private companies that charge big bucks.
D
EFIBRILLATION
: Using a machine to shock a heart that is quivering (not beating) in order to try to normalize the heart's electrical activity into a regular beat again. Also
SHOCK
.
DFO: Done Fell Out (passed out).
DOA: Dead On Arrival.
DSB: Drug-Seeking Behaviorâused to describe patients who come in with bogus complaints seeking narcotics in order to dull an otherwise unhappy life.
D
UMP
: This word has several meanings: 1) When a nursing home, a community physician, or another hospital
DUMPS
a
SICK
patient, (usually
NEGATIVE WALLET BIOPSY
) on the ER to be cleaned up and cared for. 2) When a
SICK
patient goes bad, he
DUMPS
or
CRASHES
. 3) As a noun: “The
GOMER
was a
DUMP
.”
D
WINDLES
, T
HE
: Failure to thrive, especially in a
GOMER
.
E
CHOLALIA
: The repetition of words spoken by others, as if echoing them (associated with mental illness).
E
CTOPIC
P
REGNANCY
: The implantation of a fertilized egg somewhere in the body besides the uterus. Most commonly this abnormal location is the Fallopian tube; therefore it may also be called a tubal pregnancy. Ectopic pregnancies can rupture and cause life-threatening bleeding into the abdomen.
EKG: Electrocardiogramâa tracing of the heart's electrical activity.
E
MESIS
: Vomiting.
EMT: Emergency medical technicianâa paramedic or an ambulance driver.
E
PI
: Epinephrine, or Adrenalinâa drug used to help restart the heart.
ET: Endotracheal tube; the plastic tube passed into the trachea (windpipe) when a patient is
INTUBATED
.