Life and Death in the ER

I am regularly asked if my work life resembles the long running TV show ER.  It does, although with two major differences.  First, the doctors are obviously not as photogenic.  And second, a single episode of ER condenses down perhaps 6 to 12 months of excitement into a one hour episode.

But sure, all the plot elements are there.  The tipsy, the belligerent, the heroic and the foolish. 

Most of what I do in our rural setting is routine work.  People really do use the ER as their primary care clinic, so it is a good thing that I spent many years looking in ears, removing splinters and wood ticks, pondering rashes of uncertain duration.

But eventually the bad stuff turns up.  Sometimes you can predict it.  A convergence of alcohol, motor vehicles and the tragic sense of youthful indestructibility seems to be largely a summer weekend affair.

And sometimes you have little to no warning.

I won't soon be forgetting a case from a few years back.  (Professional ethics requires me to blur some details in the telling).

The first warning is usually the police scanner.  A sudden increase in chatter, a bit of tension in the voices, maddeningly few early details.  We knew there had been an accident.  We knew it sounded bad.  We knew the ambulance was heading out.  And we had a location.

It's enough to work with, given the expected half hour it would take the ambulance to get there, load quickly and return, we would be ready.

The trauma bay was cleared.  Potentially needed equipment and personnel were called for.  Other patients in the ER were told they would have to wait.  A family with a young child was warned that things could get a bit scary shortly.

And in ten minutes, not thirty, the patient was there.  His friends had not waited for the ambulance, they had simply thrown him into their vehicle and driven as if pursued by Furies.

No pulse.  No pressure.  Blood everywhere.  Chaos as we threw ourselves, only half ready, into an attempted resuscitation.  It was a young man, his heart was strong.  You could see it marching out stalwart electrical activity on the monitor as it futilely tried to pump blood that was now congealed on the floor of his friend's SUV.  We tried to put direct pressure on his wounds, but it scarcely mattered, with each CPR compression of his sturdy chest nary a drop of blood oozed out.  He had bled out in the first couple of minutes after the accident.  His pupils were fixed and dilated.  Neurological death had already occurred, he was in effect just waiting for the bureaucratic ruling to catch up with him.

He was young, so we tried hard.  We did what we could, which was too little and far too late.  And at the end we did not even know his name.  I was still wearing my gloves-which give me slightly ridiculous Barney the Dinosaur hands-as I reached into his pocket for his wallet.

I flip it open and there, opposite his drivers license, was a picture of an adorable child, perhaps three years old.

Covered in blood.

There are some very hard phone calls to make.  Sometimes people have no clue that their life is about to be radically, horrifically altered.  And sometimes they do.  Late night calls, calls when a loved one is far from home.  From much practice I have gotten better at giving the bad news in person, but over the phone....

It is impossible to read the person on the other end.  Impossible to convey any condolence that will register at all in the face of overwhelming, surreal, discordant tragedy.  You say what must be said as best you can.

There is one unexpected benefit to leaving clinic based medicine and moving to the ER.  I am never "on call" at home.  As a parent of three children I am happy that the phone does not ring, unexpectedly, in the small hours of the morning.