ER - The Real Thing
by Dr. Mo Lerner

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"My husband lost it?" "I'm afraid to die alone." "Won't it grow back, doc?" "Two amps of Bicarb, serum rhubarb and a crit star."

The recent popularity of TV shows dedicated to Emergency Rooms and hard hitting pressure-packed medical dramas would have made Ben Casey and Dr. Kildaire proud. But is this high-powered and glamorous portrayal realistic? Which of the aforementioned cries can be heard in the hustle and bustle of the ER. and which are bogus Hollywood hype?

As a former ER and paramedic director, and having practiced in numerous ER settings over the past several years, I can tell you with considerable authority that nothing, and I do emphasize nothing, can compare to the real trauma and tragedy, laughter and hysteria, and bizarre, yet at times mundane life in the real ER. There are probably a thousand remarkable stories I could relate to you. But I will share the first few that roll off the top of my head because, frankly, each and every experience has been interesting.

An alcoholic whose hands became frostbitten some weeks earlier when he fell asleep out in the cold, presented with his wife. A few of his fingers on the dominant hand had insidiously become hard and mummified as a result of gangrene. Lacking any feeling or useful function in these digits (which literally resembled burned tree branches), he simply cut them off with a scissors. "When will they grow back Doc?", he asked with puppy-dog sincerity, while his wife wept.

An elderly nun was told that she was in terminal kidney failure. She sobbed mournfully, clutched my hand, and wondered if she had done the right thing. "I have brothers and sisters with families-beautiful children, and what do I have to show for my life? I don't want to die alone." I was a young inexperienced doctor at the time who had always assumed that people of the cloth were blessed with some special motivation for matters beyond earthly pursuits and pleasures. Were they not immune to the fear of death, welcoming it instead as a gateway to a superior existence? I brought another terminal renal failure patient (who had come to terms with her situation) to see the sad sister. It was in early experiences such as watching these two work through their grief together that I learned one of many valuable lessons: the art of empathy. It seems that we do not feel so badly about our misfortunes when we know that we are not alone.

"My husband lost it", a stoic unkempt visitor from the city's core area of homeless wanderers told me. "Lost what?" I inquired, but she turned her head away in silence and obvious embarrassment. A pelvic exam soon revealed the answer. I had seen these items as a kid at the back of what used to be referred to colloquially as "Girlie Magazines". I suppose it started out as a prophylactic to which the manufacturer added twenty brightly colored tentacles and fancy ribbing on the shaft. It resembled one of those hokey celluloid monsters from outer space, popular in the 60sB movies. French Ticklers indeed! I doubt that this item tickled the poor woman or had anything to do with France. It caused a serious and painful infection.

As an ambulance service director I was responsible for reviewing audio and electrocardiogram recordings of all incidents of collapse and resuscitation attempts on scene in a big city. The suddenness with which life threatening events were thrust upon loved ones and the strain on pre-hospital personnel was often too painful for me to audit.

I'm not sure why the mournful cries and yelps of a dying bachelor's faithful hound still ring in my ears. Maybe it has to do with my love of animals, or perhaps I cried one too many times while watching the movie Gray Friar's Bobby. It was almost as touching as hearing the trembling voice of my chief paramedic training officer trying to display professional composure as his colleagues delivered electric shocks to his father who had just died in his arms.

An elderly man came in to the department with a terribly bruised chest. Assuming that he had been robbed and beaten, I ordered the usual battery of tests and offered to call the police. Then he told me how he sustained his wounds.

The man was a shut-in who was an avid fan of the mother all ER television dramas, Emergency. You remember the one; the paramedics were named after old automobiles/parts and all patients received 'two amps of bicarb start'. My elderly gentleman astutely noticed that every few minutes the TV paramedics would come across some poor collapsed soul, feel for an irregular pulse, then thump the chest. as a means of initiating cardiopulmonary resuscitation. So while he was watching the latest episode, my patient decided to check his own pulse which, of course, was irregular. For three hours he pounded his own chest hoping to make the heart beat more regularly until he finally knocked himself out.

I could barely maintain my composure. He survived. Desoto would have approved.

Some of my colleagues at the big city tertiary care ER centers think they have it rough with a constant flow of patients. But just like on TV, there are specially trained and equipped personnel and trauma teams on call on a twenty-four hour basis for immediate back-up. My baby sister who is an ER psychiatrist will attest to this fact.

Picture in contrast the rural or smaller ERs. I have worked in all types of ERs but there is something very gut wrenching about being the lone physician on duty with a skeleton (albeit dedicated) staff in a small potential gun and knife factory. For example: One night a young mother with two toddlers clinging to her legs, attended the ER because her estranged husband assaulted her. He had been incarcerated once before for beating his wife and he was all too aware, as his wife ran out of the house with their little ones, that he would likely soon be back in prison. The mixture of guilt, shame and terror at the thought of returning to prison was too much to handle.

While I was tending to his wife and children, this man's father found him hanging by a telephone cord. Because this was a rural setting and the son had destroyed the phone, the grief stricken elderly father had to travel twenty miles to get help. An ambulance eventually brought the obtunded son to me.

After I cut a hole in his throat in a futile effort to revive him, I had to deal with his guilt ridden wife still smarting from her own wounds. She stood by her dead husband weeping and apologizing for a relationship that turned a wrong corner somewhere. At four in the morning I had to cope with two sets of grieving parents in the waiting room.

It seems like just the next night a man wearing a balaclava burst into the ER demanding we attend to injured people outside. Three teenagers lay on the cobblestones outside the sliding glass doors. Minutes later, I recall rushing my large frame from room to room attending to these three trauma victims, two of whom had serious spinal damage that would leave them partially paralyzed for the rest of their lives. Suddenly, a man suspiciously similar in appearance to the bella clavaed perpetrator, ran through the ER screaming "I'm on fire help me!" He was and we did. The emotion and physical strain of dealing alone with four seriously traumatized young men as well as others in the department cannot be adequately portrayed even on the best of television dramas. However, the rest of the story might have generated a good screenplay.

The local Mounties (I'm Canadian) did not take long tying together the tragic tale. It seems the balaclava-ed assailant and his cohort were town bullies out on a drinking binge earlier that night. They stole a small vehicle and went on a joy ride when they came upon three young athletes who were setting up a tent for a weekend of camping. It is not clear whether it was the multi-racial background of the boys that caught the eye of the bullies or just the fact that they were in the wrong place at the wrong time, but the ruffians picked this moment to start beating them. Naturally frightened and surprised by the attack, the three campers jumped into their own vehicle and fled. But the tormentors pursued the vehicle, eventually running it off the road. The vehicle flipped several times before its occupants were hurtled into a ditch.

Down the road a bit, the hooligans realized they had done something wrong and went back to the scene. Finding their victims mangled but still alive, they did the next worst thing they could have done to compound the damage. The three victims were dragged and stuffed in to the back of the small stolen vehicle.

The perpetrators, who obviously were not up to date with the first aid dictum that states one should never move a trauma victim, sped off to our hospital. They threatened to kill the victims if ever they revealed what had happened.

Once at the hospital the stuporous victims were dumped unceremoniously at the hospital front entrance, compounding further any damage that had been done earlier. But the story did not end there. The assailants now plotted to ditch the stolen vehicle and started to douse it with gasoline in order to destroy the evidence. That is where fate intervened and made one of the perpetrators meet justice. His clothing caught fire. Engulfed in flames, hysterical and intoxicated, he fled on foot almost a mile to the hospital. His partner in crime tried to tackle him although it is not clear whether his motivation was to help him or prevent him from revealing their dark secret.

To be sure, dealing with the families of both the victims and perpetrator that same night, as well as the subsequent court proceedings and publicity surrounding the incident, were traumatic. But this is all a part of the strange genre of ER life.

Sisters killing brothers, workers crushed to death beneath rolls of newsprint, babies choking, mothers hemorrhaging, psychiatric patients decompensating and all too brief lulls before the storm of more pathos.... I have experienced them all and then some.

As a doctor and especially as an ER specialist, I have often heard things that people would not even share with their spouses. Perhaps it is the white coat, or perhaps it is the panic and realization of one's mortality that turns doctors like me into priests apparent. This experience has led me to wax philosophical about what I call the universality of thought; we all love to be loved, need to be needed and hate to be hated.... We just express these things differently.

Having been under considerable stress, I woke up in panic the other morning partly because of my work I suppose. I am told that ER staff have shorter life expectancies. That's life in the real ER. And by the way, we rarely call for serum rhubarbs or 'crits' anymore. ß

Heretic Physician