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At this time of the morning—two, three, four o'clock—lonely people seek solace in the fluorescent light of the emergency room. If you've been to a twenty-four-hour grocery store late at night, you may have seen the same people. They hesitate, put a can of soup back on the shelf, then take it down again and put it back in the cart. Refugees from the daylight world, they move with the timidity of those whose lives don't mesh with others'. —Paul Austin (1)
In a Friday night ritual played out in a myriad of high school stadiums across the South, I suited up in a football uniform (Figure). Following the game, I left the locker room dressed in another uniform consisting of white pants and a white shirt and headed to the emergency room (ER) of a local community hospital where I had a job as a medical assistant. My “Friday night lights” were no longer the pageantry of stadium lights but the institutional hue of fluorescent bulbs. The 60 or so minutes it took me to transition from the rough and tumble world of a varsity football game to the surreal hum of the ER always engendered some degree of incongruence in me as I garnered some unusual and atypical coming-of-age experiences. What my teammates may have thought about my postgame activities never occurred to me. They tended to congregate after the game at a nearby pizza joint called Gigi's, having their own coming-of-age experiences, probably involving beer and cheerleaders.
This job started innocently after I volunteered in the ER, where I was made to feel useful doing minor tasks. Somehow I parlayed this into a real job at the impressionable age of 15, making $1.80 per hour in the hospital's summer program for students. Our small group was expected to periodically present ourselves to the hospital administrator and give an account of our activities. Surely he had more pressing duties, but he listened patiently and even with interest to our reflections. The following summer, having achieved the more legal working age of 16, I was back in the ER, this time with the title of male nursing assistant. When the school year started, I was asked to work weekend night shifts. Retrospectively, I realize that this was the year my innocence began to recede into the ethereal mist of maturity. I held this job intermittently over the next 7 years, finally giving it up 2 weeks before starting medical school. After nearly two decades of teaching internal medicine, I have begun to reflect on the uniqueness of my coming-of-age experiences in the ER.
One of the most time-consuming tasks ER physicians do is suturing. It also ties up an assistant, usually me, who stood by to cut the suture after each knot was tied. Quickly I learned the cryptic lingo of suturing: “Give me a four-O silk with a P3, five-O gut, 2% with.” After a week on the job, I began to scrutinize the lacerations, predict what type of suture would be requested, and place it in my pocket. When the doctor stated his preference, I would retrieve the suture from my pocket and open it onto the sterile tray. If I guessed wrong, I was usually off one size and reached in the other pocket where I had a back-up supply. The plastic cabinet with its pastel-colored rows of pink, green, blue, and yellow packages of sutures fascinated me. The more exotic and rarely used sutures were typically requested by the plastic surgeons for complex wounds. One day a surgeon wanted the suture presaturated with hyaluronidase, a suture I had been wondering about. After he explained what hyaluronidase was, I felt secure in the knowledge that I might be the only high-schooler in Georgia who knew what hyaluronidase was all about.
Working the night shift exposed me to the duality of trauma and alcohol. The typical scenario was an inebriated male who had survived a car wreck and had been evaluated by the ER doctor; by 2:00 am, the only chore left was locating a plastic surgeon to suture the patient's facial wounds. It seemed to me that the same plastic surgeon was always on call, weekend after weekend, sometimes a little snarly for lack of sleep. Frequently these patients were uncooperative, demonstrating a colorful if limited command of the King's English and emanating an aromatic triad of vomit, beer, and blood, which did not endear them to the arriving surgeon. Encountering such a situation, the plastic surgeon would typically mutter his own version of the King's English and ask me to summon the nurse, who would then deliver some intramuscular nostrum that would render the patient mute. Then we would get down to business.
When the patient was transformed, so was the surgeon. His professionalism took over as he went about the process of mending Humpty Dumpty, and his demeanor improved as he immersed himself in the task at hand, happy to converse and answer my questions. Often he would quote Shakespeare to my growing appreciation. Several hours and innumerable stitches later, we were done. Invariably, the patient would wake up and ask how many stitches it took. His stock nonanswer was, “You ever ask a painter how many brush strokes it takes to paint a room?” This reply rarely encouraged further inquiries from the patient.
Some years later, I read No Man Alone, the autobiography of neurosurgeon Wilder Penfield. I had been accepted to medical school and was biding my time, working numerous ER shifts. During our usual late night encounter, I mentioned this book and told the plastic surgeon that I was considering becoming a neurosurgeon. He stopped mid-stitch, looked up with consternation in his eyes, and retorted, “You know, you have to be a son-of-a-bitch to be a neurosurgeon, don't you?” I let his personalized career advice sink in while we finished.1
This youthful encounter with suturing would have a reprise in my junior year of medical school, when I sauntered into the surgical emergency clinic of Grady Memorial Hospital about 6:00 am on my first day of the rotation. “Good morning, do you know how to suture?” was the unisentence greeting from the guy in charge. “Absolutely,” I said. He took me into a room and introduced me to a patient who had sustained a knife wound starting just west of his left ear, journeying south past the mandible, continuing tantalizingly close to the carotid artery, over the clavicle, and down the parasternal region, and then hooking east around the apex of the heart. Having committed myself, I spent 2 unassisted hours sewing. Once done, the inevitable question came: “Hey doc, how many stitches did it take?” Gazing down on my handiwork, I experienced a brief reverie contemplating the number of brush strokes it took to paint a room. “Eighty or so,” I slowly replied.
The unique rhythm of each shift in the community hospital ER began to permeate my sense of being. The mornings were typically slow, but ER admissions began to escalate about 10:00 am, often due to construction accidents. A summer afternoon thunderstorm would predictably produce a series of car wrecks caused by rain-slick asphalt. Stationing myself near the front entrance, I would open the doors as soon as I heard the approaching sirens. Evening hours filled the ER with patients who had suffered throughout their work day and finally realized they were ill and needed help. The minor traumas associated with daily life peaked in the late afternoon and early evening.
But it was the night shift that I began to favor. One physician, who preferred working the night shift, was fond of saying at about 6:00 am, “Well, it is about time to go home and open a can of breakfast.” I must have looked puzzled the first time he told me this because he augmented his comment with “Budweiser.” The nurses and ancillary staff working the night shift were edgier, quirky, and even fun. So were the patients—a strabismic subset of souls, representing what Somerset Maugham called “humanity in the rough” in his novel Of Human Bondage.
Working a weekend night shift while I was in high school, the charge nurse called to the front where I was doing vital signs. “Get the doors open. The police just called. Three ladies were involved in a bad wreck on I-85,” she instructed. Standing on the ambulance ramp, I briefly savored the silent sounds of night, the air heavy and redolent with the scent of magnolias that lined the parking lot. Minutes later, emergency medical responders came roaring in with three horrifically blood-encrusted women. Within moments, the charge nurse called again, demanding, “Get back here. We need your help.” What I quickly deduced was that these three women were actually three men. Fortunately, despite all the blood, they were not seriously injured. The ER doctor tasked me with obtaining urine specimens from all three. One agreed to produce a sample if I left the room. Another, clothed in a skimpy garment, suddenly jumped off the stretcher and disappeared into the ladies room. The third and most injured patient, with a large laceration horizontally traversing the whole of his derrière, discreetly utilized a urinal I provided him. I doubt if the words transvestite or cross-dresser were in my vocabulary at that age. However naive I may have been about human sexuality, I knew enough to recognize that what I had witnessed was unusual. I was not sure what to do with this lesson, but I filed it away.
Poets define death better than most. Consider the poetry of Jim Harrison who notes, “Death steals everything except our stories” (2). Or live Pablo Neruda's lines from Solo la Muerte:
Death arrives among all that sound
like a shoe with no foot in it,
like a suit with no man in it,
comes and knocks, using a ring with no stone in it, with no finger in it,
comes and shouts with no mouth, with no tongue, with no throat.
Nevertheless its steps can be heard
and its clothing makes a hushed sound, like a tree (3).
Death checked into the ER when I least expected it. My problem was recognizing death when it arrived. Once, it was the guy in front of me at the triage station looking perfectly healthy complaining of “a little chest pain.” The drill instilled in me by the nurses was to immediately move any patient with chest pain to the chest pain room. While briskly commandeering a wheelchair, it was disconcerting to suddenly see this patient on the floor, looking perfectly dead, thus initiating me into the small fraternity of 16-year-olds with an applied knowledge of cardiopulmonary resuscitation.
The poet-cardiologist John Stone, a pioneer in the field of emergency medicine, has been described as “a mentor in the country of hearts,” and he was a mentor to me. He wrote in the most lyrical way about the heart, having more metaphors for the heart than the heart has beats. Years after my vestigial ER experiences, I discovered a poem he had penned, called “Death”:
I have seen come on
slowly as rust
or suddenly as when
finds the doorknob
come loose in his hand (4).
I had heard the silent doorknob moments and lived what this poem meant. Death also came in a shoebox—a box with no shoes in it. A quiet morning was made quieter when an ambulance driver handed me a shoebox containing a stillborn infant lying on a towel. Not knowing what to do, I walked to the back and put the box on a stretcher. The nurses gathered around. It was a paradoxical moment that seemed more infused with the awe and wonder of birth than the sadness of death. “He's like a perfect little peanut,” a red-headed nurse remarked with reverential poignancy.
Death often presented in the more traditional disguises: car accidents, gunshot wounds, being thrown from a horse, motorcycle wrecks—or just old, sick, and rusty as the last grains of sand slowly slid through life's hourglass one last time. Whatever the costume, death's final act was always unoriginal.
Years later, during my internship, I rotated through the medical emergency clinic of a large inner-city hospital. I must not have looked busy, because a nurse handed me four blue sheets and barked, “Ramp consult.” As I sauntered out to the steamy ambulance dock, a well-dressed funeral director mysteriously appeared and opened the side door of the hearse and politely pulled back the cover. Although it is generally obvious when people are dead, I went through the motions of shining my penlight at the pupils, maybe even checked for a heartbeat. The first hearse slowly eased away as the second and third idled into place. Same drill. Exceedingly polite, sartorially perfect, deferential to a fault, the couriers of death opened the door, pulled down the cover, and let me attest to the obvious. The fourth one glided forward. Standing by expectantly, no one materialized to open the door. From the corner of the ramp I heard a hushed voice beckon, “Hey Doc. Over here.” I tread into the morbid shadows. The driver made small talk regarding the August heat wave enveloping the city. “Yes,” I agreed, “it has been miserably hot.” “The guy in the hearse, he's been dead for about 3 weeks. In an un–air-conditioned house,” was his next comment. Engulfed as I was in the crematorium-like heat, this was a statement I immediately recognized as a pungent amalgam of information and advice. I signed his form, trusting that his carriage held the mortal remains he claimed. If life was not always perfect, death also had its imperfections.
Even though I trained as an internist, the allure of the ER never quite deserted me. As soon as I was legally qualified, by dint of completing my internship, I began moonlighting in various ERs and urgent care centers. During my training I worked a multitude of ER shifts and hundreds more in my 6-year air force career, including moonlighting at a hospital in upstate New York that stretched the limits of my advanced trauma life support training. In my teenage and college years, much of what I did in the ER was supervised by the nurses or was a physician directive filtered through the nurses. Good nurses are worth their weight in gold, a lesson I am reminded of every working day of my life. When the ER doctors realized I was serious about my desire to attend medical school, my interaction with them became more direct. To a degree that I did not appreciate until much later, I understand now that I modeled much of my professional behavior on the doctors and nurses with whom I had worked in the ER.
Another physician for whom I worked later left emergency medicine to pursue training as a psychiatrist. Reacquainted with him 20 years later, we now converse regularly about mutual patients. He does not recall how one night I was puzzling over a blood pressure reading of something like 220/0 that I had just obtained on a patient with a head injury. “Probably Cushing's reflex,” he said. The next day he thoughtfully showed up with a handbook on blood pressure for me to read. The nature of the lessons in the ER was becoming more and more about building medical knowledge. But the first and most important medical lessons I learned—about life, death, and caring—were taught to me by the ER physicians and nurses of a local community hospital to whom I would like to say thank you.
The author kindly wishes to thank the following people for their editorial comments on this manuscript: Art Kellermann, MD, Terry Repak, PhD, and Karen Stolley, PhD.
1 I have subsequently encountered a number of neurosurgeons in my medical career and do not necessarily agree with his dire character assessment.