Emergency! (8 page)

It wasn't easy for him to say this, and he had to stop several times while trying; the mother, in her turn, could barely keep upright. “We know that you are already by God's side, because you were so dear to Him that He couldn't even wait until you were grown up to take you to Himself. Maybe we would have wanted to have you a little longer with us,” he said, and though he kept from bursting into moans, his voice trailed off into silence.

It must have taken him fifteen minutes to say this, several times in slightly different ways, because his voice kept breaking down, and he had to keep struggling to regain control. The mother's sobs were more and more frequent as the ceremony went on, and at one point she threw her face against her boy's. The minister reached for her, but the father got there first, and he lifted her head, softly, and stroked her hair. He didn't say anything, and then she said, “I'll be OK,” and managed after a little bit to lessen the shaking of her body, and quiet the moans from her mouth, so that gradually the father looked back at his son, and once more tried to go on. From an angle behind the mother I could see the nonrhythmic spasms of her shoulders, punctuated from time to time by a larger involuntary movement of her entire torso, and I could hear her occasional half-stifled cries.

I have watched death come many times, and seen many people struggle with it. Usually I can maintain some detachment, even when it's a sudden death, or a child's. And I am always more interested in the living, anyway, than the dead. Standing there I really didn't think about this child, or feel for his life cut short; all I could see were these two parents, with their beautiful little child lost to them, and their world shattered.

And as I watched them go through this ritual cleansing, designed to give them strength for a future that by all statistical likelihood would be full of fearsome depression, recriminations, and anger, and perhaps the end of whatever was left of their family, I kept telling myself, This is good, what they're doing, because it will enable them
to go on. They need this belief, and this rationalization. And it hurts no one.

But that wasn't what I was feeling. I think I was even angrier at them than I get at the drunk drivers, or the kids who spin out on their motorcycles and die because they were too vain to wear a helmet. Certainly I have never before or since found it so difficult to remain silent, to hold in my own despair. “Stop this insanity,” I wanted to yell. “There is no reason and no justification for your child to have died. None whatever. Or for sickle-cell pain, or AIDS, or even an old smoker suffocating in his own sputum. There is nothing good about any of this.

“Why are you holding back your tears, and your fury?” I went on, screaming at them inside my brain. “Your little boy is dead! No god would have stolen him, nor will any give him back. This is the world we live in, and even an eternity of heaven, if it really existed, couldn't atone for this suffering.”

I didn't say anything, of course. And I really hope they found some solace. I didn't.

JEROME R. HOFFMAN, M.D.

Los Angeles, California
   

I
t had been a slow night—the usual mix of minor trauma and accidents but nothing to get the blood really pumping. Suddenly, the EMS radio went off: “Twentyish white male with stab wound to the left anterior chest. Blood pressure eighty palpable. Pulse one forty. ETA seven minutes. We're IV positive with Ringer's wide open.”

The mood in the room changed instantly. Nurses began preparing for the arrival of the patient. The trauma team arrived just as the ambulance was pulling up to the dock. When I looked at the unconscious young man, I realized he was probably about my age. I had never seen so much blood—a scarlet trail leading from the ambulance's back door all the way to the gurney he was placed on.

My job as a beginning fourth-year medical student was basically to stay out of the way and not do anything to disturb the people who knew what they were doing, so I stayed in the background and observed.

The trauma surgeon immediately took charge. He made it clear that the heart or aorta had most likely been penetrated, and in addition to needing a lot of blood, the patient's chest had to be opened.

As preparations were being made, one of the nurses spoke up: “This patient can't be given any blood. He's a Jehovah's Witness. It's right here in his wallet.” She held up a card.

Things came almost to a standstill. The noisy trauma room became silent. The trauma team surgeon either did not hear the nurse or (more likely) ignored her. “Let's get that O-negative blood up here stat,” he barked.

The nurse stood her ground. “I said he doesn't want any blood. I'm a Jehovah's Witness too. You know our belief about blood transfusions. I won't let you give that patient blood!”

The surgeon and nurse were now face to face. She wouldn't back down. I'd never seen anything like it. “If this guy doesn't get any blood, he'll certainly die no matter what we do,” he said, raising his voice. “You know every second counts.”

She looked back at the rest of us, then back to him. “If you give him the blood, he would rather be dead. He signed this card. You have to honor his wish.”

No blood had arrived yet anyway, so the surgeon turned to opening the young man's chest, hoping to stop further blood loss.

As the patient's chest was opened, blood was everywhere: on the floor in puddles, on the walls, even on the ceiling. The young man's injuries were so extensive that he died before we could get a transfusion
near him. In some small way, I thought to myself, the nurse had won.

The irony came later in the evening, when the police arrived. The young stab wound victim was not a Jehovah's Witness at all. He was a thief. He had stolen the wallet.

LAWRENCE M. LINETT, M.D.

Loudonville, New York
    

I
was a paramedic student at the time, doing a rotation in the Emergency Department to pick up some procedural skills. That gave me the chance to observe this case almost in its entirety without the distractions of any real duties.

It started when I was coming to work. I had parked across from the ambulance entrance to the ER and was walking across the large parking lot when a police car, siren screaming, came full throttle down the street and pulled into the Emergency entrance. The car was traveling so fast as it came up the driveway that all four wheels left the ground and sparks flew as it landed. The officer grabbed something from the trunk and ran in the entrance. His degree of urgency was unusual enough to make me wonder what was happening. When the scene was repeated less than a minute later by another patrol car, I knew something out of the ordinary had occurred. But what? An officer wounded? A hostage situation? A riot? As these possibilities crossed my mind, I hurried in to see what was causing so much action.

Entering the ER, I found a large group gathering around the officers'
cargoes. In a stainless steel basin lay the head and the first twelve to fifteen inches of a large snake. The second policeman had brought the remaining five or six feet of the reptile's body and tail. Though there were seven bullet holes in the carcass, the severed head would flare and rise threateningly, poised to strike whenever anyone came too close. The snake had bitten its owner, who now lay in one of the trauma rooms.

As the paramedics were evacuating the patient from the scene, they had asked the police to kill the snake and bring it to the hospital so the ER staff could identify it and determine how to treat the victim. The police shot it in the owner's kitchen. I've often tried to imagine that scene. Were the police frightened, or were they cool and professional? How many rounds did it take to hit a writhing snake seven times? What did the kitchen look like afterward?

When I looked into the trauma room, the patient appeared pale and frightened but calm. The paramedics had treated him with a rubber tourniquet applied above the bite and a nasal cannula for oxygen. IV solution was dripping into the other arm. Nurses were checking his vital signs while curious residents and medical students were gathered three deep around the bed. I found a spot in the trauma room and remained, reviewing the action throughout his stay. This scene was too good to miss.

The patient had said the snake was a Golden Falls cobra; the problem was that nobody in this western urban hospital had any idea how to treat a cobra bite victim. The pharmacy didn't even stock rattlesnake antivenin. Police had been dispatched to at least two suburban hospitals to obtain the antivenin just in case it might be useful. Meanwhile, the emergency docs tried to dig up the information needed to treat this unusual injury. Calls were placed to snakebite treatment centers in India, Africa, and South America. No expert could be found who had ever heard of a Golden Falls cobra.

While the search went on, the medical students hustled off to the ER's small library to read about snakebites. Every few minutes one would return and ask the patient if he had some symptom or other. Consistently, the patient would initially deny having the symptom
and then moments later develop it. After being asked, he reported developing tingling lips, shortness of breath, and even double vision.

Despite the symptoms, the patient remained stable. Though his arm was becoming purple and congested, no one was ready to remove the tourniquet. At last there was a breakthrough. The police dispatcher called to let us know that his officers were bringing in a snake expert from the local zoo. If he could identify the snake, then maybe the doctors could find out how to treat the injury.

The expert arrived at last, appearing somewhat shaken after his Code 3 ride in the patrol car. After taking a few moments to examine the remains of the snake, he rose to face the expectant crowd. In a calm voice he announced, “This is a Golden
False
cobra.” He went on to explain that the unfortunate animal was only minimally venomous, and that his bite was so unlikely to cause any harm that no treatment was necessary.

All the tension went out of the place like air out of a balloon. The tourniquet and IV were removed. The patient was given a tetanus vaccination and discharged. The physicians and nurses returned to the more usual calamities of an urban ER, and the police took charge. The city had an ordinance outlawing exotic pets. Though the snake had been purchased in the suburbs, when the patient had brought it inside the city limits he had broken the law. No longer a victim in need of dramatic emergency assistance, he was now just another small-time criminal. A citation was issued, and the police left.

Finally, only the two of us remained. The patient sat on the gurney, the purple hue slowly fading from his forearm, the policeman's ticket in his other hand, a dazed look on his face. I wondered what he was thinking. Was he angry that the pet shop had sold him something less than he thought he'd paid for? Relieved that he was safe? Sad about losing his pet? Perhaps he was adding up his financial losses: the snake, the fine, the hospital, the ambulance, the repairs to his kitchen. Maybe he was just trying to solve the problem of getting home. The last time I saw him he was headed for the hospital lobby in search of a pay phone. He'd had his Warholian fifteen
minutes of fame, and a little more, but he didn't seem to have enjoyed it much.

PAUL L. SNODDERLY, M.D.

Fort Collins, Colorado
   

“D
oc,” the nurse told me, “the paramedics are coming in. They have a fifty-eight-year-old seizure patient. The paramedics know him. His seizures are fairly frequent. He's still confused, but has good vital signs and no obvious trauma. ETA is seven minutes.”

The patient's name was Carl Long. He arrived groggy and not very communicative. He'd had a grand mal seizure at work. His frequent episodes had always been full-blown epileptic events that appeared to be violent, occurred without warning, and were poorly managed by medication. They were followed by the classic period of coma gradually transformed to lethargy, confusion, and, finally, understanding.

The passage from preseizure to the postseizure confusion was a Rip Van Winkle nightmare for Carl. He would be going about his business, then would awaken with crowds all around, on the ground alone, or in the confines of an emergency room. He would have no memory of the events in-between.

The last thing that Carl remembered today was being at work in the mall arcade. Years of poorly controlled seizures had limited what he could do for a living. Carl had lost many jobs when bosses, afraid of his frequent seizures, had fired him. Carl really didn't have much
education. What little he possessed had been picked up here and there. He had also learned how to keep alive in a cruel, unforgiving world. At the mall, Carl got along with the kids fairly well, kept the peace in the arcade, and counseled and helped when he could. He seemed to ignore the teenage jibes of “The Dancin' Man” given to him by some.

Now, as Carl was awakening from the fog, his mind told him not to panic. He had been here many times. I began to examine him to see what, if anything, was to be done. I requested blood tests to check medication levels. Pulling aside the gown to listen to Carl's heart, I saw the waxy smooth, rippled scars of an old third-degree burn. They extended from the base of Carl's neck, down the front of his chest wall, across his shoulders, and down onto his abdomen.

“How did you get those scars? House fire?” I asked.

“No, Doc, I got lit on fire.”

“What do you mean ‘lit on fire'? Were you drunk or something? Or accidentally splashed with gasoline?”

“Nope. Happened when I was a boy.”

“Fireworks?”

“No, Doc. I was set on fire.” Carl began his story:

“When I was a boy, people like me with fits got sent to state hospitals for the insane. They'd keep us there because no one knew what to do with us. My poor parents were shamed into sending me. I remember my mom and dad fighting before I got sent away. The schools wouldn't take me. They didn't have to back then. A lot of good Christian people figured my parents must have done something evil and I was God's punishment on them. The more upstanding, nonsuperstitious ones just figured I was a genetic misfit, kind of like a badly bred animal. Hell, back then some of them even thought I should be castrated so my bad genes couldn't be passed on.