The Emergency Ward

By S. A. Hoffman

I Vocabulary work

1. Study the following words.

Reminiscent, infirmity, wheedle, sage, penitent, convivial, vexatious, antidote, disheveled, aggravate, duped, relentlessly, supplicating, misconstrue.

II Discussing the text

1. Read the text.

Stephan A. Hoffman attended Harvard Medical School and worked as an intern in the emergency ward at Massachusetts General Hospital, at large hospital in Boston. His book, Under the Ether Dome, describes his experiences working there. In this abstract from his book, Hoffman discusses what it is like to be a novice intern working in the Emergency Ward.

1 The Emergency Ward of a city hospital often resembles a medieval fair. The scene is full of pageantry, a state of commotion prevails, and the atmosphere is reminiscent of a marketplace: people throng in with complaints as if they were hawking wares. Exposing painful chests or stomachs, or waving injured parts in the air, they clamour for an audience. Hoping to attract notice, they will bargain spiritedly, each one entering into an explanation of why his illness, like a piece of merchandise, is more deserving of attention than the next.

2 In the sea of medicants and merchants, every imaginable infirmity is represented. Like items brought in for sale, none is too plain or pitiful, too colorful, comic, or exotic to encounter. I remember treating an elderly man who developed chest pain after having been beaten by his children, a young physician with a cough who turned out to have lung cancer, a woman who complained of a buzzing sensation in her abdomen and who was thought to be a “crock” until an X ray revealed that she had a vibrator lodged in her intestine, an attractive young woman with chest pain dead only minutes after her arrival of a massive myocardial infarction, and a gentleman who walked in with an urn inverted on his head, telling us in a reverberating voice that it was the work of a jealous wife.

3 Not only is every imaginable kind of problem on display in an Emergency ward, but every variety of personality is exhibited. There are evangelists and troubadours, the self-styled clowns and princes, tragedians and trouble-makers, even matchmakers. Some people are openly out to profit or to close a deal and will try to wheedle anything from narcotics to immediate attention to a room with a TV. One comes to recognize both the practiced historian, who arrives with a prepared announcement, and the shy one, who fidgets simply in anticipation of having to speak. The innocent lies next to the sage, and the penitent patient rubs shoulders with the outraged. There are both the famous and the unrenowned. I can recall taking care of senators and television personalities as well as of a street nomad who proudly taught me the distinction between a vagrant and a bum.

4 Unfortunately, an Emergency ward is not always so convivial a place. When the pulse of action quickens, and survival becomes the sole priority, the Emergency ward is transformed from a fair to a theater of war. At such times, an intern’s job is to battle with diseases, and the people who bear them are almost incidental. Rather than being able to appreciate the human comedy around him, an intern is bent on minimizing losses, and he is apt to emerge from a day’s work shell’shocked. If there are calm moments in an Emergency Ward, there are also hectic ones, which tend to leave a more enduring mark. This is why it is so rare for any intern to escape his one-month tour of duty without coming down with a case of combat fatigue. An Emergency Ward is not one but two worlds, which can switch back and forth with vexatious rapidity like images on a Gestalt screen.

5 Even though I was not assigned to do my first of several rotations in the Emergency Ward until the fourth month of internship, I had already had some experience of it. Almost every patient I had admitted to the hospital during my days on call for the wards, the private service, and the intensive-care unit had made his or her first stop in “The Pit”, as the Emergency Ward is affectionately known, and clipboard and black bag in hand, I would descend there to do my workup. I had also become acquainted with the Emergency Ward in a purely social capacity. The EW is a way station, a place where house officers stop frequently to trade stories, ventilate, and unwind. Just as it is the medical hub of the hospital for patients, the EW is the social center of the hospital for interns and residents, and like my colleagues I had spent my share of time there.

6 If the thought of managing emergencies intimidated me at the beginning of the year, I welcomed the chance to experience the world of acute care by the time my EW rotation drew near. Much as I hated to admit it, I was already weary of working on the wards. I had spent the first three months of internship on one or another hospital floor, where in spite of daily discharges and admissions, a sizable core of patients would remain. Day after day, my colleagues and I looked after these unfortunate people. When we made our morning rounds, the same faces – angry, discouraged, pained – turned toward us, serving notice of how little we could do. It was true: few seemed to improve with our ministrations. Many suffered from diseases whose courses were affected minimally or not at all by what we did, and both for them and for us our supposed interventions seemed more like busywork designed to preserve the illusion that we were doing something than like truly curative care.

7 Despite my determination to remain optimistic, I found myself growing discouraged on the wards, and I looked increasingly to the EW for relief from this hermetic world. Not only would I see a different group of people every day, but also I would be more likely to bring about major improvements in their lives, even cures, and I craved this opportunity as if it were the antidote to my experiences so far.

8 On my first day in the EW, I arrived a little early in order to outfit myself appropriately. Having studied the attire of a junior resident who had been on duty there the day before, I copied his example, tying a rubber tourniquet around one belt loop and fixing a pair of EKG calipers to another. A reflex hammer, I had learned from watching a neurologist, could be kept conveniently in a buttonhole of my white coat, and a safety pin, which I would use to teast sensation, fit nearly through one of the coat’s lapels. I studded my pockets with scissors and tape and tucked in several intravenous catheters where I could still find room. Preparing for each rotation of the year, as every intern knows, is very much a matter of looking and becoming one with the part.

9 When 8:00 a.m. arrived and my shift began, I asked the senior resident to sign me up for the first case of the day. To be free of the constraints of ward care was a thrill, and I was eager to embark on my new career. Had I been able to, I would have signed up for every case, and there were times during the month when I nearly succeeded in doing so. Poised in readiness for any and every emergency from asthma to heart attack to overdose, I felt like a privileged member of a repertory company, prepared to perform any of a hundred roles at a moment’s notice. To do so I needed to command a knowledge not only of how to apply medications, medical props, and emergency techniques, but also of how to use words and gestures to their full effect. In any medical arena, but in the Emergency Ward especially, a doctor is always part actor. Whenever a patient presents to him for help, he must stage an individualized performance, choosing his words and timing his expressions with care in the hope of moving his audience toward the desired dramatic resolution.

10 It is over four years since my debut in the Emergency Ward, but I still recall exactly how I felt while waiting for my first patient to arrive. As I relive this sense of anticipation, I imagine myself beginning in the EW all over again. Standing at the front desk, where interns and residents congregate, I keep a watchful eye on the door.

11 The first patient to arrive is a middle-aged street dweller. Disheveled, carrying a Lord & Taylor bag, and bundled in several layers of tattered rags, she comes in coughing. Looking on while the nurse obtains her temperature and other vital signs, I entertain a quick differential diagnosis: pneumonia, lung abscess, or tuberculosis.

12 When I ask the woman more about her cough, however, she divulges only that she once lived in France. Meandering over the terrain of her life, she goes on to tell me about her house (did she say on the Rue de Rivoli?), about a string of lovers, and about syphilis, which she claimed to have contracted during a balmy night on a beach in Normandy. Eventually she married, but her husband left her. She returned to the United states and took to the streets.

13 Casting a quick glance at the vital signs on the nurse’s sheet, I notice that it is only a cold that has brought her in. Indeed, her throat appears benign and her lungs are clear. After undoing the cloths that are swathed about her, I find that there are scars across her belly, and a wave of pity hits me. Following my gaze, she too glances down and gives me a rueful smile. “C’est la vie, helas, c’est la vie”, she says, without providing further explanation.

14 Although her chest X ray is clear (it shows no evidence of pneumonia), I decide to admit her, fully aware that it is strictly a “social admission” designed to provide her with food, lodging, and a good night’s rest. As expected, the junior resident whose turn it is to take the case balks at the admission. “You’re weak, Hoffmann,” he tells me. “She needs to be admitted about as much as I do”. Prepared for his attack, I counter, “It’s an easy case, Jim. There’s hardly anything for you to do”. He knows it. She fills one of his beds and couldn’t possibly entail less work. That’s why, despite complaining, he agrees to admit the woman.

15 When I am through, the senior gives me a quick lesson on how to evaluate the patient who arrives with shortness of breath, and as we stand together in the front of the EW reviewing the workgroup, in comes a middle-aged woman who is wheezing. “It’s Clara again,” the senior says knowingly as the woman is wheeled to one of the rooms in the rear. “She has asthma and is a regular around here. You might as well get to know her.”

16 “You’re an intern, aren’t you?” Clara asks as I stride into the room. “Yes, I am,” I answer, “I’m Dr. Hoffmann.” “Well, I don’t want any intern taking care of me; get me a resident,” she responds curtly. Not wishing to provoke an argument, I seek out the senior, who patiently but firmly lays down the law. “You know how the Emergency Ward works, Clara,” he admonishes her. “You’ve been around long enough to know. You’re assigned to Dr. Hoffmann, and if that isn’t agreeable to you, you may leave.” As he prepares to return to his work, he turns around and reminds her, “Besides, your new clinic doctor is an intern, so your argument doesn’t hold steam!”

17 Clara agrees to stay. As I take a brief history, (“Can you tell me when your breathing became labored? Did anything seem to set it off? Have you been able to take all your medicines?”) Clara appears impatient and eventually cuts me off. “Look,” she says irritably, “I just want a shot of epinephrine, an aminophylline drip – run it in at forty – some Bronkosol to breathe, and my lungs will clear. I always clear with that.” A little taken aback, I decide not to argue, since her plan of treatment seems reasonable. “Fair enough,” I say.

18 But then she tells me that she wants a blood gas test, a test that requires puncturing an artery to measure the oxygen level in the blood. Since there is no reason for her to undergo the procedure, I am caught entirely off guard. It has always been the patient who has refused to undergo this sometimes painful and hazardous but often important test, and I who have had to lobby for it. Now I am compelled to argue the opposite side, and despite my most persuasive case against her undergoing the test, she gives me only a begrudging ear. “I want it anyway,” she says the instant I finish. “I always get a blood gas drawn.”

19 When I make a renewed appeal, however, she grows excited and increasingly short of breath. This, I realize, is nothing short of blackmail: by threatening to aggravate her asthma she has literally forced my hand. Reluctantly I draw the specimen from her radial artery, while she looks on with a triumphant smile. Having sent off the test, I begin her on medications, and eventually (how much from medication and how much from my having capitulated to her is unclear) Clara improves. On her way out she is all smiles, and she informs me that I am a good physician. The senior resident also tells me that I did well, giving me a pat on the back. The whole thing leaves me feeling empty and duped.

20 The next patient comes in with jaundice. She is frail and has clearly lost a good deal of weight. The obvious possibility is a malignancy, and as the thought goes through my mind, she actually puts the question to me: “Is it cancer?” My heart sinks. Put on the spot, I try to find an honest but humane reply.

21 In the middle of examining her, I am called away to assist in a code, the resuscitation of a patient suffering cardiac arrest. The emergency Medical technicians have just wheeled in an elderly man, age and identity unknown, who dropped at a nearby Massachusetts Transit Authority station. The senior asks me to pump on his chest, that is, to continue CPR, and as I do so, one junior resident slips an endotracheal tube down the man’s throat so that he can be ventilated and another hurriedly inserts a central line beneath his collarbone so that he can receive intravenous drugs. The senior asks someone to relieve me, then asks me to draw a blood gas specimen from an artery in the man’s groin. I have trouble, grow embarrassed, and begin to sweat, but finally obtain it. I relax, thinking my trials to be over.

22 Then the senior asks me if I have inserted the pacemaker; the patient’s heart has failed to generate a beat. “Uh, no, I haven’t,” I reply nervously, unsure of just what awaits me. I am handed a huge needle and syringe and told to attach the syringe to the needle. I do this obediently but reluctantly, thinking that I really shouldn’t be doing this without having had an opportunity to practice first. But I do not argue. I know that it is part of internship to learn by doing and I know that some of that learning must be done under duress.

23 Pointing out the anatomic landmarks on the patient’s chest, the resident instructs me just where to insert the needle. I do as he tells me, advancing the apparatus through the skin and drawing back on the syringe, so that I will know when I have entered the heart. I am nervous – my heart is pounding and my hands are shaking – but the senior talks me calmly through the procedure as if he were a pilot on the ground coaching an inexperienced passenger on an airplane through an emergency landing. As I continue to advance the needle slowly, it suddenly fills with blood, signifying that I have reached the man’s left ventricle. Under the senior’s guidance, I thread a wire (which connects to a pacemaker) through the center of the needle, and after experimenting with its placement in the way that the senior suggests, I hear the junior resident manning the EKG machine shout, “It’s capturing, you’ve got a complex.” When he asks if anyone can feel a pulse, someone blurts out, “Yes!” and when he then asks that the blood pressure be taken, it turns out to be not only obtainable, but high. Everyone smiles and pats each other on the back, and the mood relaxes.

24 Trembling but exhilarated, I leave the scene, wondering what my next visitation from a patient will bring, what unexpected twist of plot lies in store for me with the beginning of a new act. As my first shift in the EW plays itself out, I begin to appreciate not only how relentlessly forward-moving is the action, but also how many dramatic turns a day may take, and it strikes me that in the Emergency Ward an intern has as little control over his reactions to a day’s drama as over the course of action itself.

25 I return to see the woman with suspended cancer, but just as I am about to enter her room, the senior asks me if I can evaluate another patient first. Not only has the code set us back, but the pace has picked up. The senior resident in the Emergency Ward is like an air-traffic controller who polices the flow of patients in and out, and who is always juggling many flights simultaneously.

26 The patient I am asked to evaluate his chest pain. When I walked into the room to shake his hand, he begins to cry. It is three months since he had a heart attack, he tells me, and he is terrified of a recurrence. His pain today lasted only moments and was preceded by a heavy lunch, but he is worried nonetheless. “Is this another heart attack?” he asks me almost in a whisper. Looking at his electrocardiogram, I tell him that it is too soon to say, but that on the face of things the strip looks reassuring. The patient tells me that he is so incapacitated by fear that he has been unable to return to work. “He is a partner in a large firm,” his wife informs me, with an almost supplicating look.

27 Just as I begin to examine him, the alarm on the heart monitor at the adjacent stretcher sounds. The patient who occupies the stretcher had also arrived with chest pain and has now arrested. A code ensues, and the man, who is only fifty-four years old, dies. Although the curtains were drawn around him throughout the code, this did not prevent my patient from overhearing all the goings-on. I return to find him silent but shaking uncontrollably.

28 Next in line is a nearly toothless old Hispanic man who playfully withholds his reason for coming. The man, whose face is tan but wizened, gives me a big smile and nods his head up and down. He holds up his medicines and in broken English explains their each and every wonderful effect. It’s as if he were an advertisement. I smile, shake my head in disbelief, and ask him what’s bothering him, but he only grins. My amusement fades as the game continues, and I can’t discover why the devil he’s here. There are many other patients to see, and the time pressure has begun to weigh on me. Eventually I seek out the senior. “Remember, it’s Friday afternoon,” he tells me. “His family has probably dumped him for the weekend.” I protest, telling him I find it hard to believe. “Do you see any family members around?” he asks me nonchalantly. Regretfully, I enter the patient’s name in the admission book, knowing that I will get flak for this one. It makes me mad that the man’s family would do such a thing.

29 At six o’clock I sit down just long enough to swallow a pack of M&M’s and make a tally of how many patients I have seen (seven). Although the rest of the night awaits me, I realize that in spite of being keyed up, I am already beginning to slow down. “See this guy quickly, would you, Steve?” the senior asks as I am just about to return to my last patient. “I don’t think there’s anything medical going on,” he explains, “but look him over briefly just to make sure. Then rocket him out of here!”

30 The man complains of dizziness and chest pains. As I take a history, he confides that he is hooked on heroin. He hasn’t been able to get the drug for a day and begs me for a substitute that he can take. “You’ve gotta understand, Doc, for the wife and kids…” He breaks down, and I feel sorry for him, but when I explain that all I can offer is hospitalization at a detox center, he grows angry and abusive. Before I realize what is happening, he has smashed several IV bottles and overturned a medical cart. Thanks to a nurse who phoned the security guards, however, less than a minute later he winds up immobilized in four-point restraints. The psychiatrists see him and arrange for him to be admitted to a detox center in the morning. He gets his first dose of methadone.

31 Next, I see an old man with fever and cough who turns out to have pneumonia. I send off all the routine blood work, draw two blood cultures, obtain a chest X ray, put in an IV, and do special stains of his sputum and urine, which I examine under the microscope. Since the man will need an intravenous antibiotic, I arrange for his admission. The intern who comes down to do the honors listens to the patient’s chest, thinks he hears a new heart murmur, and complains that I haven’t drawn six blood cultures to exclude the diagnosis of endocarditis, an infection of the heart. Although I disagree with his finding and therefore don’t believe the extra blood cultures are indicated, I go ahead and draw them anyway so as to avoid argument. When the senior resident finds out what the intern has done, however, he is infuriated: “What the hell you think you’re doing, tying up my intern with stupid things like that?” he yells. The intern grows equally enraged, and the two of them get into a shouting match at the patient’s side. Throughout the argument the old man looks straight ahead of him, smiling vaguely, trying to pretend he doesn’t notice.

32 A nurse interrupts the argument to tell me that a young man who is vomiting blood and has a blood pressure of only 60 has just arrived. I run off to see him, and although I would have appreciated his help, my senior stays behind, still absorbed in argument. With the aid of another resident, I place several large intravenous lines and give the man first a saline infusion, then transfusions of blood. Using a fiberoptic instrument, we establish that a large duodenal ulcer is the source of bleeding.

33 Although it takes only an hour and a half from the time of his arrival to stabilize the patient, it takes us over two additional hours to get him a hospital bed: my senior resident had tried to “turf” him to the surgical service in order to spare the medical house officers another admission, but the surgeons want to see what’s in it for them. When the senior finally offers to do a consult on one of their patients (a woman with an acute gall-bladder attack who suffers from other medical problems that they are having trouble managing), they agree to admit our patient. It is all a matter of politics.

34 My next patient is a wealthy woman from Florida who flew up unannounced today. She has had diarrhea off and on for three years and insists on being admitted. She knows the assistant director of the hospital, she says. As I begin to explain that she will have to board on the ward service since there are no more private beds available, her husband’s face grows purple. “The hell she will,” he shouts. “Wait until I tell my lawyer!” Seeing that I am unmoved (he credits me with far more control over the admitting office than I have), he adds, “And why the hell did she have to wait fifteen minutes to be seen?” I explain that much as I regretted the wait (though I am beginning to wish that they had waited for four or five hours), such a delay was unfortunately neither avoidable nor unusual. A lady passed out in the X-ray suite, I tell him, and a woman with airway obstruction had also occupied our time. “Well, what the hell is that supposed to mean?” the husband demands. “Don’t you think my wife is important enough?”

35 Angry, but outwardly unruffled, I do a physical exam and draw some blood tests, determined not to allow my personal feelings to interfere with this patient’s care. Once again I explain that if the woman wants a private bed she will have to wait until the following morning, and I encourage her to establish a relationship with one of the private doctors. After the husband takes down my name, the two of them walk off in a huff, and when I walk into the lobby several minutes later to meet the family of another patient, I overhear the husband talking on a phone: “Can you believe it? It meant nothing to the son of a bitch that we know the assistant director!” How much does the momentary madness of illness excuse? I wonder. Although I know them to have been unreasonable, it nonetheless disturbs me that these people have seen fit to grow angry at me. I take pride in doing a good job and in making patients happy, and it bothers me that in the eyes of this couple I succeeded on neither count. What upsets me almost as much is what they have succeeded in doing: making me angry at them.

36 Still smoldering over this encounter, I learn from the senior that another patient is waiting to be seen. On my way in the door, I am met by his nurse, who gives me a wink. Wondering what she means by this, I begin to take a history and discover that the patient suffers from unremitting eructation, that is, he cannot keep from burping! The man tells me how it has affected his business, his sleep, and his sex life. He laughs (nervously), I laugh, but he confides that his marriage is on the rocks. I try to give him as much of an opportunity to talk as time permits, since a lady with abdominal pain and a man who passed out in the subway are still waiting to be seen. I schedule an upper GI series – maybe he has a large hiatus hernia – and write him a prescription for antacids. He pumps my hand gratefully, and tears appear in his eyes.

37 And on through the night it continues. I see a young woman who has overdosed on drugs, several elderly women with heart failure, two men with heart attacks, a man with decompensated diabetes who comes in in shock, a woman from a nursing home with a stroke, and a young man with cancer and bone pain so severe that he couldn’t take it at home any longer. I never do get back to the woman I suspect has cancer. By the time 9 a.m., the end of my shift, arrives, I feel as though I have seen a large slice of illness and of life.

38 In the ensuing days and nights on call, I learned far more than the technical aspects of emergency medicine. I learned a whole approach to the making of diagnoses, and I acquired an appreciation for how much artistry is involved. Having been at first unsure of my skills as a diagnostician, I grew to be overly confident of them midway through the month, only to become humbled toward the close of my rotation by how easy it was to misconstrue the evidence before me and wind up wide of the mark. Making diagnoses is fraught with hazards for the unwary, and I came to think it a wonder that it could be done at all.

Date: 2015-01-02; view: 975