Been there, done that. The “heat of battle,” the trauma, the diagnostic challenges. The world of the emergency room (ER for the uninitiated few)– stories that you have seen on TV, sometimes fanciful, always dramatic, sometimes humorous, or easily found in any number of online bookstores. However, let me remind you that not all is drama and there is the mundane, which never, or hardly ever, rises to the level of a TV script or the chapters in a book but does provide additional “slices of life.” What follows are a few accounts from the 1970’s and early 1980’s, “tales from the ER” that reflect “slices of life” during those times each with their own non-medical lesson.
In the early 1970’s I worked as an orderly in our small (<80 bed) community hospital nestled in a blue collar town of 13,000. I would always work the late shift (11-7). One of my responsibilities was to be the first to greet and assess any patient that showed up at the ER door as no one was stationed in the ER all the time. Since the ER door was locked at night a patient would ring a buzzer that sounded at the nurses’ station which itself was some distance from the ER. This was my summons to duty. The ER was a two bay affair with the waiting room directly facing the bays. One would walk by the bays, through the waiting room, into a hallway and, turning left, could quickly visualize the locked glassed paned double doors. I would pop the door open, usher the patient and any others in, find out what the problem was, and begin the registration and subsequent assessment (obviously all quickly bypassed if this was a true emergency).
One night after the buzzer summoned, I made my trek, arriving at the glass paned ER doors and looked out. What met my eye was a late middle aged man standing between two buxom women “dressed to the nines.” His arms were draped around their shoulders and I could see that he sagged a little bit between them. I let them in, noting he walked slowly and gingerly, continuing to rely on the support of these two women. In response to my question about what was going on he replied, “I threw my back out again; I need my shot.”
This was my first introduction to “Jimmy” the town pimp and at least two of his girls. Jimmy was a periodic visitor to the ER and his complaint and request was always the same–“bad back; need shot.” Apparently Jimmy was well known to the ER docs and after several previous assessments it was determined that there was nothing ever really wrong with Jimmy’s back other than mild muscle sprains. However, Jimmy always insisted that he needed a “shot” to get better and, I am told, would raise quite a ruckus if he didn’t get one. The ER doctor on call that night knew Jimmy quite well. After a brief Q & A, and limited exam (again confirming a mild sprain, if that), the doc went to a locked medicine cabinet, pulled out a vial and loaded the contents into a 5cc syringe. “OK, Jimmy,” he said, “assume the position.” Jimmy dropped his pants, turned away from the doctor, leaned over one of the ER beds, and said, “Ready.” The ER doctor then shot 5cc of normal saline into the man’s buttock. Jimmy let out a howl (I have it on good authority that injected saline hurts). straightened up, pulled up his pants, turned to the doctor and said, “Thanks Doc, I feel better already.” After Jimmy and his girls left, the ER doc turned to me saying, “Yup, it was a placebo. Technically we’re not to give placebos but I’ve been on the receiving end when Jimmy doesn’t get his shot; it also keeps him happy for several months and away from the ER. It also means it is less likely he’ll ER shop until he gets what he wants.”
On another occasion I was watching one of the older and well seasoned ER docs sew up the calf of a young man who had neatly sliced it open earlier that night after putting his leg through a glass door. The doc had a rhythm going with the suturing and the wound was closing nicely. Suddenly the entry way glass doors rattled and both of us heard shouts. I circled out through the waiting room and into the hallway. Several men were pulling on the ER doors and behind them I could see a pickup truck backing up close to the doors. Opening the doors I heard, “It’s Charlie. He collapsed while we were drinking and fishing down at the river.” The truck’s tailgate hammered down and there lay Charlie, all 300 pounds of him. We slid him on a gurney and rolled him into the waiting room. The doc put his hand up, indicating we should stop there, laid down his instruments, stripped off his gloves, and walked over to Charlie. Feeling for a pulse in the neck, he raised one of Charlie’s eyelids, waited a moment, then looked up at us and said, “Yup, he’s dead.” He went back to suturing. Charlie’s friends looked at each other, then at me, and one said, “Damn!” And that was it. The friends left and Charlie went to the morgue. Reality without the histrionics.
I got my M.D. in 1980 and began my training at an inner city hospital that same year. After the first year of training residents were allowed to moonlight in the ER. You learned a lot there and not all of it medicine.
One evening I saw a man who had hurt his back while at work. After the history and exam I concluded he had a mild muscle strain. He went on his was with a few days off and prescriptions for a muscle relaxant and a mild analgesic. Several days later I was called into the ER director’s office about this particular case. The director noted that I had not ordered any x-rays and I explained that I felt none were needed. While he agreed with my diagnosis and treatment he pointed out that this was a workman’s compensation case and x-rays should always be done. Why? Because if the patient ever hurts his back again, whether at his current job or another, and an x-ray was done showing some abnormality, the patient could claim his injury dated back to the time I had seen him and there would have been no radiographic proof to negate his claim. Lesson learned.
Another evening I was forewarned by a nurse about a patient who had come in by ambulance. Fearing a true emergency I quickly moved to her ER bay. With either, “How can I help you?” (a standard ER ice breaker) or, “What’s wrong?” (another) I began my assessment. “Need my sugar checked,” she replied. She saw the puzzled look on my face and explained, “I’m diabetic and my doctor says I need to get my sugar checked regularly. I didn’t have anything else to do tonight so I thought I’d get it checked.” “But why the ambulance?” I asked. “I didn’t have anyway to get here so I called them. Medicaid will pay for it.” Her sugar was fine and taxpayers were out several hundred dollars.
On an afternoon shift I saw a late middle aged man with complaints of abdominal pain. It turns out he had had it for quite some time (weeks). After the history and exam I felt this was not an acute problem and could be seen in the GI clinic. After I explained this to him he replied, “Oh, I already have one.” I then asked if something about the pain had changed such that he felt it best to come to the ER now. “No,” he responded, “I just got tired of waiting.” To my next question, “When is your appointment?”, his response was, “This afternoon.”
Booth “B” was the dreaded (at least to medicine residents) Ob-Gyn room. Notified by nursing about a patient waiting there, my fellow resident, John, and I flipped a coin to see who would evaluate the patient and John lost. He told me later when he entered the room he encountered a beautiful young lady, 15-16 years old, sitting on the ER bed. He introduced himself, asked how he could be of help, and she responded, “I want you to tell me why I can’t get pregnant.” She went on to explain, “I’ve been trying and trying but I just can’t get pregnant.” Taken aback, John weakly said, “And what does your mother think?” The girl shot back, “She says I’m trying too hard.” As brilliant a physician as he was, John didn’t even attempt an answer. As he told me later, “Harrison’s (Principles of Internal Medicine) failed me.”
This last tale (1970’s) is actually one recounted by my father, a general practitioner. An elderly married couple, whom I’ll call Fred and Molly, were longstanding patients of his and Fred was in the last days of a terminal illness known to many. Molly left to do some shopping after checking with Fred who was lying on the living room couch to see if there was anything he needed. According to Molly, Fred indicated he was “fine.” When Molly returned a short time later she found Fred unresponsive on the couch, dead. Not knowing what to do Molly first called Doc’s (the town knew him as “Doc”) office but he wasn’t in. Her next call was for an ambulance reasoning that the crew would transport Fred to the morgue at the hospital and then decisions could be made as to the next steps. The ambulance crew arrived, confirmed that Fred was without pulse and…began resuscitation efforts despite Molly’s protests and statements that Fred’s death was an anticipated event. Loading Fred’s body into the Basic Life Support ambulance the crew decided Fred needed to be transported to the large city hospital which was 12 miles away, rather than the local hospital which was only several blocks away. Halfway there the BLS ambulance was met by an Advanced Life Support ambulance leading to Fred’s body being transferred to the second ambulance and from there transported to the city hospital where resuscitation efforts not surprisingly failed.
My father would never have known about the circumstances of Fred’s death until he received a call from a distraught Molly. She had received 3 bills, one from each ambulance service as well as the hospital. To her the charges were overwhelming and, since Molly and Fred had not been financially well off to begin with, she was at a loss as how to pay the balances due as Medicare only covered a portion of the charges. Phone calls were made and the ambulance services, as well as the hospital, agreed to accept the Medicare payments only, thus avoiding the human interest story that might have appeared in the local newspapers.
So from these tales the non-medicine lessons taught included 1) there may be an occasional need for placebo therapy, 2) ER shopping/inappropriate use will be never ending (made worse by not allowing seasoned nurses to triage some types of patients), 3) workman’s compensation cases drive up the cost of medical care, and 4) ambulance personnel, by statute, are required to begin resuscitation efforts unless given a physician’s order to stop.
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