Medical Humanities Section Newsletter - January 2011, Vol 7, #1
From the Editor
Peter J. Paganussi, MD, FACEP
"I am as light as a feather, I am as happy as an angel, I am as merry as a school-boy. I am as giddy as a drunken man. A merry Christmas to every-body! A happy New Year to all the world! Hallo here! Whoop! Hallo!'' Ebenezer Scrooge – Charles Dickens – A Christmas Carol.
Well said, Mr. Scrooge, well said. My hope is that all of us, at some point or another, felt exactly this way over the Holidays. If you are looking for something to warm your heart a bit then read on, my friend. This edition of MUSE is chock full of cerebrally stimulating nuggets. We are pleased to have a few first-time contributors, as well as some stalwarts who have graced previous editions. Also we have the winning entry in the Medical Humanities Section Creative Writing Award for 2010.
Dr. Edwin Leap, kicks things off by reminding our section of the marriage of medicine and art. Our section really stands at the intersection of the two. We move into a short bit of prose by Dr. Jon Hager, which then flows into a wonderful narrative by Dr. Hans House, Acting Chair. Each proclaims that they love their jobs, but along the way we are treated to football, bratwurst, caffeine-fueled hyperbole and the nuances of night shifts.
We are excited to present a synopsis of a medical thriller written by member Dr. Frank Edwards. Frank has contributed prose, poetry and photography to many editions of MUSE. Bravo Frank!
We have some stirring and beautifully evocative poetry by Dr. Marianne Gausche-Hill. Dr. Ellen Taliaferro treats us to a story about the lessons that can be found in the teaching of young physicians. The proverbial “stuff they don’t teach you in medical school” sort of thing.
Visually this issue is a real delight. We have some artwork by our old pal and long time contributor Dr. Lee Robbins that is a veritable chaos of color. We welcome the contributions of Dr. Paul Dhillon. Paul is an emergency physician from Ireland and has contributed some deeply stirring photos from Haiti and Kabul. Paul is very dedicated to bringing the healing arts to the third world and is to be commended for his efforts.
We wind up with Dr. Teri Reynolds’ compelling story, “The Family Room.” It is easy to see why it was the winner of this year’s creative writing award. We finish up with some business items about an excellent Medical Humanities writing seminar that is held annually at the University of Iowa and the minutes from this year’s meeting in Las Vegas.
What a delight to put all this together. It has indeed made me as light as a feather. I shall pour myself a glass of mulled wine, light a fire in my fireplace, and sit down with my laptop and feast my mind with the creative works of our colleagues in emergency medicine. I’m sure Dickens himself would enjoy them as well.
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From Edwin Leap, MD, FACEP
2009-10 Chair – Medical Humanities Section
Over the past year as section chair, it feels almost as if...almost as if...I've done absolutely nothing. Well, I started the Humanities Section Facebook page, which hasn't really hit its stride yet (but undoubtedly will serve as an inspiration for untold numbers someday...right?). And I've sent out some notes. And, well, I guess that's life.
The thing about it is, despite our love of art and literature, music and theater and all the rest, we're just so dang busy. It's easy to call it “excuse making.'”But in the end, life drags us along, doing what we have to do.
We have children and spouses to raise, protect, provide for and enjoy. We have houses full of things that break and need to be fixed. We have dogs and cats that need to be shot...I mean, that need shots. We have yards to mow, meetings to attend, insurance to pay for, cars to maintain, churches and synagogues and mosques to support. We have parents to look after and siblings to visit. We have friends in trouble who need our care. We have colonoscopies to undergo, vacations to enjoy and books to read.
Life is like that. We physicians so often think that time works differently for us. That we are exempt from its absolute march and its solid walls and limitations. And so, in addition to the things I listed, we sign up for things. They always sound interesting and exciting, and we always hope they will add to our resumes or give us new insights or opportunities for growth, or for service. And then, they expect things of us, they creep into our schedules and we realize that it might have been easier just to add a couple hours of television watching and go to bed early.
A fair number of activities we end up neglecting or ignoring. Not maliciously; just practically. Not because their goal was, or is suddenly, unimportant. Simply because other things took precedence. Like our daughter's dance recital, our father's surgery, our hospital's insolvency, or that pesky embezzlement the group endured.
So I write with four goals in mind. First, to apologize for not having done more. I'm glad we have Tracy Napper, who reminds us of what's important, and helps us to get it done as a section, Tracy who, for all practical purposes, embodies the section.
Second, to thank all of you who have contributed, have helped, have spread the word. Thank you for the excellent contributions to the newsletter! Thank you for all you'll do at our upcoming meeting.
Third, I write to tell you that, if you haven't had much time to submit your work, to advance the cause of the section, to stand on street corners or go to conferences and wave our banner, it's all OK. You had stuff to do. After all, you're a tortured, suffering artist and no one understands you anyway.
Fourth, and finally, to remind you that your art is born in the real experiences of your life. Rather than being artists with art degrees who sit in art studios or offices and contemplate art, you are experiencing things. I firmly believe that the best art, the best expressions of the humanities, are created by those busily doing what you do. They are born while living life with other humans, suffering and witnessing suffering, raising children, going to work, struggling, overcoming and then putting what you see into music, or metal, or photos, dance, poetry, novels, drama, play-dough, beercan tabs or whatever voodoo you do.
So, I hope to see you at future ACEP meetings. We can exchange vignettes about how busy we are, but also talk about that great novel we've been contemplating.
Because that's just how life is for artists with day jobs, like all of us.
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Jon R. Hager
It's 0345 in the E.R. and there is one more patient to see. The guy just walked in and I overheard him talking with one of the RNs. This should be a simple and quick encounter, and after a crazy, busy shift I am SO hoping to grab an hour of sleep before the morning rush of patients begins. I am suddenly elated with the thought of driving home to my sleepy spouse and our ecstatic Rottweiler-mix mutt, Tara. Although I have never liked missing sleep, and despite all of the chaotic insanity that goes on in any hospital emergency room, I DO love my job. The E.R. is my theater and I am the star. I wonder if the lawyers feel the same way when they are in court?
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I Love My Job
Hans House, MD, FACEP
I had the pleasure drawing the night shift for Friday and Saturday night on the weekend of the Iowa-Iowa State game. This is arguably Iowa’s biggest rivalry game, ahead of Minnesota and Wisconsin (but soon to be outpaced by the “farmageddon”i that will be Iowa-Nebraska). For the state, this is the most important sporting event of the year. Just as in Los Angeles where every home can be identified as blue or red on the day of the USC-UCLA game, Iowans hang out their black or red this week. Also as in LA, many homes have split allegiances- this game pits brother against brother, daughter against mother, and uncle against cousin. For Iowa State, they pretty much have a two-game season: Iowa and Nebraska. Considering their usual level of football achievement, they don’t have much else to look forward to.
The Saturday of the Iowa – Iowa State game, when played in Kinnick Stadium in Iowa City, is our ER’s busiest day of the year (just ahead of Black Friday with all those shoppers trampling each other to get to the $30 Blu-ray players). And I got the night shift- sweet! I screwed my courage to the sticking place, arranged for some extra medical students to sew up the many lacerations, and poured a double mocha in preparation.
Friday night wasn’t too bad, just the usual overnight ER crazies. Soon after my shift started at midnight, the place was completely full, and we sent out the students in teams to tackle the lacerations and broken legs and other delicious trauma. We saw the usual heart attacks, strokes, and brain bleeding. There were college women with bladder infections, young men with toothaches, and nursing home patients with falls. Nothing too wild and it all moved through fairly efficiently. We had the place cleaned up nicely by 6 am.
I returned home and got to work immediately on the Game Day pancakes, which taste even better when you are tired and hungry. I also put bratwurst in the slow cooker to simmer while I slept.ii I went to bed at 8 am, and slept the dreamless, comatose sleep of the mentally and physically exhausted. It felt as good as sleeping off a margarita hangover after a Jimmy Buffett concert, but without the toxic side effects.
I awoke at 2:36pm to the smell of cooked brats and the sounds of Hawkeye football. I piled the brats onto buns and mustard (spicy brown of course, no French’s here) and collapsed onto the couch to watch all the games (the brats are even better with a dark beer, but I had another shift in a few hours). Fortunately for me, the geniuses at the networks had stacked all the great games into the same time slot: Iowa – Iowa State, Ohio State- Miami, Florida State- Oklahoma, and Michigan – Notre Dame. Besides Penn State – Alabama and my beloved yet inept Trojans, those were the only games of the day I had any interest in. Sure, most turned out to be dogs, but how often do you get three national championship rematches in one day!iii
I headed back to work early, at 8pm, because I knew there was a bad moon rising. The university has instituted a new policy of limiting tailgating in an effort to reduce binge drinking. We will have the scientific results on its effectiveness later this year, but early anecdotal reports suggest that we have fewer drunks getting into trouble at the game. As I walked into the ER Saturday night, I wondered if this means we will have fewer drunks getting into trouble outside the game.
Uh . . . . that would be a no.
The “grease board,” or list of patients in the ER, was covered in complaints related to trauma, assaults, and yes, alcohol. (We haven’t used a grease pencil on the grease board since 2004.) I gathered my slightly smaller, slightly less enthusiastic team of students and waded into the fray. After four hours of broken noses, cut feet from broken bottles, and more car accidents than I can count, I thought we had the place under control.
Then the bus unloaded . . . again.
Around 2 am, the waiting room filled completely with more lacerations, more accidents, and a few weird medical cases (what happens in a town full of bars at 2am? Hmmm). There was the worst case of “flesh-eating bacteria” that I have seen in a while. We had an old man try to bleed to death from a ruptured kidney (not fun). And we had a couple of really bad, really deep lacerations that the patients just couldn’t explain. One man cut his elbow down to the muscle, alongside the dozens of parallel superficial cuts that are characteristic for a borderline personality . . . er . . . I mean “emotional intensity” disorder. When asked repeatedly what happened, all he would divulge is that he and his friends were “playing with knives.” There you have it, kids: don’t play with knives.
Another woman presented with multiple lacerations on her left hand that she says happened when a glass broke in her hand. On a day with so much imbibing, that story is not unusual. But what was weird is that her hands, feet and part of her chest were covered in dried blood. It was quite a bit more than I would expect for a simple cut on the hand. As we went about cleaning her up, there was a palpable sense of conflict in the room between the patient and her husband. We found more cuts on her hand, legs, and one on her buttock (I still can’t explain that one). In the two and half hours it took to clean and close all the wounds, my medical student wisely asked about domestic violence. Just as with the man who played with knives, we never got a clear answer. The man left part-way through the treatment and it was obvious that he was at least partially at fault in the accident that caused the glass to break. But I think there were more than one or two glasses. The woman, although very upset, had the clarity of thought to call her mother into the ER and went home safely to mom’s. There is no mandatory reporting in Iowa for domestic violence, but the woman was encouraged to seek help and protection if needed.
This case, along with the man with the knife to his elbow, made me reconsider my role as a physician. Normally, I take care of whatever injury people incur, protect the children and elders with the force of the law, but let responsible adults go their own way and make their own choices. Here were two consenting adults that were in situations increasing their risk of harm. Should I remain on the sidelines as I always have? Or should I intervene myself in their lives to promote their security? I am still uncertain on the answer, so I have maintained the default and have done nothing. But these two cases made me think about it.
I love my job.
- Pat Forde, ESPN.com
- Bratwurst Recipe:
(this is made for a large crock-pot. For smaller units, use half the quantities)
1 dozen fresh, uncooked bratwurst
1 large onion, chopped
3 tart apples, peeled, cored, chopped
1 jar sauerkraut
1 bottle really good dark beer, like Guinness
3 – 4 cans really cheap ass beer, like Keystone light
Combine all the ingredients in a large slow cooker, cook on low for 6 hours. Remove the brats (they will be starting to fall apart- that’s OK) and reserve the cooked onion/apple/sauerkraut mixture. Serve the brats with buns, mustard, and a few spoonfuls of the cooked sauerkraut. For a more smoky flavor, try finishing the cooked brats for a few minutes on a hot grill. If you don’t have 6 hours to cook the brats, you can brown them in oil first, then cook on high for 4 hours in the slow cooker. The low and slow approach is definitely tastier!
- Ohio State vs Miami, Fiesta Bowl, 2003. Florida State- Oklahoma, Orange Bowl, 2000. Penn State – Alabama, Sugar Bowl, 1979.
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2010 Service to College Award
Jay Kaplan, MD, FACEP, presents to Hans House, MD, FACEP, the 2010 Service to College Award in recognition of the section’s ongoing work with the Emergency Medicine Foundation to raise funds for emergency medicine research.
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A Brief Synopsis of Final Mercy (a novel by Frank Edwards, MD, FACEP…www.medthriller.com)
"Maybe Dr. Jack Forester really did bite off more than he could chew. At least that's what his friends told him when, straight out of training, he accepted the job as ED director at a busy medical center desperately in need of help. But, New Canterbury University Medical Center was his alma mater after all, located in his home town, and he had a disabled brother to look after. New Canterbury also has a new interim dean, a strangely charismatic former Harvard researcher, who was elevated to that role after the sudden death of his predecessor. Who would have suspected? Certainly not Jack--that is, until he finds himself in the bullseye."
Bio: Frank Edwards was raised in Western New York and entered the Army after high school, spending a year in Vietnam as a warrant office helicopter pilot, an experience that propelled him toward a career in medicine. He majored in English and Chemistry at UNC Chapel Hill, received his MD from the University of Rochester, and has been practicing emergency medicine since completing a rotating internship in Greensboro, NC in 1980. He earned an MFA in Writing from Warren Wilson College, and has published poetry and short fiction in various journals, and has also written two non-fiction medical books, including The M & M Files in Emergency Medicine (2002). He is the medical director of a small regional EM group in the Rochester area, and holds an appointment as clinical assistant professor of emergency medicine at the University of Rochester, where he has also taught creative writing to medical students for many years. Final Mercy is his first published novel, and will be available at Amazon this fall. Two more books featuring Dr. Jack Forester are in the works.
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Marianne Gausche-Hill, MD, FACEP
This night brings me joy, not sure why, it just does…
I have not had joy nor creativity…but tonight I feel the pull of life, love, and companionship to humanity
The sky is unremarkable yet beautiful
A fountain spills its water and I smile
The creatures of the night move effortlessly, and I smile at their motion
I smell the rawness of the world and long to be a part of it
I wish to breathe life, love and have passion
I wish to give to the world to humanity
I want to explore the world and the world to know my heart
Tonight I have sipped fine wine, I have felt the joy of friendship, and I have heard the gift of artistry…we are so fortunate to be human…to know creative pursuits, to know intellectual pursuits, we are so fortunate…
Give me a palate of giving and I will paint!
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Old Growth, New Growth –Are We Any Different?
Jay Kaplan, MD, FACEP
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Ellen Taliaferro, MD, FACEP
On July 1st, 1936, at one minute shy of midnight, Dr. Brown collapsed on his bed, falling into a deep sleep. July 1st was the most dangerous day of the year in hospitals across the nation, for it was this day that all new interns began their tour of duty. Dr Alex Brown, Chief of Staff at Saint Joseph Hospital in Denver, had been everywhere that day checking on the new crop of interns. He was exhausted.
Ring. Ring. Ring.
“Hello,” he whispered into the phone.
“Hi, Doctor Brown, Sir.”
It had to be one of them.
“Sir,” echoed the voice.
“Sir, this Dennis Green. Dr. Dennis Green, Sir. One of the new interns.”
Even in his fatigue Dr. Brown could hear young Dennis call himself “Dr. Dennis Green” as though he had just stumbled onto his new title.
Dr. Green plunged into his presentation of Dr. Brown’s patient who had awakened at 3:00 a.m. with a severe nosebleed. “Sir, judging by the amount of blood on the patient’s gown and bedclothes, he lost a “ton’ of blood.”
“Doctor, just how much is a ‘ton of blood?’” Dr. Brown asked.
“Well, sir, I would say that this patient has lost at least a couple of pints.”
Meekly, the still squeaky-new Dr. Green lowered his voice and said, “Sir, could you please come to help me?”
Dr. Brown was already pulling on his trousers. He knew that a new intern would just as soon as jump off the roof of the hospital rather than admit he needed help. This might be serious.
“On my way,” he mumbled into to phone. Dr. Brown doubted that his patient, a prominent Denver banker and well-known St. Joseph supporter, had “lost a ton of blood,” but Dr. Brown did suspect that the banker was losing patience and confidence in St. Joseph Hospital.
Dr. Brown was at the banker’s bedside within 15 minutes. He exuded confidence and stopped the bleeding within minutes.
The nurse scooted out of the room to get new sheets.
“Where is all the blood loss?” Dr. Brown asked the intern.
“Right here, Sir,” Dr. Green said, pulling back the patient’s bed sheet. The red-fading-to brown traces of blood indicated that the patient had probably lost about ¼ cup of blood. A far cry from “at least a couple of pints,” much less a “ton of blood.”
Dr. Brown nodded. To the patient he said, “All’s well. See if you can get back to sleep. We’ll talk about his when I see you on rounds today.”
It was 5:30 a.m. when Dr. Brown left the room, too late to go home. Dr. Brown resigned himself to his fatigue, took a deep breath, and strolled down to the blood bank. There he found a small nun dwelling inside a generous white habit. She was known to many as “SMA,” short for Sister Mary Agnes.
“Hmmm,” SMA remarked as she nodded at Dr. Brown. “Did one of your patients lose ‘a ton of blood’ last night?”
“Indeed,” replied Dr. Brown. “How did you know?”
“Well, first, you’re here. Second, yesterday was the first day of a new intern year. But the best clue of all I found right here on the desk when I came in a few minutes ago.” With that she picked up three sheets of paper from the night tech’s desk. Each sheet represented a now-cancelled “Stat” requisition for a pint of blood and each sheet was signed by one Dennis Green, MD.”
Dr. Brown smiled. As usual SMA was one step ahead of him.
“When is your blood bank orientation lecture this year?”
“At seven this morning, the new interns will all be in their starched whites sitting in my shiny, tiled, white lab amphitheater, waiting for their orientation lecture titled, “Introduction to the blood bank.”
At 7: 05 a.m. o’clock, the new interns were sitting wide-eyed and beginning to grow restless. The teacher was running a few minutes late so casual conversation began, and echoed loudly off the tiled walls. Suddenly there was a nun standing in the middle of the amphitheater. She said nothing, simply stood quietly in her voluminous white habit, her arms hidden and folded into the sleeves of her nun’s garb. No skin showed except that on her placid face.
Voices dimmed and stilled. An occasional quiet cough amplified itself and bounced about off the ceramic white walls until silence reigned once again.
Still the mysterious nun stood quietly in the middle of their circle.
The boldest intern spoke up: “Sister, are you our lecturer this hour?”
The Sister pinned him in her gaze, and maintained her poise of perfect neutral.
Silence ensued. The anticipation of suspense filled the room and then faded into patient curiosity.
Without warning, the white habit exploded as the nun pulled out of her sleeve a glass bottle of outdated blood and flung it to the ceiling. The bottle ricocheted onto the wall behind the interns and then crashed to the floor, exploding and coughing up its red, sticky contents. Blood splashed everywhere. It dripped off all the walls, splattered the starched whites of the interns, and then pooled itself into small ponds of red on the floor.
Noise erupted. Some interns jumped, one screamed, and several uttered words not worthy of a nun’s ears.
The only pure white thing remaining in the lab was the mild sister. A faint metallic odor filled the air. The ticking of the wall clock punctuated the stunned silence.
The nun spoke: “And THAT, Doctors, is a pint of blood.” Then she disappeared.
Later, no intern could quite remember how she entered or left the amphitheater. But not one intern ever forgot, even years later, just how much of the red sticky stuff was a pint of blood.
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Images from Haiti
Paul S. Dhillon, BA, MB, BCh, BAO, LRCS&PI
Paul.Dhillon@gmail.com I paudhillon@ rcsi.ie I +(353) 87.690.0645 I BB Pin: 211219C0
Apt. 1, 91 Harcourt Street, Co. Dublin, Dublin 2, Republic of Ireland
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Marianne Gausche-Hill, MD, FACEP
Time holds us selfishly close to our own insignificance, yet as fools we glorify it as it slips from our white knuckled grasp.
As hundred of metal vehicles roll their way to destinations unknown, the glimmer of thousands of red and white lights dance across the minds of each soul pushing for a meaningful existence.
Billions of stars shine down, gleaming from other worlds making each journey by the time- worshipping soul meaningless in the stretch of universal eons that have passed and yet to pass.
A moment in time is all these souls can hope to grasp…plan, yes plan for future times but that moment slipping by each sunset must not pass without time-honored contemplation.
Rushing, working, planning, borrowing, owning, achieving, winning are all schemata in the race against time.
Time is the victor. The soul which glorifies it must bow to its might and live knowing that to admit defeat to time is not a surrender.
Try not to conquer that which is unconquerable but live a life which does not allow time to be master and a soul its slave.
No longer must the race go on against so elusive an opponent as time.
Time goes by. The soul must note its passing but not with regret but with joy for all those moments experienced!
Time is forever, and life can only hope to be a glorious part.
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Lee Robbins, MD, FACEP
Gerber Daisy and Poppies
Houseplants on Summer Vacation
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Humanities Writing Seminar
The Writing and Humanities Program at the University of Iowa Roy J. and Lucille A. Carver College of Medicine will host our fifth annual three-day conference focusing on the links between the science of medicine and the art of writing. The Examined Life: Writing and the Art of Medicine will take place from April 21 through April 23, 2011.
We've just released the Call for Presentations for The Examined Life: Writing and the Art of Medicine conference in 2011, available from our Web site at http://www.medicine.uiowa.edu/osac/examinedlife/. Click on the Call for Presentations tab at the top of the page. We're interested in any presentations that explore the intersections between creative or reflective writing and medicine. To get an idea of the breadth and range of past successful submissions, visit the archive page and the previous years' programs listed there.
Also, we’re overjoyed to announce that our keynote speaker for this year’s conference will be Paul Harding, who was awarded the Pulitzer Prize in fiction in 2010 for his novel, Tinkers. This is a fantastic start to our program. If you would like to hear from us when there are further developments, please visit the address above and look for the e-mail list signup form at the bottom of every page.
Thanks so much. Please don’t hesitate to forward this to any individuals or listservs that might be interested in attending or presenting. The more the merrier. We look forward to having you at this year’s conference.
Jason T. Lewis
Writing and Humanities Program
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
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Image from Kabul
Paul S. Dhillon, BA, MB, BCh, BAO, LRCS&PI
Paul.Dhillon@gmail.com I paudhillon@ rcsi.ie I +(353) 87.690.0645 I BB Pin: 211219C0
Apt. 1, 91 Harcourt Street, Co. Dublin, Dublin 2, Republic of Ireland
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ACEP Medical Humanities Section Creative Writing Award – 2010
Teri Reynolds, MD, PhD
The Family Room
"There is a golden hour between life and death. If you are critically injured, you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later — but something has happened in your body that is irreparable.”
—RA Cowley, MD
When people fall off ladders or roll their cars, get hit by baseball bats or bitten by hyenas, get shot, stabbed or strangled, when their bodies are injured by mechanical force, they are called trauma patients. For these patients, it is said, there is a golden hour: a brief period when even severe traumatic injury can be stabilized with limited damage to the brain and other organs, an interval after which survival rates plummet.
My intern year, there was a twenty-four hour period with twenty-three traumas. This is a lot, even for the county hospital. It comes out to nearly one an hour, but since the cases are never evenly distributed, some are simultaneous. When this happens, there is an overhead call for the “Backup Trauma Team to the Emergency Department.” There is no backup team, but this is a discreet way of asking for all available providers to come to the trauma room. Only once have I heard the operator violate this protocol, when a gunman jumped on top of a car, shot through the roof, and hit all four occupants, including the driver, who somehow managed to drive to the hospital before passing out. Faced with four critical patients and no advance “ring-down” from the field, the operator made a hospital-wide call for “any available surgeon to the Emergency Department—STAT,” acknowledging that one time, to anyone listening, that we were not in control.
When the system works, an ambulance medic calls us from the field and delivers the basics over a static-filled radio line: “We’ve got a 55 year-old man, non-responsive, BP 110/70, four minutes out…” Or they might say, “we’ve got a 28 year-old pregnant woman…” and lose the line. Thus is the trauma system activated. Doctors and nurses assemble in the trauma room, prepare equipment, don masks, gowns, and gloves, and wait for Kiwi-37.
To expedite care during the golden hour, trauma patients are assigned a code name under which the initial orders and X-rays are done. Trauma names can be any sequence of terms that do not repeat too quickly, and they are themed each year and assigned alphabetically. I don’t know who chooses the theme, but this year, we used fruits, and not just Apple, Banana, and Cherry, but Jicama, Kiwi, and Lychee. My intern year, we used art terms: P was Pastel, O was Ochre, and N was Nuance, which the clerks inexorably misspelled, so that you had to check nance, nunce and naunce to find a patient’s imaging on the computer. Aside from the obscenity of calling a dead man a Kiwi, fruits work better.
Eventually the code name is correlated with the patient’s real name, but depending on the severity of injury, the process of confirming name, birth date, and social security number can take much of the golden hour. Because X-rays and other studies cannot be done without a “unique patient identifier,” the code name is crucial to initial management. Long before we use patients’ real names to retrieve old records and contact family, we have to be sure that we don’t mix up their initial imaging and lab results. Replacing someone’s name may seem like adding insult to injury, but in the golden hour, it can be more important to render patients unique than to know exactly who they are.
This all changes, of course, when we leave the trauma bay for the family room, trading the chaos of resuscitation for a subdued conversation. Inevitably, someone stands as I enter to give news, as if reaching for it, and someone else ducks their head or folds their hands, as if they could retreat. These are lopsided conversations for so many reasons—the gap between my knowledge and their fear of what has happened, between my day job and their singular event, between the code name and the given one. I never try to explain the fruit or the art to families, and we all try not to use the code names out loud while family are present bedside. Though I’ve never discussed it with my colleagues, I think we share a tacit superstition that, while necessary and functional in crisis, to un-name someone in front of family is to put them at risk.
Because I work in a major public trauma center in a city where the rate of gun violence has skyrocketed, the 26 letters of the alphabet are nowhere near enough to last a year, so patients are also numbered by order of arrival: Apple-1, Banana-2, Cherry-3… The alphabet, of course, starts over at the 27th patient, creating the odd kinship of Apple-1 and Apple-27. It is always an index of high volume and bad times when we have two Apples in the hospital together—when we roll the alphabet from Apple-1 to Zucchini-26, and back around to Apple-27, before Apple-1 is well enough to go home.
I’ve become inured to rolling over the alphabet, but I still try to pause when we roll over the numbers, to walk out to the ambulance bay and look at something larger, the hills, the sky, when we roll over from Uniq-99 to Voavanga -1. These days, there is more time for everything—for teaching, for learning, for reflection, and I try to go to the ambulance bay most shifts, and always at 3am on a night shift—but my intern year it took almost too much effort to pause for the rollover, to remember what it meant, that 100 people had been injured so quickly.
The practical learning curve of my intern year ran so steep that it left little room for anything else. The purview of emergency medicine is the beginning of everything, and I actually ran from patient to patient, from floor to floor, from trauma surgery to cardiology to obstetrics, learning something new with each task. There was the first time a nurse called me doctor and I didn’t look over my shoulder, and the first time I introduced myself by my title. There was the first resuscitation, the first chest tube, both the first bad news and the first baby I delivered alone, and my first time declaring a death—which, as it turns out, is more complicated than birth. It is the nature of emergency medicine and the reason I chose the field that there will always be firsts, but the practical aspects—the medications, the procedures, the resuscitation pathways, and how to place hands on a newborn—are familiar now. These practical lessons come with doing, but the never-ending lesson of the job is learning to tolerate our own inadequacy in the face of what patients and their families experience.
I had an awful series in that year of art: Draw-56, Easel-57, Figure-58—three brothers who’d been shot while walking down the street together. There was a rumor that they were brothers when they rolled in, but no one knew for sure, and we hadn’t figured out their names yet in the chaos. Draw had been shot in the chest, but the wound seemed superficial and he looked stable. Easel was shot in the head, dead on arrival. Figure was the one who needed us most—he’d been shot in the abdomen and was hypotensive and fading. We started fluids and blood and sent him up to the OR, where he would die, I found out later. I was the intern on the trauma team and responsible for running the resuscitations and then updating the family, but I couldn’t do that until I knew who was who.
The social worker had left to find the family, and my senior resident had rushed Figure upstairs to the OR. I tried the charge nurse, who, for unclear reasons, said she doubted the men were even brothers. The clerk was busy trying to assign the incoming cardiac arrest patient his own code name, and the medics had disappeared to their next call. I turned back into the trauma room, where Draw was laying quietly on his gurney. He was slow enough to respond that I tried my question twice in English and once is Spanish before he answered. He confirmed in quiet but perfect English that they were indeed brothers and that he was the youngest at 18. He could tell me his brothers’ names, but I couldn’t ask him which brother was the dead one—he was pale and glassy-eyed and barely answering my simple questions, so I hadn’t told him anything yet, and he hadn’t asked. I went into the next bay where we’d resuscitated the others. There was no gurney, and the room that was usually filled with sound, where we were always running into and crowding against each other, felt huge and silent. It was a wreck of blood smears and paper wrappers that we’d peeled off sterile equipment. There was a sneaker in the sink for some reason, and on the wall, a diagram describing the proper position of each player in a trauma resuscitation—trauma nurse to the right, resident to the left. It describes an orderly configuration that I’ve never seen us achieve and that, given the location of the door, is probably impossible. I found the brothers’ sticky black jeans in a ball in the corner and riffled the pockets for ID. I stared at the photographs and tried to memorize what I needed.
Draw, Easel, Figure. Pablo, Cesar, Ramon. Stable, Dead, Guarded.
Pablo, Cesar, Ramon. Draw, Easel, Figure. Pablo, Cesar, Ramon.
There’s bad news, I thought, and more. I mumbled the rosary of names under my breath as I walked into the family room, a squalid 8 ft square with plastic chairs and peeling paint. I stepped over a plastic Thomas the Tank Engine that rolled by and hit the wall with a thump. Until someone begins to keen or punches the wall, sounds we occasionally hear in the charting room next door, the family room is infinitely quiet. It has different rules than the trauma bay, and the code names that serve us so well in the golden hour mean nothing here. I had to remember what this family called the boy I knew by his unique identifier. To the extent that they shared a mother, these boys were not unique at all.
Pablo, Cesar, Ramon. Draw, Easel, Figure. Stable, Dead, Guarded.
Hello, I said, I’m Doctor Reynolds. A young woman stood up.
This is my mother, she said. The mother did not lift her head.
This is my brother’s wife, she said, and my other brother’s girlfriend.
I cannot, I thought, screw this up.
I’ve since been in the family room countless times, to give good news and bad, and I’d like to think I’m better at it now. The room has been painted a smooth sea foam green and Thomas the Tank Engine has been joined by a roller coaster for marbles. I have learned some things: to always use the word “dead” when that is what I mean. To make sure that no one is standing and how to catch people as they faint from a chair. I’ve learned that grief often begins as rage and never to place anyone between me and the door, and that in a small room, you can feel another person’s sorrow hit your body in a wave. And I have learned to reassure families that we “did everything we could,” as I tell them with my face that the damage had already been done by the time their loved one arrived, that we had missed the golden hour.
Pablo, Cesar, Ramon. Stable, Dead, Guarded.
Draw, Easel, Figure. Pablo, Cesar, Ramon.
Please, I said, sit. It was my first time in the family room.
NOTE: This work was submitted to Norton for their “Becoming a Doctor” collection and was accepted. It was published in early 2010.
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Annual Meeting Minutes
American College of Emergency Physicians
Section of Medical Humanities
September 28, 2010
Las Vegas, NV
Participating in all or part of the meeting were: Judith Dattaro, MD, FACEP; Hans R. House, MD, DTMH, FACEP; Jay A. Kaplan, MD, FACEP, ACEP Board liaison; Tae W. Kim, MD; K. Edwin Leap, II, MD, FACEP; Chair; Jeffrey Sankoff, MD, FACEP
Others participating: Tracy Napper, ACEP staff liaison.
- Call to Order
- New Business
- “Open mic” discussion
- Select chair for art gallery for 2011
- Membership/Facebook page
- Web site development/newsletter expansion
- Writing Award for 2010
Major Points Discussed
The meeting was called to order by Hans R. House, MD, DTMH, FACEP, immediate past section chair.
- “Open Mic” – Dr. Amber Crowley is organizing the performers this year. Section members discussed the need for a sponsor next year. Some ideas are to approach wine companies to sponsor a wine tasting, or perhaps a luxury car company. Dr. House will investigate the wine company. Ms. Napper will discuss securing a corporate sponsor with Peggy Brock, who runs that division at ACEP.
- Dr. Kaplan presented ACEP’s 2010 Service to College Award to Hans House, in recognition of the section’s ongoing work with the Emergency Medicine Foundation to raise funds for emergency medicine research.
- This year the art gallery was again distributed throughout the ACEP Resource Center, using tabletop easels that were purchased with the section dues allotment. Donated art was again auctioned for EMF. However, due to continued declining numbers of submissions to the gallery, we will suspend the event for at least 1 year and will gauge continued interest at that time. Our section again provided book signers, the art, and a piano player for the Evening With EMF.
We also discussed trying to advance membership interest among those who are artisans. We want to involve more people who build, who refurbish, who create woodwork, metalwork, glasswork, etc. Dr. Leap will make a metal placard for the 2011 council meeting.
- Dr. House said that the section membership numbers seem to be holding steady, although hovering close to the 100-member mark that is necessary to maintain a section. He reminded section members to sign up their residents, as residents are allowed 1 free section membership.
- Members were reminded to submit items for the Web site and newsletter. These can be emailed directly to Pete Paganussi.
- Dr. Leap has set up a Facebook page for the section. It is open access and can be found by searching for “The Section of Medical Humanities, ACEP.” Members should send feedback/ideas to Dr. Leap and are welcome to post on the page.
- Writing Award for 2010 – This year’s award was given to Teri Reynolds, MD, PhD, for “The Family Room.” Dr. Leap is blacksmithing a quill as a prize. Articles will be solicited for the fifth annual award in June 2011. More advertisement of the award needs to be done next year. We may present the award at Open Mic night in 2011.
The meeting was adjourned.
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