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Medical Humanities Section Newsletter - March 2007, Vol 3, #2

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circle_arrow From the Editor
circle_arrow North Rim, Grand Canyon
circle_arrow New Mexico
circle_arrow San Sebastián
circle_arrow From the Chair: Writers' Resources
circle_arrow A "Christmas Carol" - A Sort of True Story


Newsletter Index


Medical Humanities Section

 

From the Editor

Hans House, MD, FACEP

The wind is howling and snow blankets the landscape. Outside my window, snowflakes drift and tumble weightlessly. Inside my window, my blanket is warm and my tea is warmer. Winter is the season for fireplaces, plush armchairs, a good book, and a dog at my feet. By the time you read this, the spring thaw should be in full swing. But until then, I thought you might need something nice to read indoors.

This season's issue is made for readers who love to read with stories by writers who love to write. No section meeting minutes or sappy Scientific Assembly remembrances.  We'll get back to all that stuff next time. This one is just for fun.

This issue also represents the last backlog of stories as I clear out my hard drive once again. You, the section members, have been wonderful about sending me plenty of material. But I have finally exhausted last year's submissions. I need more material for the next newsletter that will be published in early June. Please submit any new material by May 1, 2007. As always, just e-mail it to me care of careers.section@acep.org.

Please enjoy this issue of the newsletter by reading alongside someone you love.

 

 


 

 

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North Rim, Grand Canyon

Photo by Justin Pattee, Medical Student, University of Iowa

North Rim, Grand Canyon

 

 


 

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New Mexico

Marlene Decker, MFT, CADC
Behavioral Health Consultant
Good Samaritan Hospital
San Jose, California

What draws me to Santa Fe is lust.
Lust. Lust. Lust.

I'll admit it but only to you. I'm a pushover for terra cotta. The sound of it: terr-a-cott-a, terra cotta. Evokes for me rusts and umbers and red mahoganies, smoke-filled lodges lashed tight against pale desert winds, guttural chants echoing through deep earth colors, vibrant and alive, visceral as mountain ranges, omniscient, timeless, recording history in eons, stoic, brave as the planes of Chief Joseph's face when he, of the Northwest, vowed to fight no more, forever.

The pottery in New Mexico, where authentic people lived lives in harmony and respect for the earth and all creatures on it. When I allow myself, I feel such shame for the way I live, the consumption that my contemporary life, a working life in a crowded city assumes, demands. What draws me to Santa Fe is the raw beauty of endless sky without smog, the stark, efficient desert plants. The culture of art draws me there, invites me to grab, -I know, I know, greedy me- at the textures of the place: the Indian blankets with their symbolic, linear geometry, the pottery in a hundred shapes of round and all evoking a simpler, more honestly lived, but harder existence on a human plane higher than ours, than mine - a spiritual plane.

What draws me to Santa Fe is the craftsmanship of ancient and modern silversmiths, families of silversmiths, who together and generation after generation, embraced a blazing chunk of turquoise with liquid fingers of silver, earth and sky, rock and moon, contrast not of man, but of nature. I have a memory that isn't mine of the railroad coming, and bronze-skinned women, babes at breast, sitting in the dust of the tracks to sell their pottery for pennies in the desert dawn of a transcontinental railroad.

I hunger for the hard, clear beauty of the place, the magenta and violet sunsets, handsome, high cheekbones of a tawny, terribly injured people. What draws me to Santa Fe is everything I think my compulsive little life should be about, and isn't: Peace, Beauty, Art, Simplicity, Community, an indigenous history, a life lived with textures and authentic historical content. Terra cotta, turquoise sky, mahogany earth, silver moon, luminous, ethereal as the smoke of pinon wood fires drifting up from kitchen and cafe across a wide, storied desert where the bones of warrior chiefs are watched over by saguaro cactus, scrub pine, dark birds, and cradled in the earth's eternal rotation from tangerine dawn to scarlet evening.

I am from a murdered people. The American Indians are from a murdered people. I learned from them that mine was not the only holocaust. There is a kinship that bridges history.

 


 

 

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San Sebastián

Jennifer Blair, MD
Resident Physician
University of Chicago

The Simpsons can speak Spanish. You have to wonder if the American actors are bilingual, because Marge grates, Lisa pipes, and Homer complains so well that the joke inherent in their voices isn't lost at all. I found this out during lunch at a medical clinic in San Sebastián, Spain. Doctors chewed and watched me, amused by my laughter. I just liked hearing the voices speak Spanish. I didn't actually understand them. That was why I was in Spain in the first place.

My advisor comes from Mexico, and I'd asked him if he knew a clinic there I could visit, after I'd seen a Hispanic mother try to give birth with only one busy resident available who spoke some Spanish. I'd often tried out a little bit of Spanish with my patients, asking them the names of things, putting them at ease while waiting for the interpreter. But properly studying a new language is a big undertaking, and I'd dragged my feet in favor of other pastimes. The day the Hispanic woman gave birth, though, encouraged me. What with my passing familiarity and the similarity of Spanish medical terms to English ones (they both come from Latin), I could understand much of the exchange. I just couldn't construct anything to say. Maybe a few days' immersion would change that.

"Forget Mexico," my advisor told me, "you should go to San Sebastián." He'd spent time in Basque country, in northern Spain, and he sent a few e-mails to colleagues there, all the while singing the praises of its food, people, and landscape. Soon it was arranged. I spent a week as an observer in an urgent care clinic there, trying to follow patients' complaints and doctors' questions; reading medical writeups, looking up word after word in a little dictionary whose spine broke in short order. We had a good time. The doctors got a kick out of my cheerful willingness to blather in whatever Spanish I could scrape together, and I was thrilled if I could make out what they were saying.

The Spanish that natives speak is a lot faster than that resident's high school Spanish had been. I became an expert guesser. Trying to communicate in a foreign language when you know only a couple of hundred words is an art, particularly when you mislead people into thinking you know more by rattling off stock phrases with a decent accent. (Mimicry runs in the family: my uncle does a side-splitting Richard Nixon.) People answer in much more detail than you're prepared for, and you don't want to disappoint them. You listen so hard your neck hurts. You watch their hands, their gazes, the expressions of other people in the room. You feel your brain processing about three seconds behind what is being said: first a string of gibberish, then the old 486 whirrs, then one or two words come forward, bright and clear against the static. Seconds tick by, but finally you think you know what he said, more or less. Often, you can then just nod and smile, but sometimes the speaker looks at you inquiringly, expecting a reply. You think of one – in English. You translate, butchering your original brilliant response to accommodate your miniscule Spanish vocabulary. You remember to conjugate: third-person singular, -er verb, past tense...But too much time has elapsed. The speaker has concluded that you didn't understand, and helpfully repeats himself. Your fragile little sentence is swept away in the rush of words. If you're lucky, he'll slow down, rephrase, gesticulate. If not, you'll say or some other such inanity, and hope he won't notice you're clueless.

More than just the language was novel to me. Being European, the clinic itself was full of, as Pulp Fiction's Vincent Vega put it, "little differences." Temperatures were taken from the underarm with mercury thermometers, rather than with the flash-quick eardrum cones we use here. Sheets weren't changed unless they looked dirty – if two people with headaches had sat on them, they were left alone. Gloves were similarly not bothered with except where bodily fluids had escaped. On my first morning, I was given an enormous set of scrubs and ushered, reluctant, into an operating room, a place I had hoped never to have to enter again. I was led to a stool behind the surgeon, whom the nurse assured me had spent time in England and spoke good English. Not knowing how to protest that speaking English would defeat the purpose of my being here, I stood obediently, watching them sew in a heart valve – admittedly an impressive operation, but one with little linguistic yield. I had plenty of time to look around and notice that the surgeons' gowns were made of cloth, not paper, and so were the drapes. No doubt they'd been sterilized, of course, but I was pleased by the frugality. (I did wonder what kind of fuss they would have made if someone were to contaminate a drape.)

The urgent care clinic had a little office where the staff retreated during quiet moments between patients. The first morning, I set down my things stiffly, asking permission to eat the flaky croissant I'd bought before the bus ride. (I'd been too shy to eat it on the bus, afraid of breaking some societal rule and looking like a dumb tourist.) The doctor waved his hand in the air carelessly, and before long I learned that you could all but open a keg in that room. Nurses and doctors alike wandered in and out, popping mints, rolling and smoking cigarettes, surfing the Web. Everyone went by first names and kidded each other like siblings. Sometimes people without white coats came in and were greeted effusively with kisses and how-have-you-been conversation. They would open their briefcases, take out some flyers, and, to my astonishment, deliver a two-minute spiel about a medication. Drug reps, those pariahs of the American doctor's office, who usually have to bring lunch bribes to get anyone to listen to them, were welcomed in Spain like old friends. As soon as they finished their pitches, they resumed their social conversations with the doctors. They were not the corporate enemy. I'm still trying to figure that out.

The patients, too, were treated differently. The doctors showed the patients their X-rays, and explained the medical writeups; patients took both items home with them, which isn't done here. There was a certain ineffable casualness. It wasn't at all unprofessional, just less distant. The doctors didn't shrink from laughing at the patients' jokes; the patients didn't hesitate to lower their trousers to show a rash on the thighs – there was no fanfare of drapery and chaperone. There was time for conversation. It was as though the exam were being done during an interlude to a party to which both doctor and patient would soon return.

Speaking of parties, here I must describe what it's like to have lunch when you're a doctor in a Spanish hospital, or at least in that one. There's no tray-bouncing or soda machines or soggy paper plates. You go up to the cafeteria counter, where you are handed a menu. You tell the black-and-white-uniformed waiter what you want, then proceed to the doctors' lounge and sit down at a long table with your fellow doctors, most of whom are smoking cigarettes. An assortment of newspapers is available. Sometimes the TV is on, so you can watch news or cartoons. The waiter comes in and puts a plate, silverware, and long-stemmed wineglass down on the white tablecloth. You get bottled water, or wine if that's what you ordered. After you finish your appetizer, generally a salad, it is taken away and your entrée is brought. The options are elemental, proteinaceous; either something involving meat, or something involving fish – an enormous fish, generally served intact and lying across the plate, spilling over both edges. Spaniards seem to like their food oily (once I watched a doctor all but empty a decanter of olive oil over his salad), so the fish lay in a little oily pool. It took some work to fork all the flesh off the bones. It was not untasty, just muy rico. What with the fish and the delicious, milky, sweet desserts (yogurt, flan, ice cream, or flan with ice cream), lunch could hold me till the next morning.

The pace at lunch was leisurely, so it was a good time for language practice. One day I was eating beside Dr. P., a handsome and jovial Basque who was fluent in Spanish as well (as are most Spanish Basques). His cell phone rang. He swallowed his fish and answered with a curt "Sí?" I couldn't begin to follow what he said to his colleagues, so I paid attention to Lisa and Bart Simpson instead. When he hung up, he took a quick sip of water and turned to me. He told me that he had to go back to the clinic, and that I should feel free to stay and finish my dessert. That part I understood. Then he began to explain why he had to go. I listened carefully, as usual picking up perhaps one-quarter of what was being said. It seemed that a woman there – probably one of the nurses – had done something with some preserves. Ah, yes; the nurses in my father's office sometimes bring in food from their gardens to share, and I figured he was going upstairs to snag a jar. (I was too busy constructing this hypothesis to realize how little sense it made.) I made noises of cautious comprehension, but my expression must not have satisfied him, because he repeated himself. Gradually he zeroed in on a word I seemed to be missing. "Romper," he repeated. My face was blank. Gamely, he took my dictionary and found the word. Romper: to break. Hm. Had one of the jars broken? Maybe someone had been cut. The doctor started again, determined not to let me smile and nod my way out of this one. He spoke more slowly. Something about a woman and her novio, her boyfriend. They had been making amor. This was getting racy. But then what was this about a preservativo? I looked it up. Preservative. Now I was completely lost.

In despair, Dr. P. made a hole of his thumb and forefinger, then poked his other finger in and out, looking at me pointedly. Novio – amor – romper el preservativo. Condom! It was a Helen Keller moment. He got up, wagging his eyebrows at me, while my cry of comprehension filled the room. After only a week in Spain, I'm nowhere near proficient, but that is one Spanish word I'm glad I learned from a doctor instead of a patient.


 

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From the Chair: Writers' Resources

Michael D. Burg, MD, FACEP

Michael D. Burg, MD and Son

Every summer, The Community of Writers sponsors a series of writing seminars in Squaw Valley, CA (near Tahoe). 2007 will be their 38th year doing so. Dates for summer 2007 are available at their Web site at http://www.squawvalleywriters.org. By all accounts their reputation is excellent, and the setting is stunning.

Another well-respected summer writing program is "Writing the Medical Experience," hosted by Sarah Lawrence College in Bronxville, NY (about ½ hour outside the city). Sarah Lawrence is a small liberal arts college with a sterling reputation and puts on a week-long writing seminar that will inspire you to new creative heights. Not only will you have the opportunity to share what you've written with others, but you'll be taught by the likes of Richard Selzer, Rafael Campo, David Watts and many more. Seminar dates for 2007 are July 8th to 14th. More information is available at http://www.slc.edu/index.php?pageID=4009#2. I attended "Writing the Medical Experience" in 2005 and 2006. I highly recommend the "experience."

Home to the famous Iowa Writer's Workshop, the University of Iowa offers the Iowa Summer Writing Festival every year. The program is a wide variety of weekend and one-week seminars geared for every level of writer, from the novice to the experienced author. The relaxed, encouraging atmosphere of the program is very welcoming and extremely productive. Dr. House attended this program last year and intends to participate every year. He can even hook you up with a room for the week, since he lives about a mile from campus. Weekend and week-long courses are offered from early June to late July: http://www.continuetolearn.uiowa.edu/iswfest/.

Other colleges and institutions probably sponsor similar programs. If you're familiar with other highly-regarded writing seminars (particularly those focused on the medical humanities and designed for working professionals) please share them with your fellow section members through the newsletter or e-list. Information about other seminars that apply to the medical humanities is welcome as well.

 


 

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A "Christmas Carol" - A Sort of True Story

Pete Paganussi, MD, FACEP
Oakton, VA

Shyster was dead...dead as a doornail. Ironic he should be interred on Christmas Eve, I.M.A. Shyster positively abhorred Christmas. "Humbug!" he called it. Dying during the holiday season somehow seemed fitting; one last bit nastiness for ol' Shyster. His partner in the Law firm of Shyster and Suem Ltd., Will Suem Esq. had seen to all the funeral arrangements. A cheap pine box and a sparsely attended, emotionless ceremony. No one except a few of the wealthiest clients came. Izzy, as he was known, short for I.M.A. Shyster (Ignatius Malcolm Aloysius), had no real family, and he certainly had few friends. A couple of clients for whom he had garnered extraordinary malpractice settlements came, but few people would want to be in a cemetery on such a cold and dreary day.

"Not that there is ever a good time to be in a cemetery," Will snorted to himself as he turned up his collar to steel himself against the biting wind. "Feels like snow," he thought. "Just what we need...a 'White Christmas.' Everyone will get all dopey and sentimental for the holidays. Bad for business! Bah Humbug!" he thought to himself as he walked back to his office. The snow gently fluttered around him and was just beginning to cover the ground. Yet Will could not see the beauty before him. He really could have cared less; after all, he had a Law firm to run. He had doctors to sue, divorces to execute, ambulances to chase. This was not the time for sentimentality. Shyster himself had taught him this, and taught him well indeed.

As he turned the last corner into Barrister's Alley, a palatial row of expensive town homes near the county courthouse in old Fairfax City, the wind whipped up with even greater intensity. It stopped Will completely for a moment. He clutched the collar of his coat and pushed forward the last 50 yards to his office. After the first 3-4 steps he began to notice that gripping discomfort again in his left shoulder and upper chest. He had been getting it the last few days. It seemed to happen when he walked too fast or too far. It felt like someone was gently squeezing his chest and his throat. "Bah, Humbug!" he muttered. "Too many nachos at the Club this afternoon," he thought to himself, trying to push the discomfort out of his mind.

As he reached the office and began to climb the steps he noticed he was suddenly very winded. Despite the bitter cold, he noticed he was quite sweaty. "Gotta cut back on the salty foods and cold cuts...maybe that's why my ankles have been swelling the last few days," he thought. He paused close to the top of the stairs. After a few moments he vaguely began to feel better. He reached into his coat and pulled out a Marlboro.

"What the Hell? Merry Christmas!"Will comically thought, as he smugly took two or three long drags on his cigarette. Suddenly it all came back. The chest/arm/shoulder pain, the trouble breathing and the sweating. Only this time he was lightheaded, woozy feeling. The cigarette seemed to taste very bad as well. He threw it away. He felt sick to his stomach. "Whoa...Steady" he told himself. He gripped the banister; the cold metal felt oddly good somehow.

"Are you all right Will?" asked someone from below. "It's that infernal Bob Goodfriend," Will silently realized. Bob was the Public Defender who rented the cramped, damp, basement efficiency office from Shyster & Suem. His clients were mostly foreigners or immigrants who couldn't speak English and certainly couldn't afford a proper lawyer. He was behind in his rent.

"You owe me..." voice trailing off, "...me three months b-b-back rent Goodfriend," stammered Will, but he could barely speak. Now his legs began to feel like Jell-O, and the pain was more intense. He was most definitely nauseous. "Wow Will...are you all right?" asked Goodfriend again.

Will Suem then fell to his knees, clutching his chest, as a circle of darkness seemed to close around him. As he faded he heard Bob on his cell phone alerting 911. "Don't call them...," choked Will "...they'll kill me...they're all idiots...I know, I've sued them all.," and with that he passed out.

When Will woke up he was strapped to a stretcher, bouncing around in the back of Medic Unit with lights and sirens blaring. He had an IV in his left arm and he had electrodes stuck to his chest. It appeared he was wired like an astronaut on a moon mission. The Paramedic tending to him had his back turned, but there was something vaguely familiar about him. As he slowly turned around Will could only gasp as he realized it was his supposedly dead partner, Izzy A. Shyster. Unbelievable! Was his mind playing tricks on him?

"Yes Will, it's me Izzy. I know this seems confusing, but hear me out. I'll let you in on a little secret..." Izzy paused while he adjusted an oxygen mask on Will's face. "...There really is a God. Oh yes, he's most decidedly real and there are two things you need to know about him. He's quite pissed off with you and the life you lead. The other is that he has a twisted sense of humor. He sent me back to Earth as a Paramedic. I'm here to warn you. It's too late for me, but not too late for you Will. Soon my work here with you will be done, but as for I, well I will clerk for Judge Judy for all eternity. That is my penance for my evil ways, unless I can help save you."

"I don't need saving! Humbug and double Humbug!" roared Will through the plastic mask. "I am the captain of my own destiny...This is all a dream...I'll wake up soon...I'll..." Will's voice trailed off weakly. Suddenly he was aware of the chest pain, sweats, and queasy feeling again. Things were beginning to fade, just like before.

Izzy firmly held the mask over Will's face. He chuckled, "Look at you Will. You're having a heart attack. All those cigarettes you smoked and all that coffee you drank. All those contentious malpractice litigations have made your coronary arteries like the kitchen drains at the local greasy spoon. Oh, you'll repent my friend. Repent or be damned. Tonight you will be visited by three Physician specters, the Physician of Christmas Past, the Physician of Christmas Present, and the Physician of Christmas Yet-To-Come. Heed their words Will Suem or be damned for eternity...Remember Judge Judy!" While looking with fear into Izzy's wild eyes, Will passed out.

"Where am I?" he asked, of no one in particular.

"You're at Saint Swithins Charity Hospital," came the answer. He was on a gurney being rapidly pushed through a crowded corridor. A young woman, in a white coat, with a preoccupied look about her was pushing him towards his destination in a hurry. She was attractive, but looked haggard and drawn. The fluorescent lighting was also not especially flattering. She appeared to be in her mid to late twenties but had the air of someone twice that age.

"Who are you and where are you taking me?" asked Will.

"I'm Doctor Sheila Admittem, an Emergency resident; I am the Physician of Christmas Past. I am taking you to your room. You're lucky, a room became available in the CCU, otherwise you'd still be in the ED. Patients sometimes wait 16-24 hours for a CCU bed here, you must have a Guardian Angel or something. They were waiting for that junkie with AIDS to die for a long time...now you can have his bed," she replied matter-of-factly.

"What...my room?!...What about my heart attack?...what about the Cath Lab?...what about a Cardiologist?....What about angioplasty?....Wait a minute, what junkie with AIDS????" demanded Will.

"Cath Lab! Angioplasty!! Where are you from and who died to make you king? This is 1984 Buddy, this IS modern medicine. You're lucky to be here. You'll go to the CCU, receive standard of care therapy, nitrates and morphine, all the while with continuous ECG monitoring. You'll go there and just have to complete your infarct. If you get very lucky you'll be eligible for the Beta-Blocker Post MI Protocol, also known as BIPPI that we are doing here," Sheila answered tersely and with a hint of disdain.

"Complete my infarct! Lady you are daft! I'm outta here!!!" Will shouted as he struggled to climb out of the stretcher. "I'm better off in the freaking OB/GYN Ward then with you lunatics."

"You're not going anywhere." said Dr Admittem, forcefully pushing Will back down. She was remarkably strong he thought. "Besides, OB/GYN is an entirely different set of DRGs, so that will never fly. Sit back and rest you are making things worse." He could see her patience was beginning to wear thin.

"Hey I'm a little tense O.K....I'm sorry but I'm the one having the heart attack over here and you don't seem to give a rat's ass young lady," Will snapped back.

Suddenly Sheila stopped; she put her head in her hands as she sat on a plastic-backed chair in the hallway. She was quietly sobbing. Will actually felt a bit remorseful, he felt strangely sorry for her somehow. "Hey, hey, it's alright. Don't cry, c'mon you're a Doctor for Chrissakes."

"Oh I know what I sound like; I've been getting so harsh and so snippy lately. My marriage is on the rocks, largely because I spend 100-110 hours a week in this hospital for $18,000 a year, chasing a dream that never seemed so far away. I'm 100,000 dollars in debt from Medical School and the interest payments began the day I got my diploma."

"My resident and I have been named in a lawsuit," Sheila went on, "because some crack-addict shot coke into his IV line when he went outside the hospital to smoke. He had a heart attack and died. His family is suing because I put in that IV under my resident's supervision. They blame us for his death because of the IV...I may lose my license because of it. Can you believe it! I should have been a travel agent, I don't think I'm going to be a doctor for much longer," she lamented.

"Hey Doc, you want me to take this guy to the CCU for you? You look beat. Besides, I'm on my way to the cafeteria. I'm on break," said a young man with spiked purple hair, a skinny black tie, and a black spider tattooed on his neck.

"Wow, would you Stench?" replied Sheila

"No problem, anything for you sweetheart," said the Goth named Stench.

"Wait a minute...what about me...you can't leave me Doc...not like this...not with, with...with Stench!" cried Will.

"Easy Pops, you'll short circuit Man. Hey, you're in excellent hands with ol' Stench. Treat me kind brother and I'll teach you how to get a middle rack food tray. The roaches can't get to them as easy so they stay relatively pest free, if you know what I mean," Stench muttered as he picked his teeth and wheeled Will down the ever darkening corridor.

"Wait!" Will screamed "Dr Admittem, help me!" but all Will heard was Stench's high-pitched laughter. Things began to go dark again. "Ahhhhh...." Will moaned

"Easy ‘Daddy Warbucks', first I gotta stop for a smoke." Stench spun Will around in the stretcher. It spun and spun, out of control, until Will passed out.

Will woke up in the back of the ambulance again. This time Izzy was driving and Stench was tending to him in the back. Izzy shouted back over his shoulder, "We're pulling into the ambulance bay of George Mason Hospital, Will; it's Christmas Eve 2002 again. This is where you would have gone tonight anyway. We're pulling past the doctors' parking spots...hmm, let's see who's here."

Will looked out the back window as they pulled past and noticed not a single car in any of the doctors' parking spots. "Hey wait a minute...nobody's here! You can't take me there! Not a single doctor is in the hospital. It's Christmas Eve, they're all at parties!" Will screamed.

"Relax Cuz," Stench leered as he patted Will's shoulder, "The doctors never park in the ‘Doctor's Spots,' they know they run the risk of vandalism. People waiting too long, drug seekers who don't get the prescription they want, the drunk, the agitated...all of them can potentially take out their frustrations on the doctors' vehicles; no Dude, they never park there. Trust me though somebody's working. It's how ER's operate Dude...24/7/365 baby! You're lucky there's such a thing as EMTALA otherwise you would definitely be toast dude. All the doctors you've sued in this county, you'd better hope the ER doc is good ‘cause right now that's all you got."

They pulled to a stop and the next thing Will knew he was safely in triage at GM Hospital. "Ahh," he thought, "A modern hospital. Now I'll really get the care I need."

"Put him over there..." a harried looking nurse said as she rolled her eyes and pointed off into a hallway lined with at least 4-5 other stretchers and people in various stages of disrobement. "He's fifth in line."

"Hey lady I'm having a Heart Attack over here...I need help NOW!" Will bellowed. Everyone in the reception area froze and became silent. All eyes and attention were now on Will and the triage nurse.

She spun around, put her left hand on her hip, squared off on him and said, "Look SIR, there are two strokes and two OTHER heart attacks ahead of you. All the other hospitals in the area are on reroute. There are ZERO, count ‘em, zero CCU beds anywhere. Besides even if we had the beds we wouldn't have the proper staffing for them. No one is going into medicine anymore, too hard, too long, for too little and you only wind up taking care of impatient, ungrateful, OBNOXIOUS people like you! So back off Jack! I'd rather be home ‘decking the halls' tonight, not here in triage with no Tech and a Registrar that called in sick." A half-naked, gray-haired little seventy year old man on the next gurney clucked loudly in response and a large twenty-something year old with a bloody bandage on his head rose from his stretcher applauding.

"Hey Lady I'm not here to see the Tech or the Registrar, I'm here to see the Doctor. I wanna see the Doctor!" Will shouted back at her.

"Easy Fella, calm down. Sit back and relax. I'm one of the ER Docs, I'm Dr. Seeimall, Dr. Al Seeimall." said a tall, pleasant looking gentleman as he put one hand on Will's shoulder and reached to shake his other. He was ruggedly handsome, a 40ish year old with dark hair and features. He was just beginning to go gray around the edges. He had a calming, reassuring manner. He was Neil Armstrong landing Apollo 11; he was Barry Bonds with two on and two out in the bottom of the ninth; he was Clarence Darrow delivering his closing argument; he was THE MAN, as far as Will was concerned.

"Take it easy Cheryl, I'll wheel this guy back myself," Dr. Seeimall hollered to the triage nurse with Will nodding enthusiastically behind him.

"There's no room for him back there," she called back.

"I'll just put him in hallway DD on a Life Pack for now," Al called back over his shoulder as he whisked Will into the crowded and chaotic corridors of the GM Hospital Emergency Department. Dr. Seeimall leaned over and quietly whispered, "I am the Physician of Christmas Present, here to show you how things are. You are to remain quiet and listen. You are not to interfere with any of our processes. These are visions that you can not change, so no sense trying to ‘swim upstream' as it were."

"I understand Doctor, but may I ask you what you have planned for me?" asked Will politely.

"Well I'm just waiting for the cardiologist to call me back to see if he is available to take you straight to the Cath Lab or if not, then you will get a thrombolytic agent. We use TNKase here because it's simple to administer," Al Seeimall continued, "Of course I have had some trouble tonight getting a hold of the cardiologist. Naturally when he or she hears it's you they probably won't want to come in anyway. Everyone knows who you are. They know you had a lot to do with getting the malpractice cap raised to three million dollars. What they don't know, but I am privy to, is that you just formed a commission to look into getting rid of the cap altogether. I wonder what the other doctors here tonight would think if I told them your little secret? You know the malpractice insurance rates for our group went up 58% since last year? No specialist in their right mind would take care of you...aren't you lucky you got EMTALA on your side and the good old ER Docs here to see you?"

"Dr. Seeimall line five, Dr. Seeimall line five," intoned a voice on the overhead speaker system.

"That's about you. I'll take it over here." called the doctor as he turned and picked up the phone.

As the doctor spoke softly on the phone, occasionally glancing around to look at him, Will looked about for the first time. There were people and stretchers everywhere. A young woman sat in a chair across from him; she had a toddler in her arms, thick green mucus was running down from his nose and he was wailing inconsolably. An elderly woman lay on a stretcher along the far wall. She apparently had pulled out her IV line and was bleeding all over the floor. A nurse ran over with an assistant and began to correct the situation. A clearly intoxicated young male with his hands cuffed behind his back was being led down the corridor by a female police officer. She was trying to adjust a surgical mask over his face because he was spitting and swearing at the ER personnel. A dazed, young Nigerian man was wandering the hallway looking for anyone who would take the small urine sample he proffered. He had some sort of awful eruption on his face. He smiled at Will, and bowed as he passed.

"Jeez, what a zoo this place is," thought Will. "How can anyone in their right mind stand to work in a place like this?"

"It actually does take a special kind of person, the type that you would know little about. It takes someone who actually gives a damn about people and their problems. You're absolutely right, very few people can actually deal with work like this both physically and emotionally." It was Dr. Seeimall again.

"Well, just as I thought, the Cath Lab is jammed, so we'll go with the thrombolytics. Of course there is some more bad news; there are absolutely no CCU beds available. We will have to ‘board' you in the ED."

"What does ‘board me in the ED' mean? I'm already bored in the ED. How much more bored can I get waiting for you people to do something?" While Will was protesting, his protestations were becoming softer and less abhorrent.

"It means you will join all these other poor unfortunate souls in the hallway, on a monitor of course; waiting six, eight, maybe 12 hours for a bed to become available. Hospitals ‘downsized' in the early nineties, supposedly too many hospital beds. Well here it is 12-13 years later and now we face the opposite problem in many populace areas; that is, not enough hospital beds and resources to go around. Sorry Mr. Suem but you are a victim of the system like the rest of us." Dr. Seeimall said as he wrote on Will's chart. After he finished scribbling furiously he looked up. "Stench...Stench?" he called.

"Right behind you Mon Capitain," came the reply. Stench, this time with orange hair and a new nose piercing, was suddenly right next to the stretcher. "Where do you want me to take ‘Judge Wapner'? Since there are no CCU beds what about the morgue Doc? I hear people are just dying to get in there. Ha, ha, a little holiday humor. Seriously, where do I park this carcass Doc?"

"Take him to Hallway slot XXX...You know the one Stench," said the doctor with just a touch of malice in his voice.

"Oh yeah Doc, I know the Special XXX slot, I gotcha," nodded Stench knowingly.

Next thing Will knew he was in the middle of the cold and snowy parking lot next to the Emergency Department. He was shivering with cold and he was completely alone. There was not a soul, or a car for that matter, to be seen. The snow was gently falling around him and somewhere, far off in the distance, he could hear the Christmas church bells. It was midnight and they were tolling in Christmas. Faintly he could hear a choir singing. It was lovely; he caught himself vaguely humming along...he seemed to remember the words somehow... "God rest ye merry gentlemen let nothing ye dismay..." he trailed off as the darkness closed in around him. "Oh won't someone help me?" he thought and then he lost consciousness.

Will once again woke up in the back of an ambulance with Stench and Izzy as his attendants. They had switched places yet again and now Izzy was in the back with Will. He felt more comfortable with Izzy even though he was dead. Stench actually gave Will the creeps if that were at all possible.

"Where are we?" a dazed Will muttered.

"We're on our way to Fair Acres Mall. We'll be there shortly," came Izzy's reply.

"The Mall? The MALL?? Why the he...I mean why the dickens, are we going to the mall. I need a hospital, don't I?" Will was scared and becoming more concerned as he looked out the ambulance window. This didn't look like the Fairfax County that he knew. Garish strip-malls, neon signs touting gambling on premises, X-rated movie theaters and tattoo parlors were all that Will could see. Wait...what was this? A huge, brightly lit, revolving jet plane over a building with a sign that read: Admittum Travel Agency...we'll get you there...ANYWHERE! A holograph of that pretty young lady doctor was over top. "Wow, she really did it." Will thought, "She dropped out, or got sued out, of medicine and started a travel agency. Well good for her. What the Sam Hill...?" Will's thoughts trailed off as he read a sign in the window with bold black lettering, Chapter 11 Closure it said. He shuddered at the sound of Izzy's voice as it broke his trance.

"Yes, we are going to the Mall. It's where most people get their medical care nowadays. You see, Will, you were very successful in life when it came to malpractice legislation in Virginia. In fact you became a national figure in the field. You went all the way to the Supreme Court and you got essentially what was de-regulation for the medical profession. A lot like the airline industry. But alas, it all sort of backfired just like the airline industry. Malpractice insurance skyrocketed until it became absolutely prohibitive to afford. All the while the cost of a medical education spiraled to about a half a million dollars. No one could afford the degree, and even if you could, you would not be able to afford malpractice coverage when complete. Soon no one was going into medicine anymore. Only the military has real physicians anymore, in fact they are the best nowadays. Big corporations soon stepped in. They were the only ones who could bankroll the malpractice payments, but what they soon found out was with the relaxed legislation, that YOU helped enact," said Izzy as he pointed accusatorily at Will, "They found out they didn't really need actual doctors; they could make do with tradesmen with similar skills. Like computer programmers for neurologists, or photographers for radiologists, or postal workers for psychiatrists...like that. While they don't get quite the same medical education as the doctors of old, their mortality rates for major procedures are only in the 5-10% range. Err, morbidity is significantly higher of course but hey, with de-regulation the malpractice rates have stabilized enough that franchising medicine means the malpractice judgments aren't any worse than they were before, just the medical care is. Basically many people just don't go get medical care anymore even though it's come down in cost with franchising and increased error rates. When they do, they have more of an understanding of the risks involved. Sort of a ‘caveat emptor' philosophy, if you will."

"Who does the cardiology care then?" asked Will with obvious trepidation.

"Why that's easy...," chortled Stench from the front of the vehicle. "...it's the Plumbers!" he said with a sneer. "Of course they handle the Urology also. Yeah baby, plugged prostates and proximal coronary lesions; after all they're just roto-rower type jobs anyway. No special skills needed other than good drain opening techniques."

"Plumbers...PLUMBERS!" screamed Will. Just then they pulled into a brightly lit shopping center. At the far end sat a turquoise glass building with a giant revolving neon heart on the roof. The sign below it read: Angelo & Sal's Plumbing and Heart Services. No pipe is too plugged!

"You are NOT taking me there!" Will extorted.

"Are you kidding, these guys are the best," responded Izzy. "They are the biggest, most respected franchise, they have great rates, they have a very snappy jingle, and the founders of the franchise themselves are here tonight. They have come especially for you Will; Angelo DiPlasti and his partner Sal Monella of Angelo & Sal's. They are the Physicians of Christmas Yet-To-Come and I am sorry but they are not a pretty sight." With that they pulled up to the front entrance, past a mural of a very amateurishly depicted Mediterranean scene.

"Please don't take me here!!!!!!!!!" screamed Will. "Please, I'll repent! I'll hold Christmas sacred. I'll amend my ways! I'll completely change my law practice. I'll sell out...better yet I'll give it away. I'll join Bob Goodfriend as a public defender. I'll do at least $250,000 worth of pro bono every year. You'll see...oh please, please Izzy don't leave me here...don't do this to me. Izzy! Izzy? Stench? Stench! Hey where are you guys. Hey don't leave me here. Wait. Come back!"

Will was all alone, suddenly the back door of the ambulance flew open letting in a sharp blast of frigid air. Standing there, leering at him, were two dark men with bloody white aprons. They had small red and yellow eyes, with blackened teeth and fingernails. They groped at him, sliding him off the end of the stretcher towards them.

"No...NO...NO!!!" screamed Will as he slid towards the hideous visions.

He fell with a thump! Will shook his head as if to clear it and manually reset his neural circuits. He looked around dazed; it felt like he had been drugged and the drugs were wearing off. He was in his bedroom. The curtains were pulled but he could see the sun streaming through the crack. He got up and pulled up the window sash. He blinked against the bright sunlight and looked out at a snow covered world. It was quiet and serene looking. He noticed a little boy pulling a sled down the street. The boy was wearing a Santa Claus cap.

He opened the window and called out, "Hey there Fella, hey there!"

"Yes sir," the boy stammered looking up, surprised at being addressed by Will.

"What day is it today, my dear fellow?" asked Will excitedly.

The boy looked around as if confused, "Why it's Christmas sir," he replied as if the answer should be obvious.

"Splendid...oh splendid! You are a marvelous young man, a simply outstanding young fellow. Good moral fiber and a bright young lad to boot. Yes, a very intelligent lad. Now tell me this, is that 30 lb turkey still in the window of the Fresh Fields down on Main Street?" called out Will.

"You mean that great big one...the one as big as me?" responded the boy.

"Yes, yes an intellectual giant that boy, what..." Will muttered cheerfully, "Yes that's the one. Well here's a $100 bill...go and buy it and kept the change as a carrying charge. It's Christmas Day ‘young Diogenes' and I'm a new man!" he shouted to the boy.

The boy grabbed the bill and dashed off back down the street. Just then Bob Goodfriend rounded the corner. He looked up and saw Will leaning out the window. He tried to pretend he didn't see him and dodge quickly back around the corner.

"Bob...Bob Goodfriend come back here," boomed Will loudly.

Bob Goodfriend turned sheepishly back and rounded the corner towards Will.

"Look here Mr. Suem, I'll have your rent soon enough, with interest," stammered Bob "It's just that it's Christmas, and things are tight. You know my clientele. I'll get it soon." He trailed off.

"Now see here," Will began sternly, "I fully expect..." he paused, then continued deliberately, "I fully expect..." his voice began to swell with emotion, "I fully expect to forgive you, your back rent. In fact I fully expect you to join me, no I mean, I expect to join you! That is if you will have me, as a fellow public defender? We can use my current office...no, what am I saying. YOU could have MY office and I'll use yours. What do you say...oh please say yes?" Will implored.

Bob looked startled. He stopped dead in his tracks and gazed slack jawed up at Will.
"Sure, if that's what you want," came his dumbfounded reply, "We'll talk about it after the holidays," he said as he scurried away looking back quizzically over his shoulder as if he had just committed grand larceny.

Will returned inside. A fire was glowing in his fireplace and a Charlie Brown Christmas was playing on the DVD player. Will smiled to himself. "Humbug to Humbug!" he thought, "Thank you for the second chance. I swear I'll make good use of it." He nodded towards an ambulance that rolled slowly down Barrister's Alley. Will tipped a mug of egg nog, as if to an imaginary guest.

"Merry Christmas to all and a very, Happy New Year!" he concluded with decided finality. Charlie Brown and the Peanuts gang sang "Hark, the Herald Angels" sweetly as the fire crackled in the background.

 


 

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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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