Glorious Defeats: Lessons in Emergency Medicine by Linda Keyes

Heroes are made in the hour of defeat. Success is, therefore, well described as a series of glorious defeats.
— Mahatma Gandhi

 

Rejection

“I said, can you get me something to eat bitch?”

I stiffen. This is early on in my emergency medicine residency and I haven’t yet learned to reply, “That’s Doctor bitch to you, sir.” Instead, I hold out my hand again. I’ve gone out of my way to put on my white coat and not wear scrubs. The man obviously doesn’t understand.

“I’m Dr. Keyes, the one who took care of you in the ER.”

“I don’t care who you are! Git me some food!” He pushes the call button on the railing of his ICU bed.

The reunion is not going as I had imagined. I glance at his girlfriend on the other side of the bed hoping for help, but she just blinks at me in her shiny hoop earrings. She also seems to have forgotten the time I spent two nights ago reassuring her that her boyfriend would be okay.

My outstretched hand hangs in mid-air.

“You almost died. If your friend hadn’t called 911 … If the paramedics hadn’t gotten here so fast … Luckily I, uh, … we were able to restart your heart. I wanted to check on you. How are you feeling?”

“Hungry! And when can I get outta this place?”

He glares at me, the look of a mad Doberman Pinscher. I drop my hand.

“Do you remember anything about the other night?”

He’s already turned, about to snap at his girlfriend. I pre-empt him, trying to spark some recognition.

“How about you, Ma’am? Did you make it home OK?”

 

The paramedics wheeled in “Mr. Charming” two nights before. As they passed me in the ER hallway, he clutched his chest, moaning in a dramatic and uncooperative way. The medic looked at me, rolled his eyes and said, “Chest pain,” while making a tipping bottle gesture with his hand. An eager junior resident, I followed them into the room. As they began giving their report, the patient became oddly quiet. His arms, suddenly limp and hanging off the edge of the cart, caught my attention. I felt for a pulse.

“Get him on the monitor!”

Ventricular tachycardia – a life threatening heart rhythm that is rapidly reversible with a defibrillator.

“All clear!” I pushed the Shock button. The man’s chest popped off the gurney. His arms lifted a few inches and flopped back down. His eyes opened in surprise, closed, and his head rolled to the side. But his pulse returned and the monitor showed sinus tachycardia, a normal rhythm.

My supervising doctor arrived and I explained the resuscitation. This was the first life I had saved. I squared my shoulders, anticipating her kudos. But she was called to the trauma room without another word. I slumped and ordered a chest x-ray, blood tests, and stabilizing medications, then turned my attention to the girlfriend. The cloying scent of alcohol was evident through her sobs.  She repeated the same questions over and over:

“What happened?”

“What you doin’ to him?”

“He okay?”

After several iterations of  “We restarted his heart. He should be fine now,” she conceded to call her sister for a ride.

 

Now, here in the ICU, she sidles over to me in her platform heels.

“Look, I know you trying to be nice hon’ but can you get us outta here? We got business to take care of.”

“I’ll make sure he gets a lunch tray, but you’ll have to see what the cardiologist says before he can go home,” I answer.

“I don’t give a fuck what the cardiologist says. I gots to go, woman!” the patient interjects.

He waves his sinewy arms in a way that might be threatening if not hampered by the IV and monitor lines. In a final effort to make a connection, I grab and press his hand good-bye. He recoils, viper-like, and begins ripping electrodes off his chest and flinging them to the floor. With them goes all hope of recognition and my heroic aspirations. Turning to flee, I whisper over my shoulder. “Anyway, I wanted you to know, I’m the doctor who saved your life.”

 

Embarrassment

A thoracotomy is one of the most heroic of emergency medical procedures. “Cracking the chest,” as procedure-hungry trainees like to call it, is a last resort effort for victims of penetrating trauma. It is a desperate means to control bleeding from the vital organs of the chest until a definitive operation can be performed. Most residents are lucky to perform one during their training. The majority of practicing docs never do it again in “the real world.”

My thoracotomy happened like this: It’s around 4 am and I am in the ER joking around with the emergency attending, Clem. As the junior resident on the trauma team I’m stuck doing scut work while the rest of the team operates on the survivor of a car crash. They are up to their elbows in the patient’s spleen when the pager alerts. “Stab wound to the chest, ETA two minutes.” Clem gestures me toward the trauma room.

I barely register the young man, Carlos’, face. I am consumed instead by his ashen skin and the bright red blood soaking through the mass of gauze a paramedic has pressed against his clavicle. I put my fingers on his femoral artery. Though the cardiac monitor shows a fast heart rate, I feel no pulse. In a quavering voice I call for the thoracotomy tray; I am going to perform “The Procedure.”

Clem puts a scalpel in my trembling hand and begins talking me through the steps. I spread the ribs, revealing a chest full of blood and an almost flaccid heart. On my orders the nurse starts a red cell transfusion. Through slippery gloves I feel the heart regain force, beating as the blood fills his veins. Before I can stuff more gauze pads into the area of pulsatile bleeding, my trauma chief appears, pushes me aside, and wheels the patient away to the operating room.

 

The surgical team worked through dawn. When my chief emerged late to rounds with the news that Carlos had survived, we all cheered. I don’t recall meeting the family that night, or later during his subsequent comatose weeks in the ICU. Though it could have been his brother who filled me in on the story of a fight provoked by a drunken bully. I do remember spending hours discussing and researching answers to technical questions about his treatment–use of blood thinners, duration of antibiotics, and other surgical management issues. I was taking care of him in theory, but I was rarely at his bedside, unlike his large family who flowed in and out like a stream that I crossed mostly by jumping over and not looking down.

When I wasn’t dealing with the barrage of trauma calls to the ER, I was admitting and discharging, changing dressings, and trying to catch a few minutes of sleep. I remember watching the attending surgeon Dr. Stern drink her extra large coffee at rounds every morning, when the rest of us had been up all night without a cup.  But I don’t remember speaking with Carlos’ mother or father. I recall no discussion of the long-term plan for Carlos with anyone, though it was me who arranged his transfer to a rehabilitation facility via faxes, insurance forms, and calls to the social worker. Carlos remained in a coma. It was difficult to imagine a meaningful neurological recovery, and I had no time for reflection before the trauma pager buzzed again.

 

A year later, I am working a day shift with Clem in the ER. We are discussing the morning’s cases when in walks Dr. Stern, cup of coffee in one hand, the other holding the elbow of a young man with a crooked smile and a limp. An older woman with similar dark eyebrows trails behind.

“Remember Carlos? “Dr. Stern asks us. She grins at him.

“These are the people who took care of you in the ER. He’s been home for a couple months now. Show them your scar.”

He pauses, looking uncertainly at Dr. Stern. Then, with a jerky movement, he pulls up his T-shirt to reveal a raised red line running across his ribcage like a long accusing finger pointing towards his heart. Only then do I understand.

“Thank you,” he says.

He slurs in the way of those who have suffered a stroke. I can’t understand his next words. Despite our mutual discomfort with Dr. Stern making him show off the scar, I find myself wanting to reach out and touch it. I ought to hug him, but the encounter feels forced. We stand there, Carlos and his mother, Clem and I, not knowing where to look, and trying not to stare.

Finally, Clem extends a handshake and proffers a few encouraging words. I blink and clasp hands with them, too. Dr. Stern leads Carlos and his mother back to the surgery clinic while I flee to the bathroom and let the tears run. But I wasn’t crying because Carlos had lived. I was crying because I didn’t recognize him. The man who might credit me with saving his life had been a checkmark in my procedure log, my thoracotomy. When finally Carlos, the survivor, the person, stood there before me, I didn’t feel heroic. I felt ashamed. I didn’t even know the man whose heart I had held in my hand.

 

Surrender

A tall, older man in loose shorts and a Hawaiian shirt is pacing around the exam room, wincing and clearly uncomfortable, his hand pressed against his right side. Doorway diagnosis: kidney stones. Phew! I’m too busy in the middle of my shift to take on another complicated case.

I introduce myself as the ER doctor in charge of his care, and order urine, blood tests, and pain medicine. When I come back to examine him, Mr. P is lying with his feet sticking off the end of the bed and looking better, though anxious. Glancing at his chart, I note a normal heart rate and blood pressure; a smoker but no chronic medical problems. His blood work is unremarkable. He tells me his pain started in his right side but has subsided. I perfunctorily examine his belly, and am surprised to find right lower quadrant tenderness, not typical for kidney stones. Hmm, no blood in his urine either.

“I’m worried about appendicitis.” I tell him.

“What’s that?”

I explain, ending with, “You will need surgery.”

“And if I don’t have the operation?”

I think he’s being glib, but looking at his clenched jaw, I see he is dead serious.

“What do you mean? Not have an operation? That’s how we treat appendicitis.”

“Listen, I got no health insurance.”

I raise my eyebrows and he elaborates, “I can’t afford an operation. I have my condo, own that outright, but business is slow and I had to shut down my company. I’m a certified plumber and heating technician.”

The confidence I detect in his voice makes me think he might be a good one.

I offer warnings of “perforation” and “sepsis.”  I throw in the word “death.”

“No thanks, Doc, I can’t afford it. I’d rather just go home.”

I take a deep breath and roll my stool back from the gurney. We are in the state-of-the-art ER of a modern suburban hospital with a well-earned reputation for excellence. I don’t send people home with appendicitis! We finally compromise on a CT scan to confirm the diagnosis–a cheaper option if he doesn’t need surgery.

I jump back into the fray of dizzy grandmothers, accountants with chest pain, and coughing children, with a nagging discomfort about his case. It’s not unusual for patients to worry about costs or avoid expensive tests. But there was something resigned in Mr. P’s quick refusal of surgery.  I’m wondering about the reported success of treating appendicitis with antibiotics when I get the call from the radiologist–an 8-centimeter aortic aneurysm extending through the right iliac artery with surrounding inflammation. On further review we decide the inflammation is blood–a ruptured iliac aneurysm.

The aorta, the major conduit carrying blood from the heart to the rest of the body, travels through the core and splits at the level of the waist into two iliac arteries. Mr. P’s aorta and right iliac artery were bulging three times their normal size and ready to burst. This is an emergency. Most patients will die, and quickly, often without warning. Yet Mr. P had none of the usual evidence of someone potentially hours from death. He might stand a chance.

 

“It’s not your appendix.”

I draw a picture on my clipboard. I explain aneurysms and mention his smoking history.

“If we don’t operate immediately you will die. You’re lucky. Most people aren’t given the time for an operation.”

Mr. P nods thoughtfully, then stands. He reaches over and grasps my hand.

“Thank you Doc,” he says, “I’m going home now.”

I can’t let go. I put my other hand on top of his. Glancing around the tiled room, and into his eyes, I search for some way to keep him here.

“Don’t you want to talk to your family first?”

He divorced a long time ago and has no children, his only relatives are an out-of-town niece and nephew.

“I’d rather have something to leave them than debt. What good is surgery if I end up under a bridge when I get out?”

He seems to believe this scenario. I ask him to wait. He perches his lanky body on the edge of the gurney while I send in the financial counselor, but she and her paperwork are summarily dismissed.

“I don’t need charity, and I’m not going broke for an operation.”

I call the general surgeon thinking maybe a specialist’s opinion will change his mind.

“I can’t operate on that. He needs a vascular guy. If he won’t consent to transfer, there’s nothing I can do.”

The surgeon sees him anyway. His drawings of stents and surgery aren’t any more convincing than mine.

Mr. P tells me that his mother died in the hospital after many weeks and thousands of dollars in medical bills. She had diabetes and heart failure and other medical problems he can’t remember. I stress how his situation is different. He’s in otherwise good health. He’s relatively young. He can survive this operation.

Mr. P sighs, “You don’t know anything about me. And no offense, you know a lot about medicine, but you don’t know anything about people.”

I am offended. Mr. P’s case is straightforward. He should have surgery. I know that much. I can’t send him home to die.

“Please help me understand.” I squeeze his hand.

He starts to confess that, in fact, he has had leg pain and numbness for months.

“I’ve been reading about it on the Internet, and … oh, never mind.”

I can’t persuade him to continue, but suddenly I suspect that Mr. P knew long before I did that it wasn’t his appendix.

He remains adamant in his refusal of care, and yet seems in no hurry to leave my ER. I try to buy time to find the message that will sway him. I send in the nurse again. I try another tack myself.

“Are you depressed? Have you felt hopeless lately?”

His face is resolute, his brows furrowed, but it is not the affectless face of depression. In a steady voice, with perhaps a hint of annoyance, he insists that no, he is not depressed. He has had a good life. He understands the consequences. He declines to speak with the psychiatrist.

Swallowing hard, I say he will have to sign out against medical advice. He refuses my offer of pain medicines for home. I write “Certain Death” in the blank for risks on the form. On a prescription pad I print the name and number of the vascular surgeon and the hospital where they operate on these types of cases.

“If you change your mind, go directly there. Tell them to call us and we’ll send the scan.”

I watch him crumple the paper into his pocket as he walks out and doesn’t look back. The waiting room doors swing closed behind him. I squeeze my eyes shut and my throat constricts, but the charge nurse is calling me to see a patient who’s having trouble breathing. Instead of chasing after him, I blow my nose, grab my stethoscope, and head to the “resus” room for another shot at success.

STORY IMAGE CREDIT: Flickr Creative Commons/Bernhard Wintersperger