Ode to the Frequent Flyer

Ode to the Frequent Flier

Wryly eyes glare sneakingly
crost rooms, and halls, and doorways
Ne’er-do-well, pray do tell
What dark intent doth you bring?

Slither, slip around and under
Stony hearts and minds.
Nay, they soft, naive, aloft
The souls you seek to plunder.

Seek ye roiled poppies spew
A limp, a gimp, a forc’ed tear
Marked and meek, a gilded speak
From whence you’ve come, a rock or pew?

Be gone, be wary, I know thee well
No saint be you, forsaken
Legions o’ visits, archives exquisite
Whilst parlay yourn demented spell

Hippocrates bequeathed to me
One solemn oath non asunder
Yet there ye be, hypocrisy
Obliged we be, and ne’er be free

So we dance; thorny, epithets adorned
Fencing to, aback, and fro
‘Tis time you leave, so frantically?
Aye my flier, there’s the door.



15068099626_c6ce4172b6_bWe married the mirror of human tragedy, and its a matrimonial obligation we live with every shift.”

Medicine and the Bodhi Tree

Medicine and the Bodhi Tree

By Dr. Tae Kim

Once in a while, somebody will tell me that I have such a nice bedside manner, and for a long time I’d receive that kind of approval with a wince. I was mortified by the praise people gave me, and honestly, more than a little gratified too, because it really felt good to have nice things said about me, but mortified because that night, the one I’m writing about now, that night was a night of abject, miserable failure.

I was on another overnight shift as a senior resident, this time at the university hospital we worked the other part of the year. It was probably a Monday, since the beginning and end of the week tend to be the busiest, although nowadays it seems like every day is busier than the last, and the emergency department was in normal condition, that is to say totally FUBAR’d – ambulance gurneys lined the hallways holding patients in street-clothes, in house-robes, drunks in restraints, the paramedics who had brought them chatting with each other while waiting to be told what bed to take their charge to, the firemen’s yellow jackets smelling faintly of smoke.

Since I was the senior resident on duty, I had the responsibility of the entire department, with nurses pulling at me from all sides, medication needs, test results, consultant problems, new patients. Every time I’d leave the desk to go to a patient’s bed, to the x-ray room, to the bathroom, a crowd of RNs would swarm behind me – picture a deer followed by a pack of wolves, a pack of wolves wearing scrubs and holding clipboards.  One nurse told me that there was a new patient in Bed 1, an 18 year old girl who had chest pain and a high heart rate. Yet another patient.

Every time another nurse popped up with a question or request I’d frantically fire off the first thing that came to mind while I moved on to deal with the next one. I asked the nurse for Bed 1 to get an EKG and told him I’d be there shortly – I was relieved that he seemed satisfied with having something to do, which would hopefully buy me enough time to attend to yet another high priority. But just minutes later he handed me the patient’s EKG, which showed a heart rate of 135 – that really was fast. Not too fast, but faster than it should have been.

I finally made it to the patient’s bedside – the nurse had told me that she’d been complaining of crampy chest pain while out line dancing. What an odd detail to add, that she had been line dancing, apropos of nothing. The girl was sitting up in the gurney, her eyes squeezed shut against the pain. She was pretty? I don’t remember. She seemed young. Dressed to go out. Perhaps I should stick with the details I received in her autopsy, later: “this is the nude body of a well-developed, well-nourished young adult female appearing consistent with the stated age of 18 years. The length is 165 cm, the weight is 62 kg. The hair is black, the eyes are brown, and the complexion is fair. The body is not embalmed. Across the right medial ankle is a small tattoo of a heart. The finger nails are painted red.” I was able to get out, “I’m Dr. Kim, do you have chest pain?” She replied, “my chest hurts,” when she had a seizure.

On t.v., when actors have seizures their eyes kinda roll back and their limbs start sort of flopping around, and that’s how you know that it’s supposed to be a seizure. In real life, though, it’s the most uncanny, unnerving thing, it’s inhuman – her eyes were still open, but they looked like they’d lost the animus behind them, the rational personality who had until then been a girl out with her friends just disappeared, and all that was left was a machine, an automaton in the shape of a human being but without human thought or feeling. Her head twisted to the left, her eyes open, staring at nothing. Her mouth twisted and foamed. Her limbs involuntarily contracted, shook in a way that is impossible to do consciously, a marionette with its strings twisted, and then dropped down when she fell back in to the gurney, unresponsive, gurgling noises coming from her throat. Putting the head of the bed down, I pled for the nurse to get an attending physician, quick – I figured they might want to know that I was intubating someone – that is, putting someone on a ventilator.

Dustin, who was chief resident when I was an intern, and was now an attending, materialized at the bedside.

Before we intubated, the girl had another seizure. We let it pass, and then put her on the vent. Things spiraled. Her blood pressure started dropping precipitously. The patient’s friends and father arrived, and it turned out that her mother had died the year before from a brain aneurysm – the patient was the only family member her father had left. Dustin and I had a rapid-fire discussion about what the patient could be suffering from, while ordering IV fluids and medicines, our arms crossed, faces tight. “What do you think it is?” “Bolus one liter, start a second line and start another bolus in that one.” “All I got was chest pain while line dancing, tachycardia, then this.” “Is her sat dropping? Can someone fix the pulse ox?” “Pneumothorax? Doesn’t seem the type. Chest x-ray’s cooking.” “Can someone please start the fluids? Call blood bank – O neg.” “Tamponade?  No history. MI? Unlikely. Aorta? She doesn’t look Marfanoid. No history.”

We placed large intravenous catheters and resuscitated the patient – she went into cardiac arrest several times, and we kept bringing her heart back, the number of techs and nurses in the room growing, frantically performing CPR, calling out orders, voices strained. It’s always hard when someone’s dying, tougher still when she’s so young, and even more difficult still when she’s the only child of a widowed father standing in the hallway, standing quietly, alone, head down, arms crossed.

During one of the episodes of arrest we discovered that she was, curiously, bleeding inside of her chest. It’s often common procedure in these resuscitations to “needle the chest,” that is, place large catheters in the chest wall to relieve pressure that builds up inside the thorax. I sloshed maroon-colored iodine solution just under her collarbones and slid the needles in place, first on the left side, then on the right – what the fuck? Blood started fountaining out of the right needle, a freshet pulsing out of the catheter with every chest compression. I placed two chest tubes to drain the blood. The presence of that amount of bleeding inside the chest can actually prevent proper circulation, and part of the treatment is to drain the fluid off. The blood drained… and drained… and drained. The girl had already received several transfusions, and we started transfusing back the blood coming out of her chest, and it was clear that she was bleeding to death.

We called the chest surgeons who we learned were in the middle of a thirteen-hour heart transplant and therefore unable to take this patient to the OR – she was too unstable to be taken anywhere anyway, and anything resuscitative would have to be done in the emergency department. The girl kept going into cardiac arrest, had done so five or six times already, and opening her chest in the ER to stop the bleeding was probably futile, but come on – she was 18. Her father alone… You could feel a raw, anxious energy in the room, everyone felt helpless but we had to do something, everything, anything. But without someone to take her to the OR afterwards, there’d be no point to trying to stabilize her in the ER. Dustin called the trauma attending, Dr. O – as a trauma surgeon he’d be the only other doc in the hospital who would routinely know what to do with a cracked chest. An older Irish man, with a thick accent, he was infamous for being so compulsive that he’d often round until midnight, unheard of for a surgeon, but someone totally committed, so committed that he agreed to come in for this patient, appearing at the bedside when I had the knife poised above the girl’s skin.

We cracked opened her chest, first the right side, then extending the incision to the left, opening the chest to access the organs. Scalpel on skin, curvilinear incision, straight through yellow fat, down to muscle. Scissors in thorax, gloved finger guiding, zip through the intercostals. Weighty stainless steel rib retractors, wedged in placed, cranked open. So strange – for a young, otherwise healthy woman, the body would be a secret, the breasts an intimacy hidden from the view of strangers like us, but in the moment, there was nothing particular about her chest, just that we had to open it. It’s funny – I don’t remember much of what her face looked like, but I remember in intimate detail her thoracic cavity, the surfaces glistening with pleura, the individual articulated spinous bodies, her spongy, pink lungs, and everywhere, everywhere, blood, a rising tide of blood that we would suction away only to have it fill right back, ebb and flow. It was like something had exploded in there.

Her heart was flat. Imagine, if you would, the heart roughly like a water balloon, one that actually pumps blood around the body, so it expands, contracts, expands, contracts, but it’s always got something in it, a water balloon made of muscle. Her heart, however, was an empty balloon, nothing in it, all of the blood that was supposed to be filling it seeping in to her chest cavity instead. Her heart was a flat meat balloon. Blood, or at least what was now pinkish tinged fluid having been diluted with all of the fluid we had tried to replace it with, kept welling up from somewhere, more blood than anyone in the room had ever seen come out of a chest, blood from nothing that we could clamp off and prevent her death, and we were at a loss, Dr. O turned to me and stripping off his gloves said, “well, Tae,” in his thick Irish accent, “I tink we’ve dun all we can,” and we called it, my arms were up to the elbows in her thorax, blood was everywhere, and it was done. Later, we’d learn from the autopsy that she’d died from a thoracic aortic dissection, the same thing that later killed John Ritter, rare, unusual, a unicorn of a diagnosis, especially for someone so young.

We covered her up. You may think it’s a cliché, but we really do use a white sheet. I remember Dustin talking to her father in the hallway, the man quietly listening to the news. Dustin found me at the desk, “hey man, here’s the key to my office. There’s some caffeine in the fridge, take some time for yourself.” Okay – wow, that was some traumatizing shit, that’s a good idea. I sat in his office by myself – okay, I’m processing things, that was kind of horrifying, but I’m okay… no, really, I think I’m okay. I’m sitting in Dustin’s comfortably padded office chair, staring at the white door. I can hear housekeeping vacuuming the floor down the hallway. There is a fake potted plant in the corner. There are pictures of Dustin on various trips abroad lining the shelves. My right hand, wrapped around a can of soda, is starting to feel cold and numb. All that comes to mind is the stack of fresh charts piling up in the rack, patients waiting to be seen.

I forced myself to sit there for a full five minutes, checking my internal state to make sure – no, I’m okay. I’m alright. I quickly dictated a note, and then got back out into the ER, spending the rest of the night taking care of the patients who’d waited while we treated the girl.

Things never slowed down that night. Trotting back and forth, I kept spying in on room 1, where the girl’s father was sitting by her bedside, quiet, back turned to the door. He sat there the rest of the night. With all of the hubbub gone, I could finally see him. Brown hair, medium length. Jeans, denim shirt. His face was sad, thoughtful. I moved on to the next patient.

I have difficulty gauging how long to make eye contact when I talk to people. Fact. I’ve realized that I’m either always glancing away, or that I’m suddenly staring straight in to the other person’s eyes, and it’s only when I start noticing their discomfort that I catch on. There’s more: between, I think, 1984 or so and 1992, I could name every single car sold in the U.S. by make and model, name their fuel type, engines available, displacement of said engines, number of valves on the drivetrain, overhead cams or pushrods, interior options available, colors, pricing, and eventually I went on to do the same with motorcycles. It’s not that I’m Rainman or something, and every so often someone really does tell me I have good bedside manner, but people imagine Marcus Welby and what they get instead is me. It’s little wonder that I’m good at the sciences and that I sometimes make people cry when I talk with them because feelings… fuck it, let’s just say it’s because I can list exactly why Betamax was a better standard than VHS.

I couldn’t muster up the courage to talk to him; I couldn’t walk up and, oh, I don’t know, say something, anything. What do you say? Man, sucks that your entire fucking family’s dead, tough times, bro? I kept silent, secretly peeking into the room, the girl’s father still and quiet, that night still and quiet in my memory.

It’s been a few years now and since first writing it down I’ve struggled over how to end this story; maybe I didn’t have the maturity or the ability to articulate what I experienced. I’ve tried a number of different ways to conclude it with some kind of meaning. In one way I guess you can think of it as a cautionary tale. Now, I’m not Buddhist and can’t pretend to know anything about Buddhism, but I’ve heard a story of the Buddha that seems to fit somewhat. In an attempt to teach his disciples to understand the ephemeral nature of life and its boundaries, the Buddha instructed them to meditate on the decaying corpses in the local cemeteries. But in contemplating the inevitability of their own deaths, these students of Gautama slid into despondency and began to take their own lives in their efforts to reach enlightenment, and when the Buddha returned he was aghast to discover that most of his congregants had committed suicide, and then taught them instead to meditate on the cyclicality of their breaths. Like those disciples of Buddha, in learning the truths of medicine and then the limits of that practice, health care professionals can come to despair during their attempt to attain medical enlightenment. And you do dwell on the deaths, the patients you lose, for a long time. But I don’t think that’s what I came to take from this loss.

I told you that night was one of failure, but not because we couldn’t save the girl’s life. We did everything possible. I don’t regret the thoracotomy, I don’t regret the gore. What I regret is that I didn’t – I couldn’t – say anything to the poor man who’d lost his wife and daughter. I didn’t have the courage to walk up to him and let myself feel something while he contemplated the decaying corpse of his daughter.

I can imagine it now, the way it could have been, you know, if I’d been in a movie about how to be a good doctor or something – I’d pull a chair up next to him, put a hand on his shoulder, look him in the eye even if it’s for too short or too long, and then let him talk. Or let me talk. Or just have sat in silence. Instead, I left him to sit there alone, the rest of the night, while I ran around with other patients and stuffed my feelings down, out of sight, out of mind.

Compassion means not only feeling for others, but permitting oneself to feel. The irony is that compassion is easier to have for those who are like you, but of course even though compassion begins with oneself, its ends, compassion’s purposes, are always for the other, the one who is not you. Like I said, for a while you face nothing but death, but later, you start to see the lives around you, the lives of the patients saved, the lives of the survivors of those who don’t make it, the patients whose lives were never in danger but maybe just needed some handholding. And that was my lesson, which I have learned, and learned well, that what I can do, always do, is breathe in co-suffering, to laugh and weep, with compassion, with the ones who are here and the ones who survive those whom we have lost, and although it has only been a few years, I am becoming in medicine a bodhisattva, that is, one who will someday attain enlightenment.

How to Tell a Mother Her Child Is Dead


By NAOMI ROSENBERGSEPT. 3, 2016 New York Times


Philadelphia — First you get your coat. I don’t care if you don’t remember where you left it, you find it. If there was a lot of blood you ask someone to go quickly to the basement to get you a new set of scrubs. You put on your coat and you go into the bathroom. You look in the mirror and you say it. You use the mother’s name and you use her child’s name. You may not adjust this part in any way.

I will show you: If it were my mother you would say, “Mrs. Rosenberg. I have terrible, terrible news. Naomi died today.” You say it out loud until you can say it clearly and loudly. How loudly? Loudly enough. If it takes you fewer than five tries you are rushing it and you will not do it right. You take your time.

After the bathroom you do nothing before you go to her. You don’t make a phone call, you do not talk to the medical student, you do not put in an order. You never make her wait. She is his mother.

When you get inside the room you will know who the mother is. Yes, I’m very sure. Shake her hand and tell her who you are. If there is time you shake everyone’s hand. Yes, you will know if there is time. You never stand. If there are no seats left, the couches have arms on them.

You will have to make a decision about whether you will ask what she already knows. If you were the one to call her and tell her that her son had been shot then you have already done part of it, but you have not done it yet. You are about to do it now. You never make her wait. She is his mother. Now you explode the world. Yes, you have to. You say something like: “Mrs. Booker. I have terrible, terrible news. Ernest died today.”

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Then you wait.

You will not stand up. You may leave yourself in the heaviness of your breath or the racing of your pulse or the sight of your shoelaces on your shoe, but you will not stand up. You are here for her. She is his mother.

If the mother has another son with her and he has punched the wall or broken the chair, do not be worried. The one that punched the wall or broke the chair will be better than the one who looks down and refuses to cry. The one who punched the wall or broke the chair will be much easier than the sister who looks up and closes her eyes as they fill.

Security is already outside the room and when they hear the first loud noise they will know to come in. No, you will not have to tell them. They know about the family room in the emergency department in summer in North Philadelphia. It is all right. They will be kind. If the chair cannot be sat in again that is all right. We have money for new chairs every summer. If he does not break your chair you stay in your chair. If he does you find a new place to sit. You are here for the mother and you have more to do.

If she asks you, you will tell her what you know. You do not lie. But do not say he was murdered or he was killed. Yes, I know that he was, but that is not what you say. You say that he died; that is the part that you saw and that you know. When she asks if he felt any pain, you must be very careful. If he did not, you assure her quickly. If he did, you do not lie. But his pain is over now. Do not ever say he was lucky that he did not feel pain. He was not lucky. She is not lucky. Don’t make that face. The depth of the stupidity of the things you will say sometimes is unimaginable.

Before you leave you break her heart one more time. “No, I’m so sorry, but you cannot see him. There are strict rules when a person dies this way and the police have to take him first. We cannot let you in. I’m so sorry.” You do not ever say “the body.” It is not a body. It is her son. You want to tell her that you know that he was hers. But she knows that and she does not need for you to tell her. Instead you tell her you will give her time and come back in case she has questions. More questions, or questions for the first time. If she has no questions you do not give her the answers to the questions she has not asked.

When you leave the room, do not yell at the medical student who has a question. When you get home, do not yell at your husband. If he left his socks on the floor again today, it is all right.

An Emergency Physician’s Lament

An Emergency Physician’s Lament

by AlChristian Cosca Villaruz

We are a group of People that has been trained to save lives

We deal in stress
We deal in raw emotion
We deal in extreme situations
We deal in intense catharsis
We deal in terse language
We deal in multi-tasking
We deal in Irony
We deal in Objective Reality

We deal with Unfiltered Humanity

We deal in inexorable Time constraints
Time is more dead myocardium
Time is more irreplaceable brain cells
Time means an undesirable outcome
Get off your ass
And do that
ER Doc
Go Go Go

We don’t deal in sales
We dislike Drama

We feel that pit
Of Uncertainty
In our stomachs
The Risk
The Vague Nausea
When We take
Decisive Action
Based on


Take Action

We can get something right
999 times
And be forever remembered
And vilified
For the
1 time
We get it wrong
That’s not fair?

Life is not fair

We dislike ambulance chasing attorneys
With extreme prejudice
They collect a fee whether they win or lose
When we lose
Or are wrong
Somebody dies
Or is permanently disabled

Life is not Fair

We inhabit that
No Man’s Land
That divides Life from
We try to prevent the two
Mutually Exclusive Realities

This has changed us.

We are often
Just getting to work
When you are
Just going to bed
We have felt the isolation
And Responsibility
Of being the only Doctor
Or Nurses
For many miles in
Any direction
One of us is
Always awake
Ever vigilant
In the lonely watches of
We are there
You need us
Nothing will touch you
While we keep up



When we go home
The Rising Sun greets us
And yet
You still sleep

We have seen worlds unravel
And we want to cry out for Help
Then we remember
We give of ourselves
To the point of exhaustion
And Illness
And indelible memories
Until there is nothing
Left to give

This has changed us

And made us Comrades forever

We don’t know quite
How to answer you
When you ask us
“How was your Day?”

Do you really want to know?

Do you want to hear of the Unraveling?
Of the Great Undoing?
Of the Intensely Personal Apocalypse
That comes with
The Loss
Of a Loved one?
Do you wish to hear
Of Devastating Diagnoses
Of breaking Bad News
Of Neglect
Of Abuse
Of Indifference
Of Ignorance
Of what happens
When someone
“Falls through the Cracks?”
(We are
The Safety Net
Of Society)
Do you wish to learn
Of Migrants
Of the Mentally Ill
Of the Forgotten
Of the Forsaken
Of the Undocumented
Of Lives built upon Lies
Of the Sordid Underbelly
Just below the Surface?

Do you really want to know
How my Day was?

Do you REALLY?

It has changed us.

We want to cry out for help
But We are the Help
Who Helps
The Helpers?
For it is True
It is those
That seem the
Among Us
That often need
The Most Help

Will you help us?
CAN you help us?
When OUR worlds

But in Honor
And in Learning
There is Hope
Hope will
Always remain
The Company is

In Our ER World
Light is often
Recovered from Darkness
At great cost
Through much
Empathy replaces Apathy
Enlightenment casts out Ignorance
Death is denied
Its due
We bear witness to
A Love so Large
That It can swallow up
All Evil
A Love
Than Death
A Love that rekindles Hope

And Life Occurs
Against All Probability

Because of Our
We accomplish
The Impossible

And That
Makes US

EM Mindset


Author: Joe Lex, MD (@JoeLex5 – Clinical Professor of Emergency Medicine, Temple University School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK – emDOCs.net Editor-in-Chief; EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Manpreet Singh, MD (@MPrizzleER – emDOCs.net Associate Editor-in-Chief; Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)

“Emergency Medicine is the most interesting 15 minutes of every other specialty.”

– Dan Sandberg, BEEM Conference, 2014[1]

Why are we different?  How do we differentiate ourselves from other specialties of medicine?  We work in a different environment in different hours and with different patients more than any other specialty.  Our motto is “Anyone, anything, anytime.”[2]

While other doctors dwell on the question, “What does this patient have? (i.e., “What’s the diagnosis?”), emergency physicians are constantly thinking “What does this patient need?[3]  Now?  In 5 minutes?  In two hours?”  Does this involve a different way of thinking?

The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues.  Yes, we do it on a daily basis, many times during a shift.  Every time I introduce myself to a patient, I never know which direction things are going to head.  But I feel like I should give the following disclaimer.

Hello stranger, I am Doctor Joe Lex.  I will spend as much time as it takes to determine whether you are trying to die on me and whether I should admit you to the hospital so you can try to die on one of my colleagues.[4],[5] You and I have never met before today.  You must trust me with your life and secrets, and I must trust that the answers you give me are honest.  After today, we will probably never see one another again.  This may turn out to be one of the worst days of your life;[6] for me it is another workday.  I may forget you minutes after you leave the department, but you will probably remember me for many months or years, possibly even for the rest of your life.

I will ask you many, many questions.  I will do the best I can to ask the right questions in the right order so that I come to a correct decision.  I want you to tell me the story, and for me to understand that story I may have to interrupt you to clarify your answers.

Each question I ask you is a conscious decision on my part, but in an average 8 hour shift I will make somewhere near 10,000 conscious and subconscious decisions – who to see next, what question to ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, which consultant will give me the least pushback about caring for you, is your nurse one to whom I can trust the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home?  So even if I screw up just 0.1% of these decisions, I will make about 10 mistakes today.[7]

I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio: gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG.  I can recognize and treat those things without even thinking.  If, on the other hand, your problem has a lot of background noise, I am more likely to be led down the wrong path and come to the wrong conclusion.[8]

I am glad to report that the human body is very resilient.  We as humans have evolved over millennia to survive, so even if I screw up the odds are very, very good that you will be fine.  Voltaire told us back in the 18th century that “The art of medicine consists of amusing the patient while nature cures the disease.”  For the most part this has not changed.  In addition, Lewis Thomas wrote: “The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves.  Most things, in fact, are better by morning.”[9]  Remember, you don’t come to me with a diagnosis; you come to me with symptoms.

You may have any one of more than 10,000 diseases or conditions, and – truth be told – the odds of me getting the absolute correct diagnosis are not good.  You may have an uncommon presentation of a common disease, or a common presentation of an uncommon problem.  If you are early in your disease process, I may miss such life-threatening conditions as heart attack or sepsis.  If you neglect to truthfully tell me your sexual history or use of drugs and alcohol, I may not follow through with appropriate questions and come to a totally incorrect conclusion about what you need or what you have.[10]

The path to dying, on the other hand, is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.[11]

You may be disappointed that you are not being seen by a “specialist.”  Many people feel that when they have their heart attack, they should be cared for by a cardiologist.  So they think that the symptom of “chest pain” is their ticket to the heart specialist.  But what if their heart attack is not chest pain, but nausea and breathlessness; and what if their chest pain is aortic dissection?  So you are being treated by a specialist – one who can discern the life-threatening from the banal, and the cardiac from the surgical.  We are the specialty trained to think like this.[12]

If you insist asking “What do I have, Doctor Lex?” you may be disappointed when I tell you “I don’t know, but it’s safe for you to go home” without giving you a diagnosis – or without doing a single test.  I do know that if I give you a made-up diagnosis like “gastritis” or “walking pneumonia,” you will think the problem is solved and other doctors will anchor on that diagnosis and you may never get the right answers.[13]

Here’s some good news: we are probably both thinking of the worst-case scenario.  You get a headache and wonder “Do I have a brain tumor?”  You get some stomach pain and worry “Is this cancer?”  The good news is that I am thinking exactly the same thing.  And if you do not hear me say the word “stroke” or “cancer,” then you will think I am an idiot for not reading your mind to determine that is what you are worried about.  I understand that, no matter how trivial your complaint, you have a fear that something bad is happening.[14]

While we are talking, I may be interrupted once or twice.  See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, trying to clarify an obscure order for a nurse, or I may get called away to care for someone far sicker than you.  I will try very hard to not let these interruptions derail me from doing what is best for you today.[15]

I will use my knowledge and experience to come to the right decisions for you.  But I am biased, and knowledge of bias is not enough to change my bias.[16]  For instance, I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this diagnosis at least half the time it occurs.[17]

And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by recognition or use analytical reason.  Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking).[18]  Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking).[19]  It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.[20]

After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you.  This is essential for me to do so the hospital and I can get paid.  The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier.  The final chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process.  In my eight-hour shift today I will click about 4000 times.[21]

What’s that?  You say you don’t have insurance?  Well that’s okay too.  The US government has mandated that I have to see you anyway without asking you how you will pay.  No, they haven’t guaranteed me any money for doing this – in fact I can be fined a hefty amount if I don’t.  And a 2003 article estimated I give away more than $138,000 per year worth of free care related to this law.[22]

But you have come to the right place.  If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracostomy, I’ll do it.  If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too.  I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter.  I can float your temporary pacemaker, I can get that pesky foreign body out of your eye or ear or rectum, I can stop your seizure, and I can talk you through your bad trip.[23]

Emergency medicine really annoys a lot of the other specialists.  We are there 24 hours a day, 7 days a week.  And we really expect our consultants to be there when we need them.  Yes, we are fully prepared to annoy a consultant if that is what you need.[24],[25]

Yes, I have seen thousands of patients, each unique, in my near-50 years of experience.  But every time I think about writing a book telling of my wondrous career, I quickly stop short and tell myself “You will just be adding more blather to what is already out there – what you have learned cannot easily be taught and will not be easily learned by others.[26]  What you construe as wisdom, others will see as platitudes.”

As author Norman Douglas once wrote: “What is all wisdom save a collection of platitudes.  Take fifty of our current proverbial sayings – they are so trite, so threadbare.  Nonetheless, they embody the concentrated experience of the race, and the man who orders his life according to their teachings cannot be far wrong.  Has any man ever attained to inner harmony by pondering the experience of others?  Not since the world began!  He must pass through fire.”[27]

Have you ever heard of John Coltrane?  He was an astonishing musician who became one of the premier creators of the 20thcentury.  He started as an imitator of older musicians, but quickly changed into his own man.  He listened to and borrowed from Miles Davis and Thelonious Monk, African music and Indian music, Christianity and Hinduism and Buddhism.  And from these disparate parts he created something unique, unlike anything ever heard before.  Coltrane not only changed music, but he altered people’s expectations of what music could be.  In the same way, emergency medicine has taken from surgery and pediatrics, critical care and obstetrics, endocrinology and psychiatry, and we have created something unique.  And in doing so, we altered the world’s expectations of what medicine should be.

Now, how can I help you today?

When people learn I work in the Emergency Department they usually ask, “How do you do it”? or say “Wow, I bet you see a lot of crazy things”. My answer aloud: “It’s never dull”. My answer in my head: “You have no idea”.

What profession do you walk out of a room that someone has just yelled, “I’m gonna kill you bitch” and laugh? Do you preform CPR, call a time of death, then talk about your weekend plans all in the same breath? It gets worse. You don’t want to know.

Even the bad ones: a rape or child abuse. Even that has to be walked away from and on to the next stomach ache, cold/cold or even heart attack. It may, for a minute, leave a pit in your stomach the weight of bowling ball. But even then, you can usually get rid of it with a sigh so deep that it goes all the way down to your toes. Sometimes it takes two sighs.

Sometimes I give a high five to someone on my team. Not to say “congrats”, but to feel a little human touch and know I’m not alone.

If a tear even feels like it might try to work its way up from your throat, you swallow it quick. It does no one any good to let it out. The family can’t see it. Your co-workers can’t see it. We all get one turn to break down and then everyone else has to be strong. We can’t all walk around like sobbing messes. When I see another on my team tear up (dead children do it the most to us), I know this time, it can’t be my turn.

So we suck it up. We learn to turn “it” off. To well, in fact. What choice do we have? We cope. We walk into fatal car accidents with our first questions (mentally, at least) being…”were they drinking, were they high, they probably weren’t wearing their seat belts”. Something, ANYTHING, to separate us from this. Something, ANYTHING so we can sleep at night and try to convince ourselves that we are not so temporary. That our spouses and our children are not so temporary.

When we can’t find reasons, we have no choice but to swallow that lump. We come home, we hugs our kids, and we cope. By the time we wake up for our next shift, it’s almost gone.

Each time I had to do that, and I suspect I’m not alone, I lost a little something. I shut off that pathway: “sadness, remorse, fear” too many times. That now those feelings are hard to come by at all.

But I’m not alone. And it’s the people by my side that make me feel normal about this chaos that we live in. This peephole into reality, that only a few of us see. We, more than anyone understand the temporariness of it all. The unfairness of it all. That even children aren’t safe from this awful game of life that no matter what ALWAYS ends in death. What choice do we have? This our job. This is our life. Even if we quit it, it’s too late. Once you peep through that hole, you can’t pretend you haven’t seen it.

If you don’t live in our world then that last sentence is greepy, maybe…morbid? Depressing? In our world, it is fact. It is life. It is truth. We have no veil of ignorance when it comes to our own mortality. Much to the dismay of our family and friends we sometimes come off as “cold” and (I hate this one)…”insensitive”.

So we may cry a little less. But here is the upside: we also laugh a lot more. We love fully. We live without regret. We generally don’t waste time on negativity or pessimism. We understand fully “one life” and we aren’t about to waste it. We wear our seat belts and don’t drink and drive. We live smart, but never in moderation! We are the ones laughing the loudest! We don’t shelter our kids, because even children without trampolines are sometimes “temporary”. So we let them jump and we let them laugh, we just have a net! We don’t keep them home from the park because we are worried about the “Boogy man” because we know most of the time it’s “Creepy Uncle Ralph” that is doing naughty things to the babies anyway.

If I did this job alone, the isolation would be maddening. But, I’m not. My co-workers are my sanity. My family: my rock. Together we get through this life with our eyes wide open. I wouldn’t change my world for anything.