One Night in an E.R.
by Peter Tyson
What is life in an emergency room really like? How, for
instance, does it stack up against the popular TV show "E.R.,"
which is likely most people's only view of how such a place
runs? One snowy Friday night, two attending E.R. doctors at
Massachusetts General Hospital in Boston graciously allowed me
to shadow them for eight and a half hours as they made their
rounds. These doctors, along with their residents and many of
their patients, were generously forthcoming, offering a
fascinating peek into a big-city E.R. and the lives that
intersect there. Just one thing, I was told: Don't call it the
E.R. At Mass General, it's the E.D.—Emergency
Department.
Note: This feature originally appeared in 2001, and some
details have changed—see
footnote.
HOUR ONE
6:15 p.m.
I check my watch and record the time, as I plan to do
throughout what should be an interesting night. I'm supposed
to be at Mass General at 6, but I'm currently stuck on Storrow
Drive along the Charles River. Due to the snowstorm, traffic
is at a near dead stop. An ambulance with siren blaring
threads its way down the middle between the two lanes. It's
probably going right where I'm going. For a moment, I consider
sneaking in behind it and throwing on my flashers but think
better of it.
6:28 p.m.
After getting off the drive and sneaking through downtown
Boston, I finally arrive at Mass General. I meet Nicole
Gustin, from the Public Affairs office, who will accompany me
this evening.
6:42 p.m.
I'm introduced to Dr. Michelle Finkel, the attending physician
in the Acute/Trauma section of the hospital's E.D. Pert and
confident, Finkel has short brown hair and a wide smile. She
graduated from Stanford and Harvard Medical School, and she
finished her residency here last June. At 31, she is the
youngest attending physician in the E.D. It's immediately
clear she accepts my presence and does not see me as an
annoyance.
6:50 p.m.
Finkel leads me on a quick tour of the E.D., beginning with
the 16-bed Major Multipurpose, or MAMP, where less severe and
chronic cases are taken, then into the four-bed Pediatric
unit. Finally we head into the 10-bed Acute/Trauma section,
where patients with gastrointestinal bleeding, respiratory
troubles, trauma, and other serious problems come.
"It's so busy that we can't bring in more patients," she says.
As all beds are taken, the E.D. is currently on "divert,"
meaning ambulances are being diverted to other hospitals.
"People can still come in on foot, of course." [Editor's note:
Massachusetts no longer allows E.R.s to divert when
crowded—see footnote.]
We dip into other rooms—surgery, orthopedics, radiology.
I'm having a hard time getting my bearings in this
honeycomb-like space. It's as busy as a hive, with assorted
people darting about—physicians, residents, nurses,
technicians, patients, family members, EMTs, police. It's
surprising how calm and relaxed everyone seems despite this
buzz of activity.
"Want some?" a resident carrying a steaming pizza box asks
Finkel as we dash down another hallway.
"Love some," Finkel responds but keeps moving.
"It's slow, but if it picks up, it could get
horrific—crazy kid stuff."
6:58 p.m.
Back in Acute/Trauma, EMTs push through the swinging doors
with a middle-aged woman strapped to a gurney. Two policemen
follow them into Bay 1. She's from a nearby prison and now and
then launches into a raving tirade.
7:08 p.m.
My first patient turns me down. That is, the woman behind the
drawn-across curtain of Bay 5 says no when Gustin, my liaison
officer, asks if she would mind having a reporter listen in
while Finkel examines her; he will not use names, she says,
and will leave upon request. No.
I can't blame her. If I were in the same position, I'd
probably say no, too.
7:10 p.m.
Even as I think, "With all these people running around, how
does anybody know who anybody else is?" I notice that
everybody is discreetly staring at me. The looks are not
threatening, just curious. I must stand out like a sore thumb.
7:15 p.m.
Gustin waves me into Bay 7, where a 36-year-old man passed out
at work today without any warning.
"This ever happen before?" Finkel asks. No. "Any pain or
pressure?" No. "Shortness of breath?" No. "Allergies?" No.
"Recreational drugs?" No. "Do you smoke?" When the man says
yes, Finkel responds, "You're young, stop now." It's the only
sermonizing I'll hear her do, but I'll hear it frequently.
7:20 p.m.
Outside the bay, Finkel confers with Dr. Jonathan Fisher, the
chief resident, then turns to me. "It's strange. With old
people, we think arrythmia." Arrythmia is a change in
heartbeat rhythm. "But he's so young." Why would a guy so
young suddenly pass out?
Apologizing for leaving me alone for a moment, Finkel sits
down on a tall swivel chair to take notes. Electronic noises
fill acoustic niches in the E.D.: beeping wall monitors,
ringing phones, printers spitting out EKGs, beepers going off,
loud pages over the intercom.
Residents mill about, take calls, work at computers, joke
amongst themselves. Chairs with coats thrown haphazardly over
them belong to anyone who wants to sit there—no sense of
private possession here. Strong sense, however, of hugely
talented people forced to wait around, hungry to be of
service. But we remain on divert.
HOUR TWO
7:39 p.m.
One of those strange moments that sometimes happens in noisy
places when all becomes suddenly much quieter, as if somebody
turned down the volume. Fewer people around, hallways
near-empty.
7:50 p.m.
Finkel and several residents gather around a wall-mounted
board to discuss patients, most of whom Finkel has yet to see.
The board lists each patient's last name, along with his or
her complaint, room number, time in, registered nurse, and any
labwork, X-rays, or other tests.
The doctors speak fast and, to my untrained ears, in a kind of
code punctuated with medical terms, drug names, unfamiliar
treatments. As they make their way quickly down the board, I
scribble down a welter of phrases that later prove utterly
meaningless out of context: his chest X-ray is pending ...
right upper extremity numbness ... urine is clean ... no
neurologic symptoms....
One comment of Finkel's stands out, however: "I don't know
what's wrong with him yet, so that's a problem." It sums up
the doctors' unanimous stance: Concern for patients, thrill at
a challenge, certainty of eventually pinpointing the problem.
8:01 p.m.
"You guys have the best job!" says an RN sarcastically to one
of the policemen guarding the incarcerated woman, who has
begun raving again.
"Why do I always get the nut cases?" asks one, a beefy,
good-natured cop. He jerks his thumb back towards Bay 6, to
which the woman's been moved. "She's not playing with a full
deck."
"Listen, I'm an old man, I'm ready to die," he says, sighing.
8:09 p.m.
As Finkel excuses herself to attend to a patient outside
Acute/Trauma, I watch as a group of first- and second-year
medical students gets the same treatment I do: A resident asks
a patient if he'd mind a group of students listening in. He
doesn't, and they slip behind the curtain.
"They get to see a wide variety of patients and integrate what
they learn here with what they learn in the classroom," Dr.
Dana Stearns, an attending physician, tells me. Stearns runs
this course, which is so popular that he had to choose the 45
students currently enrolled by lottery.
Noticing me as we chat stepping this way and that to avoid
hustling residents, gurney-pushing EMTs, and technicians with
portable X-ray machines, Stearns smiles and says "we call it
organized chaos."
"It doesn't seem chaotic right now," I say.
"Just wait. It'll change like New England weather."
A nurse standing nearby uses that to comment about young
hot-rodders taking their wheels out in this storm. "It's slow,
but if it picks up, it could get horrific—crazy kid
stuff."
8:15 p.m.
Finkel tells me how busy it normally is. On a recent night,
she says, she charted a patient on average every 11 minutes.
"It's paradoxical. It's so busy that it's not. I mean, I'm
sitting here talking to you. It's unbelievable. You'll see
tonight when Tancredi takes over, when you're by yourself on
the overnight shift, you're practically running." Dr. David
Tancredi will take over for Finkel as the attending physician
at 11 p.m., but at 1 a.m., he takes over for all five
attendings currently here.
HOUR THREE
8:33 p.m.
Since things are slow, Gustin and I head to a coffee shop down
the hall for a break. It will be the only one I'll get all
night. As I order a bagel and coffee, I wonder if Finkel ever
got any of that pizza.
8:54 p.m.
Back in the E.D., I listen in as Finkel, the chief resident
Fisher, and a nurse discuss the incarcerated woman, whom
Finkel has just seen. The woman has begun hallucinating.
"She told me to stop drooling on her," Finkel says, chuckling.
"I said, 'I don't think I'm drooling.' And she said, 'Well, at
least stop spitting at me. And watch out for the dog.'" The
woman claimed that a half-lab, half-terrier was walking around
in the room.
The joking, de rigueur in hospitals everywhere, keeps things
from getting tense. But Finkel soon returns to trying to
diagnose her ailment.
"I bet she's going through d.t.'s," she says. Delirium tremens
is a violent delirium with tremors caused by excessive,
prolonged drinking of alcohol. "There aren't many things that
cause visual hallucinations."
"Well, if she's schizophrenic..." puts in the nurse.
"Right," Finkel responds, in a matter-of-fact tone that
suggests she's already thought of that, way back.
8:58 p.m.
We pause by Bay 2, where an elderly man lies drifting in and
out of sleep. He took too much heart medication, and his heart
rate has slowed into the 30s. "He feels fine," Finkel says,
raising her eyelids in mild amazement and smiling. So to make
room for other patients, he will soon be moved to the
so-called Step-Down Unit.
9:05 p.m.
A nurse tells Finkel there's an old man in the hallway who has
reduced his own hernia, because he was sick of waiting. A
hernia occurs when an organ such as the intestine pokes
through muscle layers; some patients can reduce their own
hernias—that is, push them back where they belong.
"He says he's been his own doctor for years," the nurse says.
"Okay, he can go, but let me see him first," Finkel says. No
one can leave the E.D. without first being seen by a
physician.
Out in the hallway Finkel approaches a bearded gentleman in a
black suit and white buttondown shirt, half-sitting,
half-leaning on an unused gurney. Standing a discreet distance
away, I can see numerous people in the waiting room.
"I was in great pain," the man tells her, hands clasped before
him. "I found no relief here, so I applied my own expertise."
"First let me say I'm terribly sorry this happened," she says,
referring to his having to wait. "The entire place is full.
That's not an excuse, it's a reason." She crosses her arms.
"We're between a rock and a hard place. We can't give
medication in the hallway."
The nurse tells Finkel that the man has been excreting blood.
"You shouldn't have blood coming from your rear," she says
gently. "We need to check your blood count."
"I need to go home," the man says, polite but aggravated. "I
need my rest."
"It would be dangerous for you to go home," Finkel says
patiently. "If you lose blood, you could have a heart attack."
"Listen, I'm an old man, I'm ready to die," he says, sighing.
"I'm going against your wisdom. I'm using my wisdom."
There's nothing more to be done. As Finkel disappears into
Acute/Trauma, promising to notify the man's doctor, I hear him
say to no one in particular, "I've never felt this weak
before."
Finkel devours a banana. It's the first thing I've seen her
eat.
9:24 p.m.
"I'm not happy about him leaving, but he seems competent,"
Finkel tells me. "I really try to stay off divert. People need
to be seen here. This guy probably was in a lot of pain. It's
not good when so many people are waiting."
She pauses, smiling humorlessly. "People are screaming, 'I've
been waiting three hours.' Three hours? I think. That's not so
bad." Unfortunately, a typical wait is four to six hours,
because of the lack of beds and because doctors have to see
the most seriously ill patients first.
The doctors and everyone else who works in the E.D. are
certainly not sitting around. "Many times I'll be here for
hours, literally running between patients," Finkel tells me.
"I haven't eaten, haven't gone to the bathroom." She shakes
her head and bends to fill out the hernia man's chart.
It's the first time I've heard her talk about her own good,
not just that of her patients. Overcrowding and
short-staffing—nationwide problems that clearly affect
both sides.
HOUR FOUR
9:37 p.m.
Finkel visits a man in Bay 5. He has a brain tumor and was
evaluated at Mass General about a month ago for possible
surgery. But he was brought in today for coughing symptoms
that might indicate pneumonia.
During her questioning, Finkel learns that the man has had
trouble speaking for a day. He gets a word out, but then stops
as if frozen. As Finkel patiently extracts information from
him word by word, another doctor sweeps into the room. He's
seen the patient before and gives him a hail-fellow-well-met
pat on the shoulder.
"How are you doing, Mr.—?" he says loudly. "Who's your
neurosurgeon, remind me?"
"Uh...." The man can't get it out.
Finkel leans close.
"Is anyone here with you?" No. "Does anyone know you're here?"
Yes. "Okay, we're going to touch base with them to try to find
out exactly how long the problem's been going on, all right?
Do you—"
"Okay, now it's coming back, it's all coming back," the newly
arrived doctor interrupts, turning to a gaggle of med students
that came in with him. He points to a series of brain scans on
the viewbox, in which the tumor is clearly visible. "He has a
mass that was biopsied in an outside hospital about two months
ago. It's a glyoma. Unfortunately, it's in his speech area."
The man agreed to allow me in (as well as Gustin and the
medical students), but I feel badly for him that his very
serious condition is made so openly public before a crowd of
strangers. At the same time, while I prefer Finkel's gentler
bedside manner, I realize the other doctor is not unkind and
is simply doing his job, which includes teaching the next
generation.
9:47 p.m.
While she talks with a resident about a patient in for
disimpaction of his bowel, Finkel devours a banana. It's the
first thing I've seen her eat.
9:54 p.m.
The 36-year-old man who passed out at his office signs his own
release and leaves.
9:57 p.m.
In Bay 6, Finkel drops in on a courtly Italian gentleman of 61
who's had a constant pain in his chest since this afternoon.
Finkel begins asking her litany of questions, which the man's
bearded son, still in his overcoat, translates for him.
When she asks about smoking, the father answers himself: "I
stopped two years ago."
"Good for you. That's wonderful." Her passion.
After examining the man, during which she discovers that she
and the patient and Gustin all have the same birthday, Finkel
gives her usual thorough summing up.
"Okay, this is the story. I'm not sure what's causing this
discomfort. It could be just muscle pain. The problem is, it's
very hard to tell if someone is having heart pain or not,
especially someone your age. We worry a lot more. Some of what
you've told me sounds like heart, and some doesn't."
She goes on without pause.
"We'll get a chest X-ray. Your EKG is funny-looking, but it's
always been funny-looking, so that's reassuring actually. But
I think we need to take what you're saying pretty seriously,
because you do have some risk factors for heart disease. I'm
not saying you've had a heart attack. But I do wonder if maybe
your heart is trying to tell you that it's not getting enough
oxygen. It could be just muscle, but in the emergency room we
are just very careful."
"Especially because you have the same birthday!" says the son
brightly. "You really have to take care of him."
"Yes, all three of us are bonded," Finkel says and then we
leave, smiles all around.
"Oh, I thought you were going to tell me I was dying. Sure,
bring him in."
10:17 p.m.
Dr. Bret Nelson, a resident who has made some calls, tells
Finkel that the incarcerated woman has no history of
schizophrenia, and that the phone numbers the woman's been
giving for people to contact are no good.
Finkel jokes with Jonathan Fisher, the chief resident, about
the woman's drooling hallucination. "I haven't drooled in
hours," Finkel says.
"She said I drooled, too, and clearly that's true," Fisher
responds with a smirk.
"Fish," a stout, amiable 29-year-old who reminds me both in
looks and lively personality of the actor Richard Dreyfuss,
has an irreverent sense of humor that the other staff members
clearly savor. At age four, in the hospital for a throat
infection, Fish had an emergency cricothyrotomy in an
elevator—doctors placed a breathing tube in his
dangerously constricted throat. That saved his life, but
between then and age 10, he had 40 surgeries.
Fish was left with no voice, so he whispers like someone with
laryngitis, even across the E.D. He was also left with an
abiding interest in helping the sick and injured. He first
became an EMT, then got a masters in public health, and
finally graduated from Tufts Medical School and came here.
10:26 p.m.
Finkel asks a 94-year-old woman with a swelling on her calf
whether I can come in. I hear a tiny, charming voice behind
the curtain: "As old as I am, I'm still very bashful."
Finkel assures the woman that when she examines her, she'll
ask me to leave. The woman gives her assent, and Finkel gets
on with her questioning.
"You a smoker?" Finkel asks.
"Never in my life."
"Good for you."
The swelling looks worrisome, and Finkel, concerned about a
possible blood clot, orders an ultrasound.
HOUR FIVE
10:37 p.m.
A cancer patient in her 60s initially misunderstands when
Finkel asks her if I can come in. Upon clarification, the
woman says, "Oh, I thought you were going to tell me I was
dying. Sure, bring him in."
After examining the woman, who recently had an esophagectomy
(an operation on her esophagus to remove cancer), Finkel deems
her pain a surgical complication and calls for a surgeon to
come see her.
10:53 p.m.
A newly arriving resident says that the storm has dumped seven
inches of snow so far.
10:58 p.m.
A new pair of cops arrives to relieve the two who have guarded
the incarcerated woman for four hours. Moments later, Dr.
David Tancredi appears, ready to take over for Finkel.
Tancredi's pedigree is impressive: Harvard undergrad, followed
by graduate studies in philosophy and Harvard Medical School.
He's now finishing up a Ph.D. in anthropology, which took him
to Mexico for a year to research how to bring modern medicine
to rural Indians.
Slight of build, eyes alive with intelligence, Tancredi exudes
an aura remarkably avuncular for someone not yet 40. As we
gather by the patient board so Finkel can fill Tancredi in,
residents crowd around him like students before a respected
teacher, seeking his approval of their diagnoses.
After hearing about all the patients, Tancredi decides not to
renew the divert. Mass General is again open to ambulances.
11:20 p.m.
Having finally unloaded everything she knows about the 10
patients in Acute/Trauma, Finkel leaves for the night.
HOUR SIX
11:32 p.m.
Standing by the patient board, Tancredi and Fish trade
possible diagnoses for the incarcerated woman. A heavy
drinker, she had her last drink four days ago, when she was
taken to jail. So withdrawal seems likely, yet aspects of her
vital signs give them pause.
When Fish launches into the light banter, Tancredi doesn't
miss a beat.
Fish: "Why can't she be just plain old nuts?"
Tancredi: "Could be withdrawal."
Fish: "Just give her a beer."
Tancredi (looking at me): "We used to stock it. Really." In
the past, he adds, before the advent of other medications for
alcohol withdrawal.
Fish: "Best antidote to d.t.'s."
Tancredi (still looking at me): "It was cheap beer, though."
A resident continues trying to sedate her so he can perform
tests that might confirm the diagnosis of withdrawal.
"It's nearing last call. I'd like to keep a bed open for a
crash victim."
11:39 p.m.
In Bay 1, I see my first patient with Tancredi. She's a
red-haired woman in her 50s or 60s who has pain in her legs,
which have had blood clots in the past. Tancredi bends over
and leans on the bed's railing, only a foot or two from the
patient's face. It's a personal touch that he'll bring to
every patient encounter tonight. He tells her he will order an
ultrasound of her leg to see if the pain is being caused by a
clot or is musculoskeletal in nature.
11:48 p.m.
With beds unavailable in Pediatrics, a premature baby whom I
can see waving its arms and legs vigorously on a bed in Bay 2
is moved to Bay 17 in MAMP.
11:56 p.m.
Tancredi heads out to the reception area to check on a man in
a wheelchair, who has a heart condition and is having trouble
breathing. I have to double my normal walking speed to keep
up. Tancredi's preferred stride is a near-run, as if
everything's a crisis, which I guess is not an inappropriate
way for an E.R. doctor to think. Even when he's not moving,
Tancredi's natural forward lean gives one the impression that
he's about to start forward at any moment and one should be
prepared to get out of the way.
11:58 p.m.
After a brief discussion with the wheelchair man, Tancredi
turns to talk to a mother who is holding a bloody cloth to the
head of her 15-year-old son, a hemophiliac who got drunk and
fell down some steps. Her ringed fingers are stained with
blood.
"Do you know how bad his hemophilia is?"
"It's 10 percent."
"Okay. Have we seen him here?"
"Yes. We always come here. We see Dr.—."
"Great. That means we'll have all the records. Okay, we're
going to put a collar on him, and we'll see you in a few
minutes."
As Tancredi turns to leave, a male nurse takes hold of the
semi-alert boy's shoulders and says, "I'm going to have to lay
you down, buddy, and put a hard collar on your neck...."
12:00 a.m.
As Tancredi passes the old man with low heart rate in Bay 2,
who still hasn't been moved to the Step-Down Unit, he pauses.
He takes in data flashing on the patient's monitor, which
still shows a heart rate in the 30s, then shuffles over to his
bedside. He looks quizzically between the dozing patient and
his monitor, and says half to himself but with a tone of
urgency, "Is this guy all right?"
A nurse ambles slowly into Bay 2, her seeming somnambulance a
stark counterpoint to Tancredi's hyperkinesis. "He's been like
that for hours," she says languorously. She couldn't sound
less urgent.
What she means is that she's been watching him closely for
hours, his mental status and blood pressure are normal, and
he's not in distress. Having got what he needs, Tancredi
shrugs, smiles at me, and moves off.
12:06 a.m.
EMTs burst through the double doors, wheeling in a gurney
bearing an unconscious man dressed only in boxer shorts.
Though he's out cold, the man appears young and fit. Ten
people crowd into Bay 3: four EMTs, two cops, Tancredi, Fish,
Dr. Heikki Nikkanen (a resident), and an RN.
Even as Fish begins to joke around, he straps an oxygen mask
on the patient and, along with Nikkanen and the nurse, begins
attaching various diagnostic devices and tubes to the man's
chest and arms. Tancredi watches the monitor, questions the
EMTs who brought him in, and orders a portable chest X-ray
unit to Bay 3. I stay out of everybody's way.
12:18 a.m.
Tancredi steps out of Bay 3 for a moment, and, not knowing
what is going on, I risk asking him to give me an update. He
seems only too happy to do so.
"It's probably DKA—diabetic ketoacidosis. He has a
history of diabetes, and he's had relative insulin
deprivation, meaning that his blood sugar's way up. Even
though he's got all this sugar in his blood, his body's
perceiving that he doesn't have enough. Ketoacids have built
up, and he's entered ketoacidosis."
Tancredi glances back at the monitor. Just as he does so, the
semi-conscious patient rises halfway up off the bed for a
moment, and Fish gently pushes him back down. When he sees the
patient is calm, Tancredi turns back to me.
"He's got a change in his mental status and a change in his
EKG, which means he could have a really high level of
potassium. He could have had a heart attack. All these things
are still tests away. We don't know. You kind of take your
best shot."
That is, when confronted with a condition as serious as this,
an E.D. doctor often has no choice but to act before all the
data are in.
12:22 a.m.
Everybody clears out of Bay 3 for the chest X-ray. Tancredi is
the first back in.
12:26 a.m.
The patient, still unconscious, lies alone in Bay 3.
Everything that can be done for him for the moment has been
done.
A woman at the main desk gets on the intercom: "Transport to
Trauma. Patient going to the unit. Transport to Trauma.
Patient going to the Step-Down Unit."
HOUR SEVEN
12:30 a.m.
The elderly man with the low heart rate is finally wheeled out
of Bay 2. Glancing at the clock, Fish nods toward the empty
bay and says matter-of-factly to Tancredi, "It's nearing last
call. I'd like to keep a bed open for a crash victim."
Tancredi nods and continues scribbling notes on the
unconscious man's chart. I ask Fish about the cause of the
man's diabetic reaction.
"It could be an infection, or maybe the guy's not complying
with his medication." He pauses and looks up at me. I expect a
joke, but I don't get it. "This is what kills young
diabetics," he says and takes another look at the monitor in
Bay 3.
12:35 a.m.
Tancredi visits the wheelchair man, now ensconced in Bay 4.
When the patient tells him he previously had a heart attack
and bypass surgery for his legs, Tancredi asks what medicines
he's currently taking.
"Right now, none."
"Really? Does your cardiologist know?"
"Well, I haven't seen him for a year."
"Ah, three years," his wife pipes in.
After a few more questions and an examination, Tancredi tells
him he should be taking his medication, and he offers his
diagnosis.
"Here's the story. Signs are that you have early congestive
heart failure. What we're in the business of doing down here
is ruling out the biggest threats, the worst things that it
could be. To me, that's the thing I would be most worried
about."
"So what I'd do is bring you into the hospital, get an
ultrasound of your heart. We'll be able to tell from that how
well your heart is pumping. Then we'll have an idea of what
kinds of medications you can get and where we're thinking you
are on that curve of congestive heart failure."
"He's not going to like this. Both his hands are tied, right?"
1:07 a.m.
"Weather always stops it," a resident says by way of
explaining the lack of trauma victims tonight and the
generally more subdued atmosphere.
1:18 a.m.
Standing over the unconscious diabetic in Bay 3, Tancredi
talks with two family members.
"He's a healthy kid, takes care of himself," says his
moustachioed father.
"He's obviously pretty healthy, because he's making it through
this fairly well," Tancredi responds.
"Well, to be honest with you," says the father, "the best
thing for him would be to spend a couple of days here."
"Oh, he's definitely going to be admitted," Tancredi says.
"The question is whether to put him in the intensive-care unit
or not. His condition is pretty severe, and it takes a long
time to get this way and a long time to get back. Also, we
have to find out what the cause is, and that's hard."
1:26 a.m.
As Tancredi leans against a counter in MAMP, hospital security
wheel in a drunk strapped to a gurney. Scrawny and unshaven,
he curses in a loud voice till he sees Tancredi, then breaks
into a broad grin and says something incomprehensible.
Tancredi does a finger wave and says an extended "Hiiii."
Clearly he's seen him before.
HOUR EIGHT
1:45 a.m.
As Tancredi prepares to see the hemophiliac kid in MAMP,
Heikki Nikkanen stops him to say the unconscious man in
Acute/Trauma is starting to come around.
1:47 a.m.
The 15-year-old hemophiliac has passed out on his bed. His
parents hover over him, giving Tancredi the details of his
accident. Apparently the mother found him around 11 p.m.,
passed out inside her house. She woke him up, and he told her
he had fallen down four or five stairs outside.
Tancredi lifts the boy into a sitting position and tries to
wake him up. "Who's that?" he says, pointing to the mother,
who leans in close to her son. The boy looks at his mother and
mumbles. Again Tancredi says "Who's that?," this time turning
the boy's head towards his father. Eyes barely open, the youth
mumbles once more. Tancredi lays him back on the bed, and he's
immediately out.
Tancredi orders a chest X-ray. He also calls for a CAT scan of
the boy's head; his hemophilia puts him at risk for bleeding
into the brain.
Outside the bay, Tancredi tells me the boy's alcohol level is
almost three times the legal limit.
1:58 a.m.
Tancredi visits the 94-year-old woman with the swelling on her
calf. A middle-aged couple has joined her—her kids?
Tancredi tells her he has ordered pain medication and that it
should be there soon. He expects to release her before long.
2:00 a.m.
I sit down on a chair in MAMP and am surprised at how
wonderful it feels. Then I realize it's the first time I've
sat down since I arrived over seven hours ago. E.R. doctors
must have that feeling all the time.
2:09 a.m.
The hemophiliac youth is awake. In fact, he walks with the
help of his father to the corner of the bay to urinate in a
pan. "He's looking much better now," Tancredi
says—unnecessarily, I think. Then, as if reading my
thoughts, he adds, "You never can tell with a hemophiliac.
Since he has very little blood-clotting ability, we have to
assume the worst."
2:15 a.m.
A resident suggests that a second drunk be allowed to stay
overnight, what with the weather. Tancredi concurs. "I'm
certainly into looking out for people who are homeless," he
says. "It's one population with which we can afford to be
conservative."
2:20 a.m.
"Dr. Fisher, you have a call on line—." Fish hears the
page but finishes telling Tancredi about a patient before
finally walking languidly to a nearby phone and taking the
call, a full minute later.
The driver and any passengers have already been taken away,
perhaps to the very E.D. I just left.
2:21 a.m.
Tancredi enters the bay with the drunk who recognized him
earlier. The man is now passed out. Even from where I stand in
the hallway outside, the smell of the man's socks is
overpowering.
"We call them 'toxic socks,'" Tancredi says, unperturbed.
"Sometimes you literally have to bag 'em—put bags on
them." He proceeds with his examination, poking and probing,
but the man doesn't react.
"He's not going to like this," Tancredi then says, holding up
a red rubber tube about six inches long. "Both his hands are
tied, right?" he asks an RN, who says yes.
Tancredi jams the tube up one of the man's nostrils. The man
wakes violently into a sitting position and tries to blow out
the tube, of which only an inch or so protrudes from his nose.
Then he appears to fall asleep, still in the sitting position,
head down.
Half a minute later, as Tancredi and I stand at the main desk
in MAMP, I see the red tube go flying. The man has awoken, and
he leaned down till his head met his shackled hand and pulled
the tube out.
"If he's awake enough to do that, he doesn't need it,"
Tancredi says and smiles.
HOUR NINE
2:34 p.m.
In his first visit to a patient in Pediatrics, Tancredi drops
in on a 10-year-old Latina girl who has abdominal pain. Half
the size of an adult bay, this room's only concession to its
younger occupants is a strip of wallpaper with giant alphabet
letters that winds its way around the room near the ceiling.
The girl's mother is here with three other children. Since the
mother doesn't speak English, Tancredi asks one of the
children to translate for her—curiously, because after a
question or two, he breaks into fluent Spanish himself and
speaks directly to the patient.
Outside the room, Dr. Barbara Angus, a resident, catches
Tancredi up on work already done on the girl. "We thought she
could go home and are disinclined to do blood work, but
obviously we wanted to check in with you. I don't know if you
want some screening labs or...."
"The only thing I want is, she looks to me like she's a quart
shy."
"Do you want her lined?"
"Well, no. Is she able to keep fluids down? She's telling me
that she's been drinking a teeny bit. I'd like to make sure
that she gets adequate hydration before she goes. If she can
do it by mouth, I'm very happy to do it that way."
2:46 a.m.
Tancredi examines an elderly woman in MAMP who, upon his
asking, says it "hurts everywhere." She's had it all: appendix
out, hysterectomy, repaired hernia, breast cancer, high blood
pressure, a polyp in her colon.
The woman lies on her back and doesn't open her eyes even when
Tancredi leans on the rail close to her face. "I'm very
tired," she says and starts to cry.
When he begins to examine her, I slip out.
2:58 a.m.
A wall monitor in MAMP starts beeping loudly, and a single
word flashes in red—ASYSTOLE, which means someone's
heart has stopped. I look around anxiously; no one has moved.
Noticing my reaction, Fish juts his chin toward the bay in
question, smiles, and says, "I can hear him talking, so
clearly his heart hasn't stopped." Fish and the others seem to
know instinctively when a cry means wolf and when it means a
faulty monitor.
3:03 a.m.
Things have quieted down, and I've seen most of the patients
who will allow me in. So I thank Tancredi and Fish for their
time and turn to go. Remembering one last question, I turn
back. But the doctors are already on to something else,
answering a nurse who's asking if they ordered an ultrasound
for a certain patient. I spin on my heels and head out.
3:40 a.m.
As I drive up Route 2 towards home, the blizzard still in full
swing, I pass the scene of a one-car accident. Its roof
crumpled, windshield smashed, a sports car took a nasty roll
on the slick highway. A lone police car, lights flashing,
remains in attendance; the driver and any passengers have
already been taken away, perhaps back the way I came, to the
very E.D. I just left.
Note: This article originally appeared on NOVA's "Survivor
M.D." website in 2001. Since then, some personnel, procedures,
and department names in Mass General's Emergency Department
have changed: Of the doctors and residents mentioned, only
Dana Stearns still works in the E.D. as of March 2009. Today,
the E.D. always has two attending physicians overnight (as
opposed to one), patient charts are computerized, and
computers have replaced the handwritten board of patient names
and details. Finally, by state law, E.R.s can no longer divert
incoming ambulances when they're crowded, as described in this
article.
