(That does not mean you should skip it)
I recognized her and she recognized me. I had seen this young woman once before as a patient. She was pleasant, well- mannered and worked as a waitress. Whatever I had seen her for in the past wasn’t serious and things must have gone well enough, because she did not act disappointed when she saw me.
She was more mature than most young women her age, made so by the serious disease she had been confronting her entire life. She had one of the bleeding disorders, and on her prior ED trip, I had helped her with administering the medications to stop some bleeding from an injury.
Patients with these afflictions are almost always very well informed. Medical Pearl: Do not try to bluff and act more knowledgeable than you are around them! They usually bring their own medications with them, so our job is frequently just to assist them by gaining IV access and deciding how serious the bleeding is (this determines treatment dosages.)
The woman was coming to the ER this time because she had bitten the side of her tongue and it would not stop bleeding. She had been tasting blood for hours. Nothing life-threatening, but seriously annoying.
The bleeding would not stop on its own, but neither of us wanted to use her expensive medications for such a trivial- seeming wound. The goodwill accrued to me from her prior visit was going to be helpful, because I had a plan that I needed to sell to her.
“How about you stick your tongue way out, we spray some numbing medicine on your tongue, and use a cautery stick to stop the bleeding? It won’t hurt but a little, and should be quick.”
She consented, happy not to need an IV.
I grabbed the bottle of ethylene chloride topical anesthetic. There was usually a bottle of this in the doctor’s cubicle. The first task was to make sure it was not empty. This stuff went fast, partly due to playful staff squirting it on each other for laughs. (I never did this.)
The liquid was in a blue-labeled, brown glass bottle that you utilized by holding it upside down, pulling a lever, and directing a freezing, numbing spray on the skin. (This works well for numbing skin for things that are quick and not too painful, like puncturing the thin skin of a ripe abscess.)
The nurse went to get the silver nitrate sticks for cautery. These are like long Q-tips, but with a caustic brown tip instead of cotton.
“I couldn’t find the sticks, will this work?” The nurse held up a battery-powered cautery.
As instructed, the patient stuck out her tongue, which I grasped with some gauze for grip and blotted the small trickle of blood.
I pulled her tongue out a little further for access and sprayed the numbing liquid on the bloody area for a couple of seconds. I had to work fast, because the numbing effect is fleeting.
I quickly put down the bottle as the nurse handed me the cautery and I pushed the button. Just before the orange-glowing cautery tip reached the wound, a gentle puff of warm blue fire poofed back in my face. The gauze flared up in yellow as I released her tongue. The mouth glowed with a soft blue flame.
“That’s not gonna work,” I said matter-of-factly as I discreetly snuffed out the burning gauze. The flaming, wide- open mouth extinguished itself.
I was in full self-control mode. I was the sound of one hand clapping.
Not the nurse—she was the sound of something like, “Oh, my word!”
The patient followed the nurse’s lead, not mine, and gasped in mild shock. Any hopes of the fire going unnoticed flickered away.
I hear you, but it is possible the smell of smoldering gauze would have escaped the patient.
Closer examination of the ethylene chloride bottle showed a small red “flammable” symbol hidden on the corner of the benign blue label. Some part of my brain knew that, since it was a volatile chemical, but that part didn’t speak up in time.
Oh well, the tongue was still bleeding. Time for damage control.
In fact, I was able to smooth things over enough to convince the patient to let me try again when we finally found some cautery sticks. I could tell she was having to steel herself this time.
The second attempt worked fine, with no drama, and the bleeding stopped. Everybody was happy ... but were they?
The ED was giving surveys to exiting patients at the time. I was relieved to see that she had given us the best ratings and wrote no complaints. I was still half expecting a later report of, “I can’t taste food,” or “I can’t kiss my husband anymore,” but there were no complaints.
I needed to tell you about the lady whose mouth I set on fire. That’s why I wrote this book. But first, I must explain some things. I really did start a fire in a patient’s mouth. It is a true story. There are many others in this book.
Every single story in this book is true. I am not going to lie to you.
“Wait just a minute,” the wary reader may say.
What’s the problem? It’s the line, “I am not going to lie to you.”
If you ever hear this statement declared in the emergency department of a hospital, it will always be followed by a lie. It is typically an earnest response to certain questions asked of patients: “How much did you drink? Any street drugs?”
“Two beers” means at least double that.
“No street drugs” means cocaine and marijuana. “Absolutely no drugs” means marijuana.
The emergency department is awash with such lies, and
every claim should be viewed with suspicion.
The intoxicated patients typically are the source of lies, but
falsehoods can come from any direction. Sometimes, they come from sober doctors: “Tell the police you called me for an emergency! They stopped me for speeding, and I told them the ED (footnote 1) called me. I think they are still behind me,” said the furtive- looking plastic surgeon.
After a brief pause for processing, I responded: “What? I’m not going to lie to the police! That’s probably a felony.”
Fortunately, the police never came, and I was not faced with any future unpleasantness from the law or the plastic surgeon (depending on which path I chose).
A similar lie came through the same doors when a different doctor tried the same evasive, faux emergency maneuver. In his case, according to reliable sources, the wily police followed Dr. Fugitive upstairs, the nurses chose the “not lie” path, and the doctor was arrested.
Footnote 1: Emergency Department. Newspeak for ER, Emergency Room, which is regarded as belittling and misleading.
Clearly, lies can cause you problems. Indeed, truth should be the default and is often your only reasonable option. Truth in this book is important to me for several reasons: I want you to believe the stories fully, I do not want to teach any young medical minds anything untrue, and I am trying to reach my own Truth.
So, when I say, “I’m not going to lie to you,” I am definitely telling you the truth. But you will need a little more than that. This is what I mean: This book is full of true tales from my life in the ED. Many of them do not sound like they could possibly be true, but they all are. They are not even embellished.
I am going to tell events and facts that I am sure I can distinctly and correctly recall and describe. Yet, in truth, the truth needs some qualifications.
For privacy, legal, and even compassionate reasons, I cannot reveal the identities of the individuals involved. Some of the personal details I have forgotten, and that makes the concealment of their identities easy for me, but that is frequently not the case.
If I give a hair color, then I remember one. For example, “curly blond hair” means I recall the color. This color hair is important, as it was present in both a sad story and a happy one: a young lady mauled to death by a dog, and a young man who miraculously survived death. The narratives are completely true, but the hair color is fake.
I cannot clearly remember the hair color of the girl whose mouth I set on fire, so I did not mention one. I will not guess or invent one for the sake of the story’s flow.
I clearly recall the names of both fugitive doctors involved in the events above, so I could mention them, but I will not. For now.
Nothing has been added to the events to make them more scary, yucky, or funny. Everything is true. I am not going to lie to you.
Sometimes I will mention a particular detail because, for some reason, I specifically recall that. I seem to have an unhelpful knack for remembering the less important details. Note that this characteristic of my memory was at times very annoying on important tests in medical school—I remembered exactly where in the textbook the answer is, but not the answer itself.
So, when I write “4A,” it means I remember what room the patient was in. I specifically recall that detail because killing a patient sharpens the memory, even if was not exactly your fault and even if the patient was dead only temporarily.
In this book, the quoted conversations may not be word for word, but they will be very close. There will be nothing added of any significance. The most striking of these talks are word for word.
None of the names in this book are real. I, Dr. McAnonymous, have changed them all, including my own. It may surprise you to learn that Dr. McAnonymous is not my real name. If you thought it was, this book may not be for you.
Other details could possibly reveal identities, and I have had to change those. Typically, when I mention a descriptive detail or number or name, it is because I remember the actual detail and feel the need to change this for privacy reasons.
To clarify the ground rules and beat the dead horse: all of these stories are true. I will change any details which could be used to identify individuals but none of these changes will materially affect the trueness of the stories. In some cases, I will just leave out data, in others, I will change any detail that could give a nosy person some sort of clue. In the plane crash story, I have changed the numbers of the victims involved as an extra precaution.
I have preserved the relevant information in such a way that all of these tales will be recognized by coworkers who experienced them with me.
Do not worry about these modifications. They will not cause you to miss any of the insights these events may contain. You can trust any insight, horror, or laughter you experience here to be a valid response to the real world. The main goal of this book is to relay a reality I have experienced.
When I say “I,” the story is my eyewitness account. I am the real doctor. For example, in the story of the lady’s mouth I set on fire, the “I” is absolutely me, Dr. McAnonymous.
Can you trust my memory? Some of these tales I recall so precisely because I have retold them hundreds of times over the decades. Many of these events are extremely easy to remember. You will see.
Now that you’ve suffered through all that methodology, should you even be reading this book?
Anyone planning on treating sick patients should read this book. You need to know what you are getting into. My career is not exceptional, and every experienced ED caregiver will have similar stories. You can fully expect to have your own. Many of your stories will be better, more horrific, funnier, or more shocking. Write them down for the rest of us.
If you are a medical student, you will learn a lot. But if looking for help with your board questions, you are out of luck. With solemnity, I was told in medical school, “Half of what you learn will be obsolete in five years.” Well, I learned the wrong half, and now it’s all obsolete. Feel free to laugh or gasp at some of the things we did back in the olden days.
I’ve certainly forgotten way more than I’ll ever know, but most of it wasn’t important. Much of the information in those gatekeeping classes was just to give the excuse for tests, to weed out those deemed not scholarly enough for medicine.
However, medical student, do not despair (Footnote 2). I have written this book for you, really. There is lots for you here. And it is
Footnote 2 Regarding this book, I mean. Otherwise ...
slightly possible that some snapshot of pathology will help you pass some test or, less likely, impress a nurse. I don’t really include any stories about luxatio erecta (footnote 3) patients, but I have seen two such cases.
In one of the patients, the triage nurse was fooled into thinking the patient was faking because of the weird appearance of this shoulder dislocation—he looked just like a student raising a hand with a stupid question (no offense). Knowing about this condition would give you the rare chance to one-up a nurse. You may learn some other valuable oddities in this book.
Speaking of nurses, and I obviously always do this with caution (nurses can strike from a distance of more than twice their body length), this book will be perfect for you. You will not learn much, but you will be entertained.
Nurses feel no need to pause at the border checkpoints of civilization, so you may find the verbiage tame, the gore underwhelming, and the jokes lame. If you are looking for the grittiest fare, find something written by a fellow nurse.
One last note. I am telling these stories in the manner I would use when speaking with any student involved with patients. I will mention many things that are not usually mentioned in polite society. Some episodes require anatomic descriptions and I refuse to use the term “down there.” Some stories involve gore, death, grieving, etc., and many readers may find the unpleasantness too hard.
Medicine is not for the squeamish. My tone might offend some, but there is no malice or insensitivity here. If you want to help the truly ill, you will have to at least act like you have a ruthless streak, especially in the really hard cases where you have to do painful or invasive things to people. It is not possible
Footnote 3: Even most doctors don’t know this word. I was taught it by Dr. Google. It is a type of dislocation where the patient cannot lower his or her arm.
to concentrate, to do your job, to save lives if you are too emotional. You cannot intubate and save the dying baby if you have tears in your eyes.
With some fear and trembling, I also recommend this book to any non-medical reader who is interested in seeing the full range of the human experience. This reader needs to not be squeamish or easily offended. There is true horror here. You can turn the page and plummet right into Hell. This is your warning.
My reality has cost me some sleep and given me some nightmares, and the stories herein may do the same to you. Nervous laughs are often the result when I tell these stories, and my wife sometimes winces when I talk. This book may mess you up.
In some way, I feel like we in the medical profession owe it to our patients to record and read these stories. A lot of suffering, pain, and death went into the making of them, and it doesn’t seem right for humanity to not have some record of these events. Someone hurt enough that we should resist the blindness that forgetfulness brings.
Whose vision is better? Who sees more clearly? My friends who live in cleaner, brighter, happier worlds, or those of us who are denizens of the dark? To find your way in the ER, your eyes must be prepared for the lack of light.
Unless there is some light, of course, which reminds me of that woman and the mouth fire.
We might as well have started with that story. I am not proud of this episode and I am always embarrassed by telling it, but it has to be told. If just one person learns from my ways, and doesn’t follow them, the world will be a better place.
Do not do much of what I have done and recorded here. I list lots of mistakes. The mouth fire story illustrates one on type of error. These are the worst: When some part of my brain “knows” the answer but doesn’t speak up to convince me of the correct decision when there’s still opportunity to get it right.
For example, I might hear a barely audible whisper of, “That’s flammable” or “Don’t discharge that patient with chest pain,” but it just isn’t loud enough to override the dissenting parties.
Typically, the correct voice doesn’t make itself heard until several hours after the event, when I’m trying to sleep. Then it is very loud and seems unquestionably right. If that voice proves to be correct, then it taunts, “I told you so.” Or, “I told you, volatiles are flammable!”
In addition, the mouth-fire incident illustrates the fact that maintaining composure is an important patient care technique. I am fairly certain that nothing in my face or voice conveyed the sudden shock I received when the blue flame burst forth, but that is only because I am in the Zone of Initial Response Control. Any shock on my part might increase her discomfort, adding fuel to the fire, so to speak.
Learn to live in this Zone, because control over your facial expressions or immediate verbal reactions makes a lot of interactions much easier in the ED. Most of your plans will be worthless if you can’t get the patient to go along with them. Crinkling your nose at a horrible smell, a micro-expression of anger, a look of condescension, a sudden “Yuck”—all of those things can wreak havoc on your treatment of an ED patient.
In this book, I will insert some pearls and pointers about mastering your initial reactions to sudden surprises, shocks, smells and sights, but first I should tell you about the grain of salt you should be looking for in my advice: I may not be normal.
I feel fine, but that is often not a good indicator. I may have been damaged enough by the events I describe here that my advice is inapplicable to you. I don’t think so, of course, so I think you should listen to me, but . . . anyone would be changed somewhat when confronted with these events.
The next chapter marks the beginning of my career, and it may have shaped my whole approach to medicine, and that is part of the reason I want to relate it up front.
In my mind, there is a deadly earnestness underlying everything related to medicine. It should be recognized that all the joking and superficialities float on the surface of a dark, threatening ocean. Some of these stories are funny, seriously funny.
I want readers of this book to see the black depths of that ocean first—then, as the eyes adjust, begin picking out the glowing, outrageous, beautiful creatures surviving there.
This whole book exists on the border of life and death, light and dark. The stories are often hilarious, but often sad. The ED does not allow you to have either kind alone. These two regions are pushed into view, both of them forcing you to pay attention.
I apologize in advance if it is too much. It is not overly sad, but it may be overly dark or gory. I cannot really tell. I just know it really happened and it must mean something. It must provide some insight that helps. It is an indispensable part of my life.
This next story is lodged in my brain surrounded by therapeutic, poetical musings, and I will add some of those. I’m sorry if you find them weird. The next chapter tells his horrible, gory story. I do not exactly advise reading it, but I can’t help telling it. It is part of me.