Involving esquites.
I was catching up with a friend on a phone call when she asked, “What’s the most exciting thing you’ve seen in the emergency room?” I was coming off a night shift and my brain refused to churn. I remember how inspired I was in medical school by seeing new things and meeting new people, but lately I feel like I’ve been running out of RAM.
I get asked the question about most interesting stories from the ED all the time, actually. But getting home after 12 hours of tangled chaos on rollerblades, I don’t want to process. I just want to sleep. And shift after shift, memories pile up and mat together and eventually it’s just too hard while sitting at a sunny brunch table in LA with R’s friends to actually pick out one thread that is “the most interesting.”
Instead I’ll write about a weekend night shift I had maybe a month ago. It wasn’t the busiest or most exciting or most difficult shift, but I had a lull in the pre-dawn hours so I jotted down notes of what happened. (As always, patient identifying details are changed for HIPAA)
6 PM. I had time to swing by the cafeteria before it closed and grab a water bottle before putting my bag down. As soon as I walked into the central work area, my senior flagged me down. “Want a lumbar puncture?” “Sure thing!” One of my favorite things about intern year is the chance to do procedures with other people watching and giving feedback. After the first year, your procedures are on your own — and though I haven’t needed anyone to swoop in and save me since the first month of residency, I still like the security of knowing that I could be saved.
Most procedures now are pretty rote. Laceration repairs (stitches and staples): easy and fun. Paracenteses: satisfying, then boring (you stand around for 20 minutes filling bottles with belly-juice). Ultrasounds: meh. But lumbar punctures can be quick and easy (some of my patients told me they didn’t feel anything) or so difficult that they require X-ray guidance. I’ve had really nice, confidence-boosting LPs, and sweaty, tense, frustrating LPs. The key to success is in perfect positioning. The patient’s spine must be curled in a tight C, elbows and knees straining to touch the belly button. Any asymmetry, any scoliotic angle of the back, any squirming or recoil, closes the tiny chink between vertebrae that the lumbar puncture needle needs to hit. Plus, many patients requiring lumbar puncture are encephalopathic, confused and disoriented. This patient was flailing around in bed despite his hands being ensconced in soft restraints, sweating so hard his EKG leads were falling off, febrile to 40 degrees C. Plus, it was shift change and the nurses were itching to go home. It was the opposite of prime conditions for a lumbar puncture. I nodded for the patient to be given sedation, directed the two techs to hold the patient in the right pose, and got out my iodine swabs. “Okay guys, time me.”
7 PM. Time to clear out the waiting room. I picked up an unhoused patient who just wanted a place to stay. He told the nurse out front that he was having debilitating chest pain. By the time I saw him, he was fast asleep with the blankets over his head, refusing to answer questions. I got him a sandwich. I would have loved to let him sleep if there weren’t a crammed and angry waiting room of sick people outside.
Surprisingly with 100 patients in the department (50 of whom were in the waiting room), there was nobody else to see. The problem with hospital congestion is this: when patients don’t get discharged upstairs, newly admitted patients can’t be sent up to rooms. So they stay right where they are, in the emergency room, getting cared for by ER nurses. But then where do ED docs see patients? The answer is different at different hospitals. At one hospital, we move patients to chairs in the hall, quickly assess them, order tests, and return them to the waiting room. At this hospital, we don’t even have the hallway space for that, as hallways are taken up by beds. On this shift, of the 52 ED beds available, 37 were taken up by “boarding” patients, or patients that were admitted to the hospital. Only 15 beds were actively turning over patients who were being evaluated and possibly sent home. Every patient we admitted became one less bed for us to use.
It’s like a dim sum restaurant in an old-timey Hong Kong martial arts film. You start out with 50 tables, but eventually one after another gets destroyed by people fighting each other, so you can only serve new customers at the few remaining tables until they, too, get smashed up.
The night passes. I picked up a stroke patient rolled in by EMS. He smiled and laughed as the neurologist asked simple questions. He mixed up his right and left, but otherwise seemed okay. I ordered a stroke MRI (incredible that this is the first line option) and CT and he was whisked away.
ED doctors don’t carry pagers. And why would we? If someone needed to contact us, we’d be right there in the emergency department. There is literally nowhere else we could be, as we don’t exactly eat, drink, or go to the bathroom. Instead, we carry ancient nokia-like brick phones, which we call bat phones for some reason.
Anyway, my bat phone went off. It was my senior resident. “Come to the attending room, quick!” Then she hung up. The attending room is a windowless cell with two computers and a coat rack. Its main draw is that it’s keypad-locked, so all the stereotypical EM doctors keep their bikes in there while on shift. When I opened the door, I found the whole night crew eating tacos. The attending had treated us with Doordash. I got a fish taco and a cup of street corn. It was my first time having esquites and the tang of lime over cotija cheese was better than caffeine.
12 AM. I saw my next patient. He was pale and rail-thin, only a year younger than me with a rare fatty acid metabolism disorder and covid-related chest pain. He had died twice before from viral myocarditis (brought back with CPR). But today the pain had come back. Even my meh ultrasound skills were enough to show that his heart was surrounded by a huge sac of fluid.
Halfway through the ultrasound, my bat phone rings. My stroke pt had a huge brain bleed. I rushed to his room. He was now unresponsive and somnolent. We began bringing down his blood pressure. As I set up a sterile field to place an arterial line, I heard an announcement overhead: “Rescue 27 with a critical level trauma, ETA 10 minutes. “Okay,” I said to myself. “Time me.”
An arterial line is placed by feeling for the pulse of the radial artery in the wrist and puncturing it with a needle. Then once blood starts to come out, you thread a thin soft wire into the artery, and slide a soft plastic catheter (like a drinking straw) into the artery, and take out all the metal bits: needle, wire, and all. As I sew it in place (3 minutes), another overhead call. “Rescue 27 with a second critical code trauma, ETA 5 minutes.”
I quickly clean up my sterile equipment and jog over to the trauma bay, where the nurses and techs are escorting out the previous trauma patients and prepping in their assigned corners for the incoming patients. The charge nurse tells the story in bullet points. “Patient in Trauma 1, young man with three gunshot wounds, left arm x 1, left leg x 2. A&Ox2, GCS 4–4–6. Combative. Patient in Trauma 2, young man with one gunshot wound in neck, only entry wound, no exit wound. GCS 4–5–6.”
As it turns out, there was a huge shootout. Gang-related, whispered the nurses. At least four young men were dead on the scene, hit by large caliber, probably AK-47 bullets. From what I could overhear, the rest of the victims of the shootout were parcelled up and shipped to multiple hospitals to maximize resources. Our patient was so young. He couldn’t have been much over 20. Somewhere on the ambulance ride he lost pulses and CPR was started. His leg swayed sickeningly in the wrong direction, shattered at the thigh with baseball sized holes that had stopped bleeding sometime before he got to the hospital. As he was intubated, a fountain of vomit splattered around his head and onto the floor.
I felt the street corn sit in my stomach, rolling around and not going down. But I refused to feel nauseated.
The next patient rolled in, much more quietly. As the rest of the night crew was taking care of the more critical patient, I slipped over to Trauma bay 2, who was talking and crying and in a cervical-collar but seemed otherwise alive. As it turned out, he had a million dollar wound. The gunshot had gone through his neck muscles and lodged between the spinous and transverse vertebral processes, a perfect c shaped pocket for the bullet, millimeters away from his spinal cord and permanent paralysis. Centimeters away from the carotid and jugular and trachea and esophagus, all of which could also have killed him. He was completely, perfectly, miraculously intact.
Meanwhile in Trauma 1, we worked almost an hour to resuscitate, to get catheters into flat veins and pump some much needed blood back into the heart, but there was nothing we could do to fight gravity. When we finally called the time of death, we took a moment of silence. All I could hear was the blood dripping to the floor.
3 AM. The rest of the night flew where the beginning crawled. Boarding patients started to get rooms upstairs, so new patients were actually getting beds in the ED. I reduced a shoulder dislocation, placed a fascia iliaca block for a broken hip, and sent patients home. I saw on the trackboard (which lists all the patients in the department) with mild interest that my homeless patient who was discharged earlier had come back to the ED demanding psych admission, stating he would shoot up everybody in the ED. “Joke’s on him, the people here are already shot up,” I quipped. I got laughs all around the docbox. ED doctors are a sad, dark bunch.
4:45 AM. I finally sat down to write notes and heard screaming from the lobby. The mother of our patient had arrived for the news. Actually, a whole group of mothers, sisters, and girlfriends had arrived. There were multiple people missing from the shooting, and no one knew which people were at which hospitals. No one knew if their loved one was the one who died. The police wouldn’t let them see the patients because of some weird forensic legal thing. So the night attending had to take pictures of the patient’s face tattoos and break the terrible news to whomever recognized their son as the one who didn’t make it. The whole ED stood still and quiet, listening to her shrieks of pain. The lump in my throat resurfaced. I downed my whole bottle of water, my first drink all night. The lump remained.
6 AM. The morning residents trickle in, holding cups of coffee and yawning. “How was the night?” “Awful,” I said. “But hey, we cleared the waiting room!”
