The Acute/Trauma unit at Massachusetts General
Hospital as it appeared on a recent Friday night.
One Night in an E.R.
by Peter Tyson
In "Tattooed Doctor," the first hour of NOVA's "Survivor M.D." series,
emergency-room physician Dr. Tom Tarter eloquently describes some of the
challenges and rewards of emergency medicine. Intrigued by his experiences in
the E.R., we decided to see for ourselves what life in an emergency room is
really like. How, for instance, does it stack up against the popular TV show
"E.R.," which, if they're lucky, is most people's only view of such a
place?
On a recent snowy Friday night, two attending E.R. doctors at Massachusetts
General Hospital in Boston graciously allowed me to shadow them for eight hours
as they made their rounds. These doctors, along with their residents and many
of their patients, were incredibly 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.
6:15 p.m.
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 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.
Dr.
Michelle Finkel, in a rare moment off her feet, fills out a patient's
chart.
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."
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.
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 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?
Never a dull moment: Residents in the E.D. analyze EKGs on computers,
make and take calls, and otherwise try to keep up with an escalating
workload.
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.
7:39 p.m.
One of those strange moments that sometimes happen 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.
Can you take notes and talk on
the phone at the same time? For emergency-room doctors like Michelle Finkel,
multitasking is par for the course.
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."
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."
A rare moment of relative
quiet in Acute/Trauma.
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.
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.
