I remember all my first deaths.

The very first was our cadaver in medical school.  As first year medical students, we shuffled quietly into anatomy lab, nervous giggles escaping pockets among the crowd.  Lying cold, still, aseptic, was our body.  Charlie.   It’s an unsettling feeling, laying hands on a dead body.  There is a quiet dignity about death, a final stillness that is unmistakeable.  I remember stainless steel tables with stainless steel scalpels, and the subtle scent of formaldehyde barely masked by the cloying smell of wintergreen.  My hands shook violently as I made the first incision.

The second was the first death I ever witnessed in person.  Surprisingly, it took until my 4th year of medical school, on an ER rotation in Seattle.  He was an elderly gentleman who had shot himself in the head after downing a 5th of vodka when his wife divorced him.  His features were barely recognizable with all the damage.  He was intubated, paralyzed, and barely had a pulse on arrival.  CPR continued only for 5 minutes before he was pronounced dead; somewhat of an afterthought.  The only thing keeping his heart beating until he reached the hospital were the massive doses of epinepherine circulating in his bloodstream.  I remember being sorry for him, but not devastated – he was already DOA.

Last night, my patient died.

The page came: ADULT TRAUMA CODE ONE FIVE MINUTES OUT BY AIR

I sprinted downstairs and into the trauma room, a sea of faces greeting me.  My favorite nurses, our best physicians, waiting.   These are the most capable people I know.  They were ready –  I prepared myself for the survey.  As the trauma intern, it’s my job to perform the whole physical examination in front of everyone and call out significant findings.  All we knew is that the patient was a 70-ish woman in a car accident.

The medics rolled the stretcher in, and instantly the mood changed; suddenly silent and tense as we saw how bad off she really was.  For a second, the only sound was her quiet wailing, “Oh, Lord.  Oh, Lordy, my arm hurts.  Please, my arm hurts so badly…”

The moment ground to a halt.  I remember utter quiet as the seconds ticked by, as long as minutes.  Her forearm had three joints where it should only have two…

Silently, I took in the damage.  Horrific, tenting fracture to the left forearm.  Right wrist splayed off to the side, every bone in her hand likely shattered.  Right ankle sideways.  Left shin with shards of bone sticking out the front.  Amazingly, she was still talking and protecting her airway, the first thing ever said in a trauma assessment.

So I spoke.

“Airway… is currently intact.”

Time sped up, sounds and colors rushing in to fill the void.  What once was silence and stillness was bedlam and cacophany.  Everyone talking.  Everything moving.  I was lost in the exam, hoping against hope that if I could just find the one thing that was wrong, I could save her.  But there was too much.

Broken bones were quickly realigned, blood lost was quickly replaced, but we were waging a war against death and we were losing.  For every vein that we accessed, another collapsed.  For every unit of blood given, she bled two more.  I was struck for a moment by how beautiful it was, all of these people working in harmony to try to save one life.   Grim faces and furrowed brows desperate to help this stranger.  People at their best.

Blood pressure started dropping.  I had my hand on her pulse and felt it ebbing away, slowly, surely, towards that final quiet stillness.  I remember at one point looking up at the clock and realizing an hour and ten minutes had elapsed.   There was the chill, certain realization that nothing would stop this woman from dying.  My fingers felt her pulse getting weaker.  Slower. Fading.  A few minutes later, she was dead.  Everyone shuffled out of the trauma bay until it was just me and her.  I was struck by how cold she was.   Like Charlie.

And then the page came:  PEDIATRIC TRAUMA CODE ONE 6 MINUTES OUT BY AIR

Off to save a life, this time.

“Hey, brotha. I need help. Look, I’m not gonna shit you, I’m an alcoholic. I’m homeless. I’ve got back pain. You can help me, you’re a doctor. I need Ativan so I don’t go into DT’s and some Percocet for my pain.  Please, brotha,  I lay myself at your feet.”

Before me lies an emaciated husk of a man, frost-bitten, his bleach-blonde hair pulled into dirty dreadlocks. The room reeks of alcohol, the tang of shitty beer lying uncomfortably in the air.  His bloodshot eyes track me as I walk over to examine him.

This was my first introduction to Chilly, our resident frequent flier. He’s famous; every ER doc in the city has treated him for everything from alcohol withdrawal to blood infections. He even has a facebook fan page which boasts thousands of “friends”. Among other things, he’s an asshole, a florid alcoholic, and an abuser of the system (a news article estimated his ambulance rides, ER visits, and ICU stays costing the taxpayer more than $10 million).

Unsurprisingly, my exam is unremarkable. It’s freezing out, and the ER is a refuge for a few hours from the biting cold and the unforgiving streets. I prepare myself for his discharge, and give him his papers.

“Chilly, your exam is normal today. I can’t find a reason that your back hurts. I’m sending you home.”

“Fuck you, man. I can already tell, I can’t change your mind. I know your type. Yea, I’ll fuckin’ go. You know how cold it is outside? Yea, I’ll fuckin’ go. I’ll go, you privileged sumbitch. You have no idea what it’s like to be homeless.”

Chilly leaves without much fuss. A nurse claps me on the back for handling him well. She thinks my no-nonsense attitude approach will serve me well as an ER doc.  All the same, a small voice in the back of my head wonders if I should have been more compassionate.

The rest of the shift goes uneventfully, and as I drive home, I notice it’s cold out, cold enough to freeze the windshield on my car. I run inside my heated house and crack a beer. Life is good.

“You have no idea…”

Out of guilt, I throw on a sweater and my overcoat, and shuffle outside. It is bitingly cold; I start shivering instantly. The stars are frigid, beautiful, and unforgiving, the moon austere behind a single veil of cloud. Chilly was only wearing a sweater and some thin pants when I discharged him. He must be freezing right now. I last all of 5 minutes; my teeth chatter so hard I fear I’ll break the enamel. I rush inside, the warmth enveloping me like an old friend.

4:55 AM, and I was dragging. My 12th day straight in the hospital, leaving a string of three call nights behind me with one left to go. Twenty patients to see before grand rounds at 7AM.

My knee has been hurting. I suspect it’s from the miles and miles I’ve been putting on my body 14 hours a day, 90 hours a week, running around the hospital. I’ve been taking the stairs everywhere in an attempt to remain in better shape, but this morning it was too much. No coffee yet and too little sleep. I gave in and took the elevator from the 3rd to the 11th floor.

I leaned back in exhaustion against the side of the elevator, eyes closed. It whirred into life, and I let the tug of gravity pull me to the ground. The elevator reached the top floor and *dinged* quietly. I stirred, mentally preparing to start rounds.

And then, the door made a few feeble attempts to open, and quit. Servos whined to a halt. I was stuck in the elevator.

Funny, how things can change. Any other time I would immediately panic. What if I have to go to the bathroom? What if the cable breaks? What if the call button doesn’t work? What if I can never get out?

Instead, pure, unabashed relief washed over me. I couldn’t work while trapped in the elevator.

Zac, why haven’t you finished rounds yet? The situation played out in my mind, There’s so much to do today! We have to get on it!

Sorry sir, I quietly replied, I’m physically trapped in the elevator on the 11th floor, there’s really not much I can do from here.

Well, I suppose you’ve got an excuse then. Take the day off.

I sat there for a few minutes, relishing the solitude. I planned out my entire day of rest, mapping out every delicious hour I would spend in each corner. Perhaps I’d take a nap right in the middle of the floor. I smiled. It was going to be a good day.

Then the elevator *dinged* softly again, and my hopes sank as I traveled back down. The door opened on the third floor. A tech stared at me in surprise, papers stuffed in my pockets, hair askew, sitting on the floor of the elevator.

“You alright, man?” he asked.

“Not really”, I responded. I stood up, knee hurting, as I limped off towards the stairs.

Faceless children throng through the doors of the Peds ER; parents, illnesses, charts all flowing into one feverish, runny-nosed amalgamation.

The waiting room is full of these kids. Anyone who didn’t have the flu before, does now. It takes 7 hours to be seen, plenty of time for snotty hands to wipe all over the tables, the chairs, the playthings.

I vaguely listen to my voice on autopilot, droning on about the benefits of motrin and tyenol for fevers. I’m surprised to hear myself lose patience with a particularly insistent mother who wants her daughter hospitalized for a fever of 101.3 and a cough. Her kid is fine. She won’t take no for an answer. We get security to escort her out.

This isn’t fun. At one point I see 8 children in a row who I diagnose with the cold. The monotony is broken by a child with a cut on his finger, but he starts screaming the second I enter the room. We have to sedate him before I can sew it up. He hates me for it, and his mom judges my repair every step of the way. I look too young, she explains. My next 5 patients all have the cold. Nothing about this is enjoyable or fulfilling.

The shift ends with a whimper, as we finally clear out the waiting room 15 minutes before I’m scheduled to leave. My last patient is a kid with a cough. I send him home with tylenol for the fevers. The parents can’t believe they waited eight hours for me to tell them that. I can’t believe they did either.

I treated a guy a few days ago for the “worst lower back pain of his life”. This is a surprisingly common occurrence for emergency doctors, and I must admit that I immediately wrote him off. Mohawk, neonazi tattoos, bad teeth, nasty attitude.

I went through the song and dance, pretending to care about his “back pain after twisting it the wrong way”. I’ve heard this story so many times, from so many drug seekers, that is has competely lost its luster. Immediately I informed him that I was not comfortable prescribing narcotic medications.

“But I’m allergic to tylenol, aspirin, and advil!” he decried, “Please, doctor, it hurts so bad. Can’t you give me something else? Nobody can help me but you…”

Even a couple of years into hearing these complaints I still cringe a little on the inside while I put on the hard, callous exterior. “I’m not going to prescribe you any narcotics today, sir.”

But what if I’m wrong? What if he’s truly in pain and I’m just being stubborn? He was barely able to sit up from the bed without wincing in pain when I examined him. Every small touch sent him into paroxysms of agony. I discharged him with an anti-inflammatory I hoped he wouldn’t recognize the name of.

Two days later I was walking back from the cafeteria and saw him strutting down the hall towards the urgent care with a heavy backpack on, no evidence of the “extreme pain” he had 2 days earlier. The doctor covering urgent care called me when he came in 10 minutes later for an inability to walk.

Nobody likes to be made a fool of, which I suspect is part of the reason Emergency Physicians undertreat pain. I follow up many of my patients in the hospital (did my suspected heart attack actually have one?), but I never follow up on suspected drug seekers. Why? Because I don’t want to turn cynical earlier than I have to.

This is a story that happened to the good Dr. O while I was on shift with her tonight. If female genital complaints gross you out, I suggest you stop reading now and go visit another website… although, it’s pretty funny.

The patient’s chief complaint was “vaginal discharge x 2 weeks”, which – at minimum – requires a pelvic exam. Dr. O interviewed the patient, getting some more background information. Whitish discharge. Unprotected sex. New boyfriend. Run of the mill, most likely a sexually transmitted infection. The nurse comes in, they set up for the pelvic, and begin.

By her account, this was the most horrifically awful pelvic examination she has ever performed. Milky white fluid was leaking everywhere. On the sheets, on her scrubs, on the speculum. It was all she could take not to gag.

Impeccable, composed physician that she is, Dr. O obtained her samples, and then calmly told the patient that she was quite concerned about the amount of discharge. “This,” she said, “is honestly the most fluid I have ever seen on a pelvic exam. We will empirically treat you with antibiotics for a suspected STI, and will call you with the results of the tests as soon as we have them.”

The patient looked at her and said “Aw, that ain’t no discharge. Me and my boyfriend just raw-dogged it right before we came to the ER. That’s all cum.”

After my interview I head back to the hotel, change into more comfortable clothes, and take a stroll around town. Street jazz bands play while the warm breeze gently caresses the city. People take it slow down here in the South. Today during the interview a woman stopped our group, “Y’all should know I’m the survivor of a pul-mow-nary em-bow-luss. Thanks to God Almighty and to y’all wonderful doctors, I’m still here today to speak with you. God bless”. And she continued upon her way, a smile on her face.

An Irish pub with cheap Guinness beckons, and I sit at the bar with a few NASCAR fans. One offers me some chicken tenders, which I politely decline. Eventually the conversation turns round to jobs. The guy next to me, Budweiser in hand, with a flannel shirt and a trucker hat, speaks up.

“So, buddy. What brings you all the way out here from the southwest?”

Slowly, drinking my beer, I reply. “ER residency, actually. Your hospital out here is one of the best in the nation.”

“Now, that’s a job I can respect. Me, I roof houses.” He pauses, catching a quick glance at the cars flying around the track. “You seen people die? And there ain’t nothin’ you can do about it?”

“Yep,” I reply, “it can be pretty rough.”

“So what makes it worthwhile? I think I’d up and quit the first time someone died on me.”

I pause. This is the most honest question I’ve gotten on the interview trail, and it isn’t from an attending, a resident, or a program director.

“I suppose,” I slowly say, “I suppose it’s when you can help people that makes it all worthwhile. When you can look someone in the eye and tell them they’ll be ok.”

He smiles quietly, as though I said just what he expected to hear from a doctor in the making. I smile too. We clink glasses and toast, then sit back and watch the cars race around the track in comfortable silence. This is a good place for me.

A few weeks back I had to leave our med school tailgate to put in a shift at the urgent care. While I was truly saddened by my inability to contribute to the shotgunning of copious beers, alas, some of us are productive members of society. Then again, I’m of the mindset that shotgunning beers at tailgate is productive, but that’s a debate for another time.

I had a pretty great shift, mostly because drunk college kids were brought in for various and sundry complaints†, and they were stoked to see the school colors under my scrubs. Halfway into the night, though, there was something… different. Cruising around the corner, I immediately noticed two things.

Firstly, my nostrils were assaulted with the pungent odor of vast, unimaginable quantities of shit; a horrific wall of feculent odor that knocked me backwards. This was shit to be reckoned with. This was shit that didn’t take “no” for an answer.

Second, there was a very attractive sorority girl in school colors and butt shorts screaming blindly “I’m NOT as DRUNK as you THINK I am” at the nurse who was unsuccessfully trying to start an IV.

The incongruity of these two simultaneous events was difficult for me to comprehend, so I used my carefully honed powers of medical observation. “Ah, there’s the problem” I thought to myself, “that lovely young lass has shat herself”.

I mean, folks, I didn’t realize you could even poop that much††. It was all over the poor guy drawing blood, the bed, the floor. It was splattered on the wall like a Jackson Pollock painting. It was a veritable cornucopia of fecal matter. It was Shitterhouse-Five.

That, my friends, is why I both love the ER and could never make it as a nurse. We love you so very much, you don’t even know.

† If by “various and sundry” you mean “solely related to alcohol and the imbibing thereof”. Pearl: if a piece of a broken beer bottle pierces through the insole of your Chucks, your antibiotics must cover Pseudomonas Aeruginosa.

†† let alone a girl who couldn’t have weighed more than 90 pounds.

I went ahead and pointed out the pain with a few red arrows. That humerus is really supposed to be one unbroken piece of bone.

So in a week I start 4th year, and I’m debating whether or not to do Radiology first, or switch it out for ENT (ear/nose/throat surgery). Youtube is a fantastic resource for budding young surgeons, as you can watch whole surgeries from the comfort of the home. Bonus: you don’t have to stand in the back of the OR looking bored!

Let me talk you through my thought process. As a quick warning, none of the links in this post are safe for children. Or adults. Or really anybody, including doctors. I’m not sure I can do ENT any more.

Zac (thinking): I wonder if I should look in to some sort of surgical field again? Honestly, I like procedures a lot. What about Urology? Nah, I don’t really want to stick my fingers up dudes’ butts all day long.
Another Med Student: Hey, man, look in to ENT! They do some really cool procedures.
Zac: Cool… lets just go ahead and YouTube some ENT stuff… lets see, this’ll do. Endoscopic Dacrocystorhinostomy.

Hey, nice nose, man. They do this while the patient is awake? That’s pretty cool, you can do it in-office. Neat-o, this is a pretty nifty, delicate procedure. Wait… wait, he’s using a “chisel”? And the guy is awake? He’s going to chisel through his nose while he’s AWAKE? Oh, god, you can hear the bone breaking. Huh, that’s kinda neat, though, he just removed all that bone and now there’s a “sac” protruding. Wait, wait, wait… he’s cutting open the sac. Oh, no – please no – now there’s stuff draining EVERYWHERE… ugh, it looks like it’s all going down the patient’s throat. I think I’m going to vomit.

Zac (nauseated): OK, ok, I can do this. That was just one surgery. How about this one… Nasolabial Cyst Excision.

Hm, that’s funny, that guy has really terrible teeth. Surgeon is getting ready to cut… nice incision, doc, strong wor- WHAT THE FUCK, WHAT THE FUCK IS THAT OH MY GOD ITS ALL DRAINING TOWARDS HIS THROAT!!!! THE IMAGE HAS SEARED ITSELF INTO MY BRAIN AND I WILL NEVER GET IT OUT… OH SWEET JESUS THAT MAN JUST SWALLOWED PUS EVERYWHERE OH GOD THE SURGEON IS MILKING THAT STUFF OUT LIKE ITS A COWS UDDER