It was 8 a.m. on July 1 at the Maryland Institute of Emergency Medical Services, or ‘Shock Trauma’ as it was known locally, and the shift was supposed to be over. But I was still finishing up the last few stitches of a semi-open peritoneal lavage on a guy who had run his motorcycle into something very hard. As soon as the other members of the trauma team saw that the returning fluid was clear, they all ran for the door. “Let’s take a picture,” I said. “It’ll be our ‘graduation photo.’ The attendings are already gone. We are the last rats to abandon the ship.” The remaining residents gathered around the patient, using him as a rather grisly backdrop.
Sitting upright in the bed, comatose, he had half of his head shaved to accommodate the placement of an intracranial pressure monitor, a ‘head bolt’ as they say. The remaining hair was left long and flowing, though somewhat matted with blood. A nasogastric tube protruded from his nose and an endotracheal tube from his mouth. A large bore central line was sewn into his chest, as were two 36 French chest tubes. He was almost obscured by all of the monitor lines, catheter lines and vent tubing. But we arranged everything so that the camera could also see the punch line of the photo. Prominently tattooed on his left shoulder, over the color picture of his prized Harley, were the words “Helmet Laws Suck!”

“Say ‘organ donor’” the trauma nurse with the camera called out to everyone gathered around the bed. Everyone had big smiles. But to be honest it had nothing to do with the trauma nurses attempt at dark humor. This was the end of a very long journey for all of us. This was graduation day from our emergency medicine residency.

Within minutes everyone was gone, leaving me alone in the room with the patient. I began humming the melody to Pomp and Circumstance. Finishing the last stitches and covering the wound with a Betadine dressing I looked the patient over for any last unfinished details. “Vent settings—check,” I said going through my mental pre-flight check list. “ICP monitor working – check. Chest tubes draining—check. NG draining—check. Foley draining —check. BP satisfactory—check. NSR on the monitor—check.” One last pause and I was done. I shook the hand of the patient like he had just given me my diploma. “Congratulations,” I said to myself. I whipped off the trauma gown and headed for the door. The feeling of freedom and accomplishment was absolutely exhilarating.

That was twenty five years ago this month.

Some medical students know what specialty they want to practice even before they start medical school. But mine was a specialty that didn’t even exist until the year that I graduated from medical school. In fact, when I told my faculty advisor that I wanted to be an ‘emergency physician’, he just looked at me quizzically as if to say “What’s that?” I later found out that my advisor sent a note around to other faculty members saying “Please dissuade this student from pursuing this pointless career path.”

Nevertheless, I chose an EM program at a community hospital in Akron, Ohio. There were only three residents each year and most of the faculty had graduated the year before. There were only a handful of residency programs around the country training ‘emergency physicians’. Since there was no board exam, EM training was a dead end. But I had heard that there would be a board exam in emergency medicine administered that year. Never mind that it would be administered by people from other specialties. It was a ‘board exam’ that would certify me as a real ‘emergency physician’.

At the medical school Match Day Party it was announced that I would be going to a rotating internship without any mention of emergency medicine. I was embarrassed at graduation to find that the written program listed all the specialties that everyone was going on to, except mine. After my name it was simply blank, as if I was planning to go work in a convenience store.

My mind had been made up three years before while doing a summer orientation project. It was the only summer we had off in medical school and I wanted to make the most of it. I also wanted to get as far from Missouri as possible. So when St. Luke’s Hospital in Bellingham, Washington offered to give me a place to stay and a meal ticket in the hospital dining room while I rotated through the hospital, I jumped at the opportunity. My wife quit her job, we bought a used tent for $20 and strapped our bikes to the car my dad loaned me and headed for Washington. Everyone in the hospital administration was incredibly kind to us. We were given the use of an empty house (and I mean empty) that the hospital owned. The president’s secretary loaned us a mattress and a love seat to ‘furnish’ the house. Each day I followed a different physician through their daily routine. Mostly I just stood and watched, but many of my host physicians let me help. I got to assist with a delivery of a little boy named Travis, in OB. I thought that might be fun to do as a career. But I fell asleep in radiology as the radiologist flipped through film after film in the cool dark room. I was so bored I was exhausted. Surgery looked interesting, but my back was screaming at me and my legs felt like tree trunks after standing in one place for hours. The ER, on the other hand, was just plain fun. The physician director of the ER was a short balding man named Marvin Wayne. He was a dynamo of energy who defined adult attention deficit disorder. No matter what he was doing, you could tell he was thinking about the next twelve things he was going to do. Even though I was twice his size, we had the same spirit. As I followed him around the ER he got excited about every new case. He loved the challenge of finding the right diagnosis and treatment for each new case, in record time. Every patient was a new challenge. And just when the patient’s problem was figured out or resolved we moved on to a new and different challenge. I knew then that this was what I wanted to do.

I had a few second thoughts as I rotated through the ER at my medical school, however. It seemed like someone different, from every specialty, was called down to see each patient depending on what the nurse thought they needed. The ER intern saw what was left. Looking back, it is difficult to imagine an ER operating so inefficiently. But that’s how they did it. It was a mad house of interns from every service trying to see patients, call their chiefs with a report, then discharge the patients or dump them on another service. Everyone thought they were in charge, but in truth, no one was in charge, least of all the ‘emergency physician’ to whom I reported.

My ‘coming of age’ experience in emergency medicine came when I heard from some other fourth-year medical students that a small rural hospital nearby would hire medical students to “help out (wink, wink)” in the ER at nights and on weekends. The story was that you got to do everything but I suspected it was an exaggeration. The best part was that you got paid.

My experiences at that rural hospital are the subject of another column, but it was the first time I saw the real breadth of what I was getting myself into. I’ll never forget the first time I thought I could take a break and go to eat. I made a quick check of the patients waiting to see me. One had a dislocated shoulder, one had just vomited up bright red blood and passed out, and one had chest pain and huge ‘tomb stones’ on his EKG. Needless to say, I never got to eat. In fact, it was there that I learned to go without food and sleep for long hours.

In the years since my graduation from medical school, emergency medicine became its own department with a dedicated EM staff. My medical advisor went on to establish an emergency medicine residency and later became the president of the state chapter for ACEP. Looking back at my academic record and how competitive EM residencies are now, I doubt that I could have secured a spot in one if I hadn’t been in one of the first classes.
I still see Marv Wayne from time to time. The last time I saw him he was just as energetic as ever. I always thank him for opening my eyes to one of the most interesting careers that a person could ever have.

Mark Plaster, MD, is the editor-in-chief of Emergency Physicians Monthly and a practicing emergency physician in Baltimore, Maryland.  

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