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.