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Last month I mentioned my “coming of age” experience in emergency medicine occurred at a rural hospital during my fourth year of med school. At the time, my wife and I were dirt poor. We were so poor that we gave plasma for platelets as often as twice a week for $15 a unit. (A story we enjoy telling our children). So when I heard a hospital in the area was hiring medical students to “help out” in the ER, I jumped at the chance to earn real money. I called the hospital administrator, went down for an interview, and after a very brief discussion, was hired as a “nurse technician”in the ER.
 
The first night I arrived for work, the two nurses showed me the charts and the call room. When I looked around for the doctor I would be working with, they told me I was the closest thing to a doctor until the next morning. The local physician had left stacks of signed, blank prescriptions in the call room for me to fill in as I saw fit. I could call the physician for advice, but only until 11 p.m. After getting over the initial shock of going it alone, I noticed that they had lots of medical reference books in the call room. Looking at those books, I determined that I could do this. I made small talk with the two nurses and waited for my first patient.

Without warning (there were no radios then), an ambulance, which doubled as a hearse, swept up to the ED door. Two young men came in pulling a gurney with an ancient looking woman on it. She lay completely still, wrapped up with blankets like a mummy, her face barely exposed. Family members were wailing and trying to touch her as the two men wheeled her past.

Having just finished a rotation on psychiatry, my first thought was to comfort the family. “I’m sure she will be all right,” I said. “Let me just go see her and I’ll come back to talk to you. Don’t worry. Everything will be all right.” I turned and strode boldly into the treatment room.

“I think she’s dead,” one of the gurney men said as soon as I closed the door behind me. Everyone in the room just stood there looking at me. “Well, maybe we can resuscitate her,” I replied with some hesitation.

“No, I think she’s really dead,” the other gurney man said. My mouth went bone dry. They were both right, of course. She was stone cold, rigor mortis dead. “You don’t want me pressing on her chest do you?” he asked.

“I guess not,” I said. “No, maybe you should. I just told the family everything would be all right. I can’t just go out there and tell them she’s dead. Let’s at least wait a few minutes.” Silence. One of the ambulance drivers pressed slowly and gently on the old woman’s chest.
 
“Maybe you ought to bag her as well,” I said, drumming my fingers on the bed rail and studying my shoelaces. The other ambulance attendant held the mask over the lady and squeezed the bag without touching her face. After what seemed like an eternity I turned to the younger nurse, “Would you go out and tell the family that she’s not doing well. She’s worse than we first thought.” As she left the room, everyone else remained still and watched her go. “This will help them adjust to the situation better,” I mumbled to my new team.

“That’s really kind of you,” the older nurse said sweetly. After the young nurse returned, we stood silently for several more minutes. I broke the silence to address the younger nurse again “You better go back out there and tell them that she’s doing worse and we may not be able to save her.” She dutifully left the room with the poor progress report. After another long interval I finally went out to face the family. “I’ve got bad news,” I said with a long face. “We weren’t able to save her.” I waited for the weeping to begin. Instead I got a question.

“I thought she was ‘dade’ at the house?” a heavily tanned man in overalls drawled.

“Oh, you don’t know nuthin’,” snapped a heavy set woman next to him, presumably his wife. “The doctor tried everything he could to save mamma. It was just her time.” I was extremely grateful for this woman’s vote of confidence. And I learned a lesson that has proven invaluable in my years as an EP—always determine whether a patient is alive or dead first, before comforting the family.

I learned a second invaluable lesson that night in the ED that I can summarize in three words—patients before food. That one was a little more difficult to learn. After hours of seeing colds, bumps, and minor bruises, I decided it was time for me to eat. Before I headed out to the cafeteria, I thought I should just poke my head into the waiting room to see who was waiting there. Only two patients sat in the room, one a young man holding his shoulder and another man, older, who was sitting stoically holding his stomach, with beads of perspiration on his forehead. I thought I was good to go for a snack, but decided to first ask a nurse about their complaints.

“I think the boy has dislocated his shoulder and the man has pain in his chest.”

“Well, let’s get a shoulder X-ray on the boy and an EKG on the man,” I said starting to walk away.

“We already got the EKG,” she said proudly handing me a folder with a single strip EKG that had been neatly captioned for each lead. I took the folder and retreated to the call room to compare it to my copy of Dubin, a sort of EKGs for Dummies. Leads I and AVF had big arching ST segments.

“Oh my G—” My words stuck in my throat. “This guy is having a real MI!”

“Get that guy into a room,” I shouted to the nurse. “And get me a real doctor,” I said under my breath. Thankfully, she did. When the patient’s doctor arrived I saw him look at the EKG and step over to the corner to pull out a miniature version of Dubin’s. “He’s having an inferior MI,” I said with confidence. The family doctor looked at me as if he needed reassurance. “I think we need to transfer him to the medical center.”

“That’s right,” he said with visible relief while picking up the phone.

“The kid with shoulder pain just vomited bright red blood all over the waiting room and passed out,” the nurse shouted.

“Now at least I know how he injured his shoulder,” I mumbled to myself. “Get a couple of IVs and blood for type and cross. We’ll pass an NG. Then I’ll reduce his shoulder,” I said with growing confidence. The MI did well. The shoulder went back in without difficulty. Nothing else too serious came in that night. But I never did get any dinner.
 

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